If you have statutory health insurance, your way to a specialist is set to change. The federal government plans to guide people with statutory health insurance through the health system more strongly in future. Family doctors and pediatricians are to take on the central role as primary care providers. The direct way to a specialist practice that exists today is to become the exception.
The Federal Ministry of Health started the dialogue process on this on January 27, 2026. A draft bill from the ministry had been announced for summer 2026. By its own account, the ministry does not expect the first major effects before 2028.
What applies today
Under § 76 SGB V, people with statutory health insurance have free choice among licensed doctors. If you have back pain, you can go straight to an orthopedist. You do not need a referral for this, and family doctor models are voluntary. In private health insurance, free choice of doctor is not a question of law but of the plan.
In practice, this direct access has long been limited, not by laws but by waiting times. According to our study from 2024 with 125 specialist practices in Bielefeld, privately insured people got an appointment faster in around 25 percent of cases, on average about ten days earlier. The difference was greatest in dermatology and orthopedics. The results are available under appointments with specialists.
What is planned
The primary care system is to consist of three building blocks that together manage access to specialist care:
| Building block | Task |
|---|---|
| Family doctor or pediatric practice | First point of contact, initial assessment, referral and arranging an appointment with a specialist |
| Appointment service 116117 | Initial assessment by phone and arranging appointments as an alternative to the practice |
| ePA app | Digital initial assessment, electronic referral and appointment booking through the electronic patient record |
Only after this initial assessment is a targeted referral to a specialist to follow, if needed. The ministry describes the principle as “digital before outpatient before inpatient”. The ePA is to become the central hub: initial assessment, referral and appointment are to be stored there and visible to all practices involved.
The goal is clearly stated. Specialist capacity is to be used in a more targeted way, patients are to be guided better and specialist visits without medical necessity are to be avoided. Nina Warken, Federal Health Minister at the time, called the plan “something completely new” and an ambitious project. In the political debate, it is described as a paradigm shift.
Which exceptions are planned
Not every visit to a specialist is to require a referral in future. According to the status of the dialogue process, people are to be able to go directly to ophthalmologists and gynecologists, and to dentists as well. For people with certain chronic illnesses, it is being discussed whether the treating specialist, for example an oncologist or urologist, can take on the coordinating role.
How the guidance will be enforced is still open. Options under discussion are a bonus for insured people who follow the intended route, a fee for going directly to a specialist without an initial assessment, or no coverage of costs in that case. Which option will come is not certain.
Timetable
| Step | Status |
|---|---|
| Start of the dialogue process | January 27, 2026 |
| Draft bill from the ministry | announced for summer 2026, not yet presented |
| Cabinet decision | aimed for fall 2026 |
| First noticeable effects | according to the ministry, not before 2028 |
At the very start, the National Association of Statutory Health Insurance Physicians (KBV) pointed out that the change will not save money in the short term. Building the digital initial assessment, the appointment database and the ePA functions takes time. That is why 2028 is realistic as the earliest date for noticeable changes.
What this means for privately insured people
Private health insurance is not affected by this reform. Access to specialists there is not regulated by law but by the plan. Most comprehensive plans provide for free choice of doctor without a referral. There are also plans with a primary care principle, where the insured person goes to the family doctor first in return for a lower premium.
The difference lies in freedom of choice. In private health insurance, the insured person decides when taking out the contract whether they want direct access to specialists and pay for it. In statutory health insurance, the guidance would apply to everyone in future, regardless of contribution and preference.
If direct access to specialists becomes the exception in statutory health insurance, it gains weight as a plan feature of private health insurance. A faster specialist appointment is already one of the most common reasons why people with statutory health insurance think about switching in our consultations. In our satisfaction survey 2025 with more than 2,200 participants, 30 percent of statutory members interested in switching named shorter waiting times as the main reason, and 56 percent of people with statutory health insurance were dissatisfied with how specialist appointments are given.
If you are thinking about a switch to private health insurance, you should therefore pay attention to one point when choosing a plan: whether the plan provides for free choice of doctor or contains a primary care principle. The premium advantage of a primary care plan is smaller if access to specialists is also managed in statutory health insurance in future.
Our assessment
Guidance through the family doctor makes medical sense if it works. It fails if the family doctor has no appointments either. The ministry has recognized this problem and is therefore relying on 116117 and the ePA app as second and third access points. Whether the digital initial assessment will work reliably in 2028 is the open question of the reform.
For people with statutory health insurance, nothing changes until then. For privately insured people, nothing changes either, except that their plan feature gains value. Whether a switch is an option for you depends first on the requirements and on your health.
Conclusion and outlook
The federal government is planning a change of system in statutory health insurance: family doctor, 116117 or ePA app first, specialist second. Exceptions for ophthalmologists, gynecologists and certain chronically ill people are planned or under discussion. According to the ministry, this will not be noticeable before 2028.
Free choice of specialist remains a plan decision of the insured person in private health insurance. If it is restricted in statutory health insurance, it becomes one of the clearest distinguishing features between the two systems. We are following the bill and will update this news item as soon as the draft from the ministry is available.
