Benefit entitlements for those in need of care: Statutory long-term care insurance pays for people in need of care who apply for benefits or expenses incurred in connection with care.

Under what circumstances am I entitled to benefits?

Statutory long-term care insurance (gesetzliche Pflegeversicherung) pays for people in need of care who apply for benefits or expenses incurred in connection with care.

Everyone with sickness insurance either with the state or privately has mandatory cover for the nursing care in either the state or private insurance system.

Eligibility requirements

Nursing care benefits (SPV) may be only claimed by those who have paid contributions for at least two years or were family-insured for at least two years (qualifying period) and are in need of care.

In the meaning of the law, a person in need of care exhibits health impairments limiting their independence or abilities and therefore requires the help of others. It concerns people who are unable to compensate or manage their physical, cognitive or psychological impairments or health burden or tasks on their own. The need of care must exist either permanently or for an anticipated period of at least six months and be at least of the severity defined in § 15 SGB XI.

What am I entitled to and where can I apply for the benefits?

The nursing care insurance commissions the MD (Medical Service) or other independent assessors to establish whether the prerequisites of the need for care are fulfilled and what level of care is required. In the case of privately insured persons, the private insurance company instructs the assessors of MEDICPROOF.

Assessors (specialist nurses/doctors) visit the applicant and check as part of the assessment the degree of health impairments limiting their independence or abilities in six areas of their lives: mobility, cognitive and communicative abilities, behaviour and psychological problems, self-sufficiency, managing and dealing with challenges caused by illness or therapy and burdens independently, managing every-day life and social contacts.

For every criterion in the areas of life listed above, the degree of independence is evaluated on the basis of a points system. At the end, all points are added up and the total value (with different weighting) then corresponds to one of the five following care levels:

1. From 12.5 to below 27 total points is care level 1: little impairments of independence or abilities.
2. From 27 to below 47.5 total points is care level 2: significant impairments of independence or abilities.
3. From 47.5 to below 70 total points is care level 3: heavy impairments of independence or abilities.
4. From 70 to below 90 total points is care level 4: heaviest impairments of independence or abilities.
5. From 90 to below 100 total points is care level 5: heaviest impairments of independence or abilities with special requirements of nursing care.

Persons in need of care with special need constellations requiring a specific, extraordinarily high need for help with special requirements for nursing care, can be classed in care level 5 for reasons of care, even when the required total points are not accumulated. The Medical Service (Medizinische Bund) specifies the prerequisites justified by the need for care of these special needs constellations in their surveying guidelines.

In particular, elderly people want to show themselves to strangers “in their best light” and present themselves during the evaluation and assessment as more independent than they really are. Therefore, it is important to the assessor and their assessment that the carer (e. g. the spouse) or the responsible nurse (e. g. outpatient care provider) is present during the examination so that they can provide information.

Care benefits from social assistance: People with health impairments limiting their independence or abilities and therefore require help, have a right to “help for care”, provided they are also in financial need and do not receive similar benefits under other legal provisions (in particular, under SGB XI). This is only provided if the person in need of care cannot pay for themselves and does not receive them from others – e. g. the nursing care insurance.

In addition, for relatives providing nursing care and other unpaid caregivers, the nursing care insurance will under certain conditions pay their pension contributions, contributions to unemployment insurance and other support measures such as counselling or free training. Carers are under certain conditions insured without having to make contributions into the accident insurance.

Benefits in kind:

Nursing care insurance pays out relative to the applicant’s care level up to the amount of the established contributions to benefits in kind.

• outpatient nursing staff, caregivers or outpatient care staff who provide care and look after those in need in their home and do the housework;
• day-patient care and short-term care as well as inpatient care.

The support depends on the level of the need for care.

Where necessary, the applicant receives care equipment for care at home (e.g. disposable gloves, nursing bed), or special care measures to improve the living space, such as building alterations in the home, or subsidies towards these.

The care insurance benefits are paid for as long as the conditions are met. If the condition of those needing care worsens, they may apply for their care level to be reassessed by the medical unit.

Long-term care benefits from income support: Long-term care benefits are largely equivalent to the types of benefits provided by the statutory long-term care insurance but are not limited in amount. In the event of financial need, they are provided to cover requirements.

Financial support:

The insured parties must choose between financial and benefits and benefits in kind: Instead of moving into a nursing home or using the benefits in kind to pay the care services, the person in need of care or their relatives may organise the care themselves. The care insurance then pays a care allowance.

Those who prefer can also claim for only part of the care services and support arranged and paid for by the insurance and organise some of the care themselves. The care insurance pays a proportionate care allowance for this (combined benefit) on top of the pro-rata care benefits in kind.

Anyone (from care grade 2) who receives care benefits in kind or long-term care allowance for homecare is also entitled to day care/overnight care in a care facility.

For additional private nursing care insurance, a government grant of up to EUR 60 can be received per year, if the supplementary insurance complies with certain legal requirements.

Long-term care allowance from income support:

The amount of the long-term care allowance provided by “help for care” corresponds to the long-term care allowance provided by the social long-term care insurance.

Application forms

A person who is insured under a state health insurance scheme automatically also has care insurance.

Care insurance is organised as part of health insurance. Each care insurance is linked to a health insurance provider where insured people can apply for support from the care insurance. Care insurance providers have developed application forms that are often available online, but people can also apply informally.

Privately insured parties need to take out care insurance with their mandatory care insurance. Private insurance companies also offer optional insurance cover for additional private care. There are many different products on offer for this, with different conditions and prices.

Since 2013 it has also been possible to take out a state-funded supplementary care insurance. This special type of care insurance is linked to certain legal conditions. For example, health checks are therefore also ruled out; persons who have not yet required care cannot be rejected by insurance companies due to previous illnesses or age.

Your rights

European Commission publications: http://ec.europa.eu/social/main.jsp?catId=849&langId=en

Further information

You can obtain more information and advice from your health insurance or care insurance provider and the healthcare advice centre in your district, city or municipality. You can find a list of the state health insurance policies and plenty of other relevant information at http://www.gkv-spitzenverband.de/ on the site of the National Association of Statutory Health Insurance.

If you still have social security coverage in one or more countries besides Germany, please check whether this has an impact on your health insurance:

GKV Spitzenverband,
Abteilung Deutsche Verbindungsstelle
Krankenversicherung - Ausland (DVKA)
Pennefeldsweg 12 c
53177 Bonn
Tel.: +49 228 95300
http://www.dvka.de

You can find the Federal Ministry of Health at http://www.bmg.bund.de