# Dual US/German citizen - health insurance retirement question



## Rixlari

My husband and I are hoping to retire to Europe in the next few years. We’re both US Citizens, but I was able to get German citizenship through my father. I’ve always lived and worked in the US, never in Germany. We currently live in very costly Los Angeles but hope to find somewhere cheaper to live in retirement so that our money goes further. I’m 61 and my husband is 59. 

Health insurance is a big concern. I understand we can pay for private health insurance. If we retire to Germany would we be able to access the public health system to save some money. Would there be any age limitations or pre-existing condition concerns if we do? Thanks!


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## kaju

Rixlari said:


> My husband and I are hoping to retire to Europe in the next few years. We’re both US Citizens, but I was able to get German citizenship through my father. I’ve always lived and worked in the US, never in Germany. We currently live in very costly Los Angeles but hope to find somewhere cheaper to live in retirement so that our money goes further. I’m 61 and my husband is 59.
> 
> Health insurance is a big concern. I understand we can pay for private health insurance. If we retire to Germany would we be able to access the public health system to save some money. Would there be any age limitations or pre-existing condition concerns if we do? Thanks!


My understanding is that if you're over 55 you can't automatically get public health insurance, unless you are a German Citizen and have worked in Germany in the past (maybe pre-2009? Can't remember).

Same for Non-German, and even if you have worked there years ago, that must have been for over 12 months, and there are some other awkward conditions too, such as having continuous cover since that point.

So you're left with about 3 options. 

1. Get private insurance if you're fairly healthy, without significant major pre-existing conditions - look around and find the best policy - often an insurance broker can help with this. May not be much more than public cost, and may have better cover and actually be better overall value - if you have no serious pre-existing conditions.

2. If you have pre-existing conditions, private cover will often be very expensive indeed, even if you can get it. But, there is a level of protection for people with health issues that private insurers can't actually deny, although some may try. They are obliged to offer you the "Basistarif" - comprehensive but average-level cover to anyone, and they can't exclude you due to ANY pre-existing conditions.

You may need the support of a free independent adviser (but probably not a broker) to get this, but really it should be possible. Trouble is, the Basistarif is about 700 Euros per month per person, so if both couldn't get ordinary public cover, a couple will pay 1400 Euros a month. Ouch! 

3. The remaining option might be to go and live in another EU country, join their health system and after at least 12 months in that country, you could move to Germany and transfer into the normal German public health insurance as you are transferring from another EU country's public health system. 

These other countries will often require you have full private health insurance for at least a few months, until you become eligible to become a resident, and join their public health scheme. 

Since one of you has EU citizenship, you could live in say France, Ireland, Austria and maybe a few others - countries where you can become a resident and get public health cover, then move and transfer later to Germany.

After much investigation on the net, and paying a little in fees to a professional advisor/broker in Germany that made enquiries on our behalf with a "friendly" krankenkasse that they often work with, this information seems to be confirmed. However, I'm always a bit conservative and careful, so when we arrive in Germany one of the first things we'll do is check with a free independent advisor to confirm it all: https://www.patientenberatung.de/de

We're planning to do this in a few months time - our house here in Australia is on the market so we should be in Germany before Christmas. 

My German wife can rejoin the public system, but I can't, (annoys me as Australia lets Germans of any age join our public system, and we've always been in that, and been privately insured too!) so we'll go to Germany, but only for a few weeks, then to Austria and rent a place there for perhaps 18 months, then move to Germany permanently. Anyone can join the Austrian public system but there is no cover for the first 6 months. 

When we go back to Germany after that, we will transfer into the German public system from another EU country's public system, having been in that system for at least 12 months - all good!


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## Rixlari

Thank you very much! This is very helpful! So it sounds like we could live in France for three months and then apply through PUMA for French public health. After a year we could move to Germany and the public health would transfer and allow us to be covered by German public health? Would France have to issue us an S1 form or EHIC card in order to do this? Would France continue to pay for our healthcare and reimburse Germany for our expenses even though we aren't French citizens and only lived there a year? If it can work that way, I'm all for it.


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## Bevdeforges

I don't think it works that way here in France. In France, you can indeed enroll in the public health care system after establishing your residence in France - however, if you are retired and receiving a pension (US SS, for instance) you won't have to pay for the national health care system.

The "catch" is that in France, the national system only covers a part of your health care expenses. You're expected to then purchase a "top up" insurance, called a "mutuelle" that pays the remainder of the health care charges, depending on what level of policy you buy and pay for. 

I don't believe that you can get an S1 to automatically transfer to German (or any other EU country) health care system. Each national program has its own requirements (and levels of cover) depending on your level and sources of income. It's a relatively recent development here in France that they have extended coverage in the national system to just about all retirees receiving a pension and I believe that provision is unique to France. It might be possible to transfer coverage to another EU country if you were drawing a French pension, though I'm not sure of that. That is based on the idea that you "pay for" your health cover in the years while you work.


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## kaju

Rixlari said:


> Thank you very much! This is very helpful! So it sounds like we could live in France for three months and then apply through PUMA for French public health. After a year we could move to Germany and the public health would transfer and allow us to be covered by German public health? Would France have to issue us an S1 form or EHIC card in order to do this? Would France continue to pay for our healthcare and reimburse Germany for our expenses even though we aren't French citizens and only lived there a year? If it can work that way, I'm all for it.


I don't think an S1 form or EHIC Card would be acceptable. A German krankenkasse would want to see evidence that you had public health cover in another EU country for at least 12 months continuously in the last 5 years. I suspect that often, your health insurance membership card will be enough for the gaining krankenkasse to confirm your membership of over 12 months.

Once you join the German system your contributions go to Germany, and Germany pays your claims, there is no involvement for France - you leave the French system when you go to Germany and enter the German system.


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## kaju

Bevdeforges said:


> I don't think it works that way here in France. In France, you can indeed enroll in the public health care system after establishing your residence in France - however, if you are retired and receiving a pension (US SS, for instance) you won't have to pay for the national health care system.
> 
> The "catch" is that in France, the national system only covers a part of your health care expenses. You're expected to then purchase a "top up" insurance, called a "mutuelle" that pays the remainder of the health care charges, depending on what level of policy you buy and pay for.
> 
> I don't believe that you can get an S1 to automatically transfer to German (or any other EU country) health care system. Each national program has its own requirements (and levels of cover) depending on your level and sources of income. It's a relatively recent development here in France that they have extended coverage in the national system to just about all retirees receiving a pension and I believe that provision is unique to France. It might be possible to transfer coverage to another EU country if you were drawing a French pension, though I'm not sure of that. That is based on the idea that you "pay for" your health cover in the years while you work.


The pre-requisite to register in a "new to you" EU country's public health insurance as an incoming former EU resident is that you must have been in your original EU country's public health system for 12 months continuously in the last 2 years, or 24 months not necessarily continuously in the last 5 years. The requirement does not depend on whether you hold any mutuelles, or whether you have to pay for public health cover or not, simply that you were covered under the basic public health insurance for your original country.

You can't transfer anything in this situation, you lose entitlement to anything from France as you are simply moving from one country's public health insurance system to another's as you are becoming a resident in your new country. Once you change countries (after being in the French health system for a provable 12 month minimum) you would leave the French system and start in the German system. 

Some EU countries public health systems are more difficult to get into for some people, even with EU partners.

So, the system in the EU country that you're planning to use to get into the EU system must actually let you join that system first, of course. You couldn't join the German system for 12 months to transfer to another EU country's system, because Germany wouldn't let you join to start with, if you see what I mean! What you need is an EU country that permits universal public health fund membership with conditions that you can meet. France seems to be ok, as you should be able to join, the other obvious countries are Ireland and Austria which both make it simple to join their public health systems.

For Rixlari:

Actually, since you have German Citizenship but have never worked/lived/been in their health system, you do have grounds for them to let you join - but your husband does not. So you could simply roll up in Germany and join. Although oddly enough, you couldn't join the German public system on this basis if you have ever been self-employed or freelance in the country you grew up in. 

Your husband however, could not join, as he's not German. He could probably be added onto your insurance as your dependent if his income was less than about 425E a month, otherwise, it would be private insurance, or the Basistarif for him - unless he/both of you have been a member of another EU public health system for 12 months. If you join German private health insurance at all, you forfeit your right to join the German public health system.

The German requirement is actually fairly straightforward: https://www.sozialgesetzbuch-sgb.de/sgbv/9.html

and https://www.sozialgesetzbuch-sgb.de/sgbv/5.html (see number 13)


Public health systems do vary significantly from one EU country to another. But the common thread is that someone who has been covered for at least 12 months (in the last 2 years) by one EU country's public health system can (subject to the normal requirements for entry to that new system) move into another EU country's health system. 

It is absolutely imperative to apply in Germany within 3 months of registering your residence - after that point, the public health system is not compelled to insure you, even if you have 12 months in another EU country's public health system.

The really important thing to remember is that you can't live in Germany without either public or private health cover. 

Rather than rely on information posted by me or others, or from single sources, for your own safety, I'd be inclined to investigate more until you are absolutely sure of your situation.

This may also include getting professional-level advice from a versicherungsberator or two - they may not be willing or able to advise you much as they may mostly deal with private health insurance, but they may help you find out about and even register for public cover for a fee. Or if you both agree that can't be done, they might be able to get you into the Basistarif with a reluctant krankenkasse, or find good private health insurance, for a fee of a few to several hundred euros, or they may able to direct you to someone else. 

The link I provided to free public support in my first post may also provide help and confirmatory evidence of what would be acceptable for your situation, but you might have to be there to get that support.

I would caution too that there may be significant and far-reaching changes to the German health insurance system over the next few years - if you are not planning to arrive in the quite near future, requirements may well change. There have been strong political rumblings about this for some time in Germany now - the SPD in particular want the health system changed to become more universal. However, their support nationally is not what it used to be. Then again, maybe a deal will be done with the CDU (who they don't really like too much at the moment) which may include this, so that the CDU can try and retain power. Who knows, especially after Merkel goes and AKK holds the reins? 

Given freedom of movement is an essential right for EU Citizens, I don't see that the ability to change countries and transfer to a new public health insurance system will change, but the necessary requirements to join your first EU country's system might! 

In most countries, the rules sometimes change (often very significantly) over several years. Things may become harder or easier for your particular circumstances, and indeed your circumstances can change over time too! So if you're planning to move say in a few years, sure, get a feel for the requirements now, but check again closer to the time of your proposed move too.


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## ALKB

kaju said:


> Some EU countries public health systems are more difficult to get into for some people - for example, if you were in the UK, you need to be a resident and there might be a fairly high income requirement before your non-Citizen partner could live there, so for some people, going there to get 12 months cover might not work. If you can get into the NHS system, then sure, Germany will accept 12 months NHS membership to transfer into the German system - but that won't work if you can't get into the NHS!


There is no income requirement for EU citizens and their non EEA family members, at least until Brexit. All I (and my then non-EEA husband) needed to join the NHS was proof of address. I called the council right after arriving and registered on the electoral roll, two days later I had official correspondence to use for registering with a GP, opening a bank account, and applying for a NINO.

Of course, GP practice staff are just as confused about Brexit as everyone else and I have heard stories about registering getting harder because everyone is scared to make mistakes. Also, depending on how Brexit will go down, the option to move to the UK could come to an end abruptly in as little as three months.


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## kaju

ALKB said:


> There is no income requirement for EU citizens and their non EEA family members, at least until Brexit. All I (and my then non-EEA husband) needed to join the NHS was proof of address. I called the council right after arriving and registered on the electoral roll, two days later I had official correspondence to use for registering with a GP, opening a bank account, and applying for a NINO.
> 
> Of course, GP practice staff are just as confused about Brexit as everyone else and I have heard stories about registering getting harder because everyone is scared to make mistakes. Also, depending on how Brexit will go down, the option to move to the UK could come to an end abruptly in as little as three months.


Clearly wrong information on my part, although the requirements will apparently change in 2020 or 2021. The UK was a bad choice to talk about anyway as who knows what will happen! I've edited my previous post accordingly, thanks!

What I can say is that not all EU countries will let non-EU partners (especially older ones) join their public health insurance systems. Given that non-EU partners would need 12 months membership to transfer to the German public health system, interested people need to check carefully what countries public health systems would accept them for this 12 month period.


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## Rixlari

Thank you all for all this information. I shall try to digest it all. At this point, I'm trying to do research and get all the information I can to guide us toward the right destination for retirement. And we so appreciate the information we're getting! Once we have a better sense, we'll explore the country at bit more and start learning the language. Hopefully within 4-5 years we can move with the confidence there won't be TOO many surprises! However, we understand nothing in life is guaranteed so it's become clear to us that no matter where we go, we should have several backup options if things don't go according to plan, including moving back to the US to a cheaper area than Los Angeles. 

One question to kaju. You said:



kaju said:


> Actually, since you have German Citizenship but have never worked/lived/been in their health system, you do have grounds for them to let you join - but your husband does not. So you could simply roll up in Germany and join. Although oddly enough, you couldn't join the German public system on this basis if you have ever been self-employed or freelance in the country you grew up in.


I grew up in the United States. When you say "country you grew up in" did you mean the country where I may move first and qualify for public health, such as France? I am self-employed in the U.S. and was considering continuing to be self-employed for a while when moving to Europe!

Thanks!


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## Bevdeforges

Rixlari said:


> I grew up in the United States. When you say "country you grew up in" did you mean the country where I may move first and qualify for public health, such as France? I am self-employed in the U.S. and was considering continuing to be self-employed for a while when moving to Europe!
> 
> Thanks!


Just be careful - I think you'll find that "self-employment" as such doesn't really exist in most european countries. If you're working for and by yourself, you normally have to register some sort of "business entity" (certainly in France, but I think also in Germany) so that you pay all your taxes and social insurances.

And generally speaking, you do have to pay into the retirement system, even if you are past "retirement age" in the country. You may or may not get any benefit from those payments - though usually there is a "social security" agreement that allows you to count your US working time toward accumulating benefits in your new country of residence.


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## kaju

Rixlari said:


> Thank you all for all this information. I shall try to digest it all. At this point, I'm trying to do research and get all the information I can to guide us toward the right destination for retirement. And we so appreciate the information we're getting! Once we have a better sense, we'll explore the country at bit more and start learning the language. Hopefully within 4-5 years we can move with the confidence there won't be TOO many surprises! However, we understand nothing in life is guaranteed so it's become clear to us that no matter where we go, we should have several backup options if things don't go according to plan, including moving back to the US to a cheaper area than Los Angeles.
> 
> One question to kaju. You said:
> 
> 
> 
> I grew up in the United States. When you say "country you grew up in" did you mean the country where I may move first and qualify for public health, such as France? I am self-employed in the U.S. and was considering continuing to be self-employed for a while when moving to Europe!
> 
> Thanks!


My understanding is that if you were self-employed in the most recent non-EU country before going directly to Germany, that they can require that you get private health cover - but this is one of those things that you need to check with a versicherungsberator (an insurance broker or advisor). Of course, this problem (if indeed it is a problem) would only affect you if you went direct to Germany from the US and applied for public health cover - apart from this possible issue, you should be entitled to get it.

But even if this was not an issue, your husband still needs to be covered of course, so you're probably looking at needing to be in another EU country's public health system for at least 12 months anyway so that you can both transfer into the German Public Health system. 

Transferring from an EU country's public health system to the German one is done on the basis that "you had public cover there, so we'll give you public cover here" - so going this way means your self-employed history in the US is not relevant in this situation - what matters then, from Germany's point of view, is that you are both coming from another EU country's public health system. 

Unless you go directly to Germany from the US and join a German public health fund and your husband's income is less than about 400E a month (and even then you'd need to get past your self-employed history and join German public cover as a German, with him as your dependent), the transfer from another EU country's public system to the German public system is likely the only way you will both get cover in the German public system.


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## Rixlari

Thanks so much for all the helpful and very specific information. It appears to me that, because of my German citizenship, Germany would be the most difficult place us to go to retire! That wasn't what I was expecting when I first started my research. But now I see that German immigration laws would apply to me and my spouse whereas EU laws allow me to take advantage of more favorable rules in other countries. I'm leaning toward France. But I won't be far from Germany and will plan on crossing over to visit my father's birthplace of Bad Durkheim when I have the chance. Danke schön!


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