What the insurer pays where care is needed

Since 2018 the benefits catalogue of the statutory health insurance has included dental preventive services of their own for people who need care or receive integration assistance. They are little known, and they are therefore rarely claimed — even though it is precisely this group that has the greatest need.

Who is entitled

• People with a care level from 1 to 5
• People entitled to integration assistance under the Social Code
• People whose everyday competence is permanently and considerably restricted

The entitlement exists regardless of whether someone lives at home or in an institution.

What is included

• An examination of the oral cavity twice per calendar year, with a record of the state of oral health.
• An oral health plan. It records in writing how the mouth is to be cared for, which aids are needed and who takes on which step. It is expressly addressed to the carers as well.
• Instruction for the carers — practical, on the person being cared for, not as a leaflet.
• Removal of hard dental deposits twice per calendar year instead of once.

The oral health plan is the most valuable part of this, because it clarifies responsibility. In home care, oral care often fails not for lack of will but because nobody knows exactly what is to be done and with which aid.

When the journey to the practice is no longer possible

Dentists may bill for home visits if someone cannot attend the practice for health reasons. Beyond that there are cooperation agreements between practices and care institutions: the practice then looks after the institution regularly on site, with fixed appointments instead of individual visits in an emergency.

What is possible in a flat or a care home room has limits — there is no treatment chair, no X-ray equipment and no suction as at the practice. Examination, advice, removal of deposits, simple treatments and the adjustment of dentures are feasible. For anything larger the journey to the practice is needed, if necessary with patient transport, which can be prescribed where there is a corresponding indication.

How to get it

1. Ask expressly at the dental practice about the services for people with a care level. They are not offered automatically.
2. Provide evidence of the care level — the decision letter from the care insurance fund is sufficient.
3. Ask for the oral health plan and pass it on to everyone involved in the care.
4. Where there is immobility, clarify whether the practice makes home visits. If it does not, the regional association of statutory health insurance dentists can help with the search.
5. In an institution, ask whether a cooperation agreement with a practice exists. If not: the institution can enter into one.

Dentures and the hardship provision

Where income is low, the health insurer covers twice the fixed contribution for the standard care, and in certain cases the full cost of the standard care. The decisive factor is income limits, which are adjusted annually; anyone receiving basic security benefits, social assistance or citizen's income generally falls below them.

The application is made before the start of treatment, together with the treatment and cost plan. That matters: after the event, the hardship provision is hard to obtain.