I will be sent for care
Applying for the care level correctly: you need to know that
The new definition of the need for long-term care
The second law on the strengthening of long-term care no longer differentiates between illnesses and their need for care as it used to, but considers the person in need of care and their health-related impairment of independence. The need for care is divided into five levels of care. The higher the need, the higher the level of care and the benefits associated with it.
Apply for a degree of care - this is how it works
All health insured persons are automatically insured for long-term care and benefits from social long-term care insurance can be requested from the relevant long-term care insurance company. In addition, long-term care insurance funds can help you find free, qualified advisors near your place of residence. Because with the second law on the strengthening of long-term care, which came into force over a year ago, an application for one of the five care levels is necessary.
Make an appointment with the MDK: The decision about the need for care is at the discretion of the care insurance fund. In the case of a legally insured person, the decision-making process is based on the expert opinion of the Medical Service of the Health Insurance (MDK). In the case of privately insured persons, medical experts from MEDICPROOF assess the need for care according to assessment guidelines and a personal conversation. The reviewers usually register for the appointment a few days before the review. It is important that the person in need of care and the main caregiver are present together at the appointment. The assessment can take place in an inpatient facility such as a clinic or rehab. However, it is recommended that the appointment takes place in your own home, because this way the local conditions can be taken into account for the report.
Prepare for the assessment date: If you would like to find out in advance which care level may be assigned, we recommend using an online care level calculator. You can then already assess the need for care.
Clear description of the situation: To clarify the care situation, it is advisable to explain the situation to the expert using direct examples. In addition, a specialist present such as a carer or a relative can provide competent information, provided they are familiar with the care situation. Information that is as precise as possible will help the expert with a very specific assessment of the need for care and the care situation.
What else is important for the appointment? When assessing the degree of long-term care, the experts adhere to 64 key questions. Keeping a care diary plays an important role here, because good documentation reflects the care situation and can help in the event of an objection to a possibly too low classification. It is also advisable to take a look at the New Assessment Assessment (NBA). It is an appraisal procedure that is based on knowledge of nursing science. The NBA is therefore recommended as a guideline for keeping care diaries.
Sample for an informal application for long-term care insurance benefits
I hereby apply for benefits from long-term care insurance for:
Application for degree of care: where and how do you apply?
Applying for a care level by telephone: Call the insured person's long-term care insurance to apply for a care level. You or the applicant will then receive a form that has to be filled out. This can be done by the insured himself or by his or her legal guardian. The application must be signed and sent back to the long-term care insurance. Shortly afterwards, an appraiser should register for a personal assessment.
Apply for care level in writing: You can also submit an informal application for care benefits to the care fund. There are a number of free sample letters that you can download from the Internet.
Apply for the level of care at the care support center: If you prefer to apply directly on site and in person, you can visit a care support center (also together with your relative). As a rule, you will receive advice there and then submit an application for care benefits.
After the appraiser's visit
After the expert's visit, the long-term care fund sends a notification to the applicant with the result of the expert's assessment and the decision of the long-term care fund. In addition, the days of the request, application, assessment and decision should be noted on the notification. In the event of approval, the long-term care insurance fund pays the subsidies retrospectively directly to the nursing service or the nursing home, if benefits have already been used there.
Application for care level 1 and 2
The five care levels result from the result of the report and a point allocation of a maximum of 100 points. For care level 1, there must be a "minor impairment of independence or skills" and a result of at least 12.5 points. If there is a "significant impairment of independence or skills" and a result of at least 27 points, the requirements for care level 2 are considered to have been met.
Application for care level 3 to 5
If the expert comes to the conclusion that there is a "severe impairment of independence or skills" and a score of at least 47.5, the long-term care insurance fund generally grants care level 3. Similarly, the expert speaks of "most severe" for care level 4. Impairments and a minimum score of 70. If the result is 90 or more points, there is a "most severe impairment of independence or skills with special requirements for nursing care".
Upgrading the level of care
An application for upgrading the care level can be worthwhile even with small changes in the care situation. Because with the Second Care Strengthening Act, among other things, the assessment of self-sufficiency, follow-up care after an accident as well as social contact care has moved more or for the first time into focus. However, a reassessment of the care situation can also have the opposite effect and the degree of care stinks or is completely denied.
A conversation with the staff in the nursing home or the outpatient nursing service can help with the decision to submit an application to upgrade the nursing level. They do not have any decision-making power, but because of their daily relationship with different people in need of care, they have broad experience. In addition, their view of the situation can be more objective than that of a relative.
The procedure is analogous to that of the initial application. An informal letter requesting an upgrade must be sent to the long-term care insurance by the insured person or the authorized representative. This sends a form back, which the applicant returns, filled out. It can happen that an appraiser examines the care situation of the person in need and gives the care fund a recommendation. The decision, however, lies with the long-term care insurance fund, not the expert.
Benefits are also paid retrospectively
It may take a few weeks for you to receive a notification from the long-term care insurance. However, if your degree of care is approved, your benefits will in any case be paid out retrospectively. For example, if you applied for benefits at the end of the month, you will retrospectively receive the entire benefit for the month in which you submitted the application.
The duration of the care must probably be longer than six months
According to Section 14 (1), people who show “health-related impairments of independence or skills” and are therefore dependent on the help of others are deemed to be in need of care. "It must be about people who cannot independently compensate or cope with physical, cognitive or psychological impairments or health-related burdens or demands."
In addition, the expected duration of the need for care must be at least six months. If professional help is required after a hospital stay, for example, and the duration is expected to be less than six months, the health insurance company is responsible. If you do not receive a degree of care, the care fund does not pay any benefits.
Care level can be applied for in the hospital. As soon as your relative is in a hospital due to an operation or an illness and they may no longer be able to live independently and go about their everyday life, you should speak to the hospital's social services as soon as possible. In this way, you can achieve an urgent grading. This guarantees your relatives immediate benefits from long-term care insurance. An appraiser is only used afterwards. He examines whether the classification in a care level was correct or whether a new classification is necessary.
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