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Table 1 Summary of specific definitions and terminology related to refugee healthcare in Germany

From: “We assist the health system doing the work that should be done by others” – a qualitative study on experiences of grassroots level organizations providing refugee health care during the 2015 migration event in Germany

1.1 Legal definitions of migrants and refugees in Germany

Recognizing international law, Germany defines “migrants” as persons leaving their homeland on their own accord in search of better prospects in life; “refugees” are defined as persons forced to flee their homeland as a result of external influences (e.g., persecution, war, conflict, or other crimes against humanity) [19]. The German Residence Act (Aufenthaltsgesetz) requires migrants to obtain a residence title (e.g., residence visa, work permit, permanent residence permit) [20]. So-called “illegal or un-documented migrants" refer to persons residing in Germany without or beyond the duration of their residence title, or those whose asylum application was denied. Migrants do not meet criteria for asylum (but specific arrangements exist for migrants from other EU countries).

1.2 Asylum application in Germany

The German Asylum Act (Asylgesetz) grants protection in form of asylum to refugees [21]. Refugees can register as “asylum seekers and apply for asylum through various official institutions in Germany or at its borders. Eligibility for asylum is decided by the Federal Office for Migration and Refugees (Bundesamt für Migration und Flüchtlinge, or BAMF). Positive asylum decisions fall into one of four protection categories: entitlement to asylum (i.e., persons persecuted on political grounds), refugee protection (i.e., persons persecuted by non-state players), subsidiary protection (i.e., persons with a presumed risk of serious harm in their country of origin), or national ban on deportation (i.e., person that cannot safely return to the country-of-origin due to risks of life or health). A negative decision (rejection) requires a refugee to leave Germany, which can be temporarily suspended if obstacles to deportation exist.

1.3 Healthcare coverage of asylum seekers and applicants in Germany

Healthcare entitlements of asylum seekers are defined in the Asylum Seekers Benefits Act (Asylbewerberleistungsgesetz), which limits publicly funded health coverage to only loosely defined health problems for a period of 15 months after arriving to Germany, and include: medical treatments of acute pain, medical care necessary to recover from or to improve or alleviate ill health, as well as pregnancy-related care and vaccinations [8]. After 15 months – or once asylum applicants receive a positive decision on their protection status – healthcare coverage includes the same entitlements as for German citizens enrolled under Social Health Insurance (SHI).

During these 15 months, healthcare-related costs of asylum seekers incurred for entitled services are covered through public welfare funds administered by the local social welfare offices. Initially, asylum-seekers are assigned to reception centers organized by federal states and municipalities responsible for providing food, board, and other health and social benefits. Primary medical care in reception centers is provided by clinics located in these centers. Outside reception camps, healthcare is to be provided by health professionals working within the health system (i.e., general practitioners, specialists, hospitals, pharmacies, etc.) and accordingly reimbursed by the state or municipality under which an asylum seeker or applicant is registered.

Prior to 2015 and in order to reimburse healthcare costs, most federal states required asylum applicants within the initial 15-month period to first contact their local social welfare office to obtain a treatment voucher (Behandlungsschein) prior to be treated by a medical provider [22]. From 2015 onwards, increasingly more federal states opted to introduce an electronic health card system to replace treatment vouchers. This system is closely aligned to the access and reimbursement processes established within the SHI system.

1.4 Additional legal regulations related to the asylum-seeking process after 2015

Political responses to the 2015 migration wave resulted in the passing of new or amendments to existing immigration law. In October 2015, the Accelerated Asylum Procedures Act (Asylverfahrensbeschleunigungsgesetz) affirmed the obligation of the German SHI to cover healthcare costs of entitled asylum applicants and allowed federal states to adopt the electronic health card system to replace the voucher system [23]. Further, this Act recategorized a number of countries previously considered unsafe (e.g., countries along the Balkan Route) as “safe states”, thus limiting the legal right to asylum in Germany for migrants of or passing through these countries.

In March 2016, the Act for the Introduction of Expedited Asylum Procedures (Gesetz zur Einführung beschleunigter Asylverfahren) or “Asylpaket 2” limited health-related reason to include life-threatening conditions only in order to justify the halt of deportations of rejected asylum applicants [24]. As a result, diseases such as post-traumatic stress disorders (PTSD) are now no longer considered a legal obstacle to a pending deportation. Further, individuals with pending deportations are now presumed to be of adequate health unless they can provide a medical certificate prepared by a qualified physician addressing specific criteria (i.e., actual circumstances that led to such medical assessment, diagnostic methods used, the severity of the disease, and potential negative health effects in case of deportation).