ÖGK (Austrian Health Insurance Fund)

Concept

The Austrian Health Insurance Fund (Österreichische Gesundheitskasse, ÖGK) has been, since the 2020 merger of the former regional health insurance funds, the largest carrier of statutory health insurance under the ASVG, covering the majority of employees and their dependants. It primarily provides benefits in kind – medical treatment, hospitalisation, medicines, dental care – under the benefits-in-kind principle, where costs are settled directly between the ÖGK and the service provider, as well as cash benefits such as sick pay for prolonged incapacity for work.

Co-payments and cost-sharing

ÖGK members bear statutorily defined cost-sharing for certain benefits, in particular the prescription fee (Rezeptgebühr) per medicine package, and, for certain private-practice physicians (Wahlarzt) and elective treatments, a co-payment for the portion of the fee not reimbursed by the ÖGK. For private patients and treatment outside the network of contracted providers, the ÖGK typically reimburses only a partial amount corresponding to its own fee schedule.

Relevance for insurance practice

The coverage gaps of the ÖGK regarding free choice of physician (Wahlarzt), private hospital rooms, and dental prosthetics are the central rationale for private supplementary health insurance; for intermediaries, precise knowledge of ÖGK benefits and co-payments is a prerequisite for correctly assessing a client’s actual need for supplementary cover and avoiding double insurance.