6 steps to getting private therapy covered by public health insurance in Germany

45 percent of the German population is affected by depression - many more with mental health challenges -  and the country’s limited public mental health services are struggling to keep up with demand. But there is still a route to getting free therapy in Germany. We explain the six steps you need to take.

Does statutory health insurance cover therapy in Germany?

Anyone who lives in Germany and is covered by statutory health insurance is entitled to psychological support, the cost of which is covered by their health insurer.

According to 2019 figures from the Federal Statistical Office (Destatis), in the country of 84,4 billion people, there are around 48.000 qualified therapists.

However, only 32.500 of the 48.000 qualified therapists have a “Kassensitz” licence. This is the licence therapists need to treat people covered by statutory health insurance (88 percent of the population) not just those covered by private health insurance. 

What’s more, half of these 32.500 therapists only have a partial “Kassensitz” licence, meaning they can treat publicly insured patients, but half of their professional work must be in another medical area, such as at a hospital or university.

All this means that while there are enough qualified therapists to meet demand in Germany, too few of these therapists have the Kassensitz licence required to treat patients with statutory health insurance.

Why does the Kassensitz system exist?

It seems illogical that there are enough qualified therapists in Germany, but many of them aren’t permitted to treat patients who need mental health support. So why does the Kassensitz system exist?

The answer is: Bedarfsplanung (demand planning). Bedarfsplanung is an “instrument for ensuring that people covered by health insurance have equal and need-based access to healthcare,” according to a definition from the Gemeinsamer Bundesausschus (GBA or Federal Joint Committee), which regulates the German healthcare system.

The GBA set certain Bedarfsplanung expectations in 1999, limiting the number of Kassensitz licences issued in each region. The organisation can make more Kassensitz licences available and added 900 nationwide in 2019, but assessments of whether new licences are required are still based on the Bedarfsplanung standards set nearly 30 years ago.

Already in 2014, the Federal Chamber of Psychotherapists decried that the 1999 standards “had nothing to do with the real requirement [in 1999] and are far too low”.

This system has created a whole grey industry for trading Kassensitz licences. Rather than therapists having to apply for the licence - as you might expect - they have to track one down and buy it from another therapist, often one approaching retirement.

The prospective therapist receives a list of psychologists approaching retirement and contacts them with the help of a lawyer, who negotiates the sale and licence price. This whole process can cost the prospective therapist up to 100.000 euros.

The GBA’s decision to continue to limit Kassensitz licences could be motivated by multiple factors: better access to therapy would cost statutory health insurance providers more money, they believe more people would seek help, and there is still a stigma around seeking mental health support.

A step-by-step guide to getting free therapy in Germany

But making it hard for people to go to the doctor doesn’t stop them from getting sick. So the current Kassensitz distribution system leaves people in need of mental health support to navigate a Kafkaesque system at the worst of times, which is hard enough to figure out at the best of times.

It is possible to have your statutory health insurer reimburse the costs of visiting a private therapist if you can prove that no therapists with a Kassensitz licence have the capacity for new patients. This is called the Kostenerstattungsverfahren (cost reimbursement procedure).

However, this procedure requires determination, patience, organisation and finding the right loopholes. We break it down into six steps:

1. Call the 116 117 hotline

The first step you have to take is to call the 116 117 Federal Health Hotline or download the 116 117 app.

When you call, the hotline employee will ask for your name, date of birth, address and gender of therapist to which you would like to speak. They search the 116 117 directory for appointments, give you options of therapists available to talk to in the next few days and book the appointment you choose.

If you haven’t been referred to therapy by a doctor, the hotline employee or app will also designate you a 12-digit referral code (Vermittlungscode). You should write down this code and keep it safe. 

2. Go to your first therapy meeting

The initial meeting with a therapist (Erstgespräch) lasts 50 minutes. During the appointment, the therapist may ask what has brought you to seek therapy, and you will have space to discuss any specific issues and general thoughts.

At the end of your session, the therapist will give you a pre-diagnosis, guidance about what kind of therapy they think would be helpful for you and how urgent it is for you to get treatment. This information will also be given to you to take home on a PTV 11 form. Keep it safe, you will need this form in future.

Limitations on Kassensitz licences mean that most therapists offering 116 117 Erstgespräche are unlikely to have the capacity to take any new patients covered by statutory health insurance. The therapist will probably tell you whether or not they have a spot. If not, it is always good to ask!

3. Call back the hotline

With your PTV 11 form by your side, it is time to call 116 117 again. Now that you have the form and pre-diagnosis, the 116 117 team is technically supposed to find you a spot within four weeks of your call back. Of course, stretched capacity means this is nigh impossible for them. 

Important: For future reference, you should take note of the specific date and time you call back 116 117 to ask them for a placement.

4. Begin contacting public therapists and collecting rejections

While this step is monotonous, it is relatively straightforward. It is now up to you to contact as many therapists with a Kassensitz licence as you can (between 20 and 30) and ask them if they have space to take a new patient. If they have the capacity, you’re in luck and you can begin therapy.

If not, each rejection brings you one step closer to proving that your statutory health insurance provider must cover the cost of you attending private therapy. As the rejections roll in, create a document where you list the therapist's name, address, email, the date you contacted them, the date they rejected you and what the rejection said.

5. Begin contacting private therapists

While you collect rejections, you should also begin contacting private therapists and asking if they can take a new patient. If you’ve collected your list of 20-30 therapist rejections and you find a private therapist with capacity, you can prepare your application for the Kostenerstattungsverfahren (cost reimbursement procedure).

Since psychotherapy is covered by statutory health insurance, providers are obliged to give you access. With your document of 20-30 therapist rejections, you can prove that the statutory system has failed you, obliging your health insurance provider to reimburse the costs of private treatment.

6. Submit your Kostenerstattungsverfahren application

The limitations on Kassensitz licences mean this approach to finding therapy is increasingly common in Germany. For that reason, your new private therapist will likely be experienced in guiding patients through the Kostenerstattungsverfahren process.

The private therapist will help you gather the required documents, which include a statement from them and a treatment cost estimation. You can submit all of these files to your health insurance provider and within several weeks you should receive a confirmation that they will cover the costs of your treatment.

How can I find a German therapist who speaks English and meets my needs?

On top of digesting the unnecessary complications of the Kostenerstattungsverfahren, you may be thinking, how can I find a therapist who speaks English, or another language?

Therapie.de is the best place to start your search. This directory lists therapists across the country, including information about which languages they speak.

Apart from language, you might have other needs. Perhaps you would like to find someone who is trained to work with the LGBTQ+ community, with people with eating disorders, grief, addiction, trauma or PTSD. Therapists' specialised areas are also listed in the therapie.de directory.

Thumb image credit: Srdjan Randjelovic / Shutterstock.com