Pflegeversicherung, Leistungsantrag bei der Pflegekasse stellen

• § 18 Sozialgesetzbuch Elftes Buch (SGB XI) – Verfahren zur Feststellung der Pflegebedürftigkeit

Procedure for determining the need for long-term care and applying for benefits in accordance with the German Social Code, Eleventh Book (SGB XI)

In order to claim long-term care insurance benefits, you must submit an application to the long-term care insurance fund of the insured person in need of long-term care. The prerequisite is that the need for long-term care has been established. The long-term care insurance fund will then determine a so-called care degree for the person in need of care.

Benefits

The long-term care insurance funds pay according to the categorisation for

• Care allowance
• Care services (home care assistance from an outpatient care service)
• Combined benefits from care allowance and benefits in kind
• Benefits for people in need of care in outpatient assisted living groups
• Day and night care
• Short-term care
• Substitute or preventive care
• Grants for remodelling and home adaptations
• Care aids and technical assistance
• Support services in everyday life
• Social security for carers
• Care courses for carers
• full inpatient care

Note: The Care Support and Relief Act (PUEG) has resulted in changes to the level of contributions to care insurance, the care support allowance and the level of care benefits.

Contact points

• Care insurance fund of the person in need of care (located at the health insurance fund)
• Association members of the private health insurance companies

Care reports

• Need for care

Authorised applicants

• the insured person
• another person authorised by the insured person
• the legal representative(s) or carer(s) of the insured person
• the parents in the case of minors

Further requirements

Long-term care insurance benefits are paid to anyone who has paid contributions for at least two years or was covered by family insurance.

none

Submit an informal application to the care insurance fund of the insured person or - if available - use the corresponding application form.

The following generally applies:

• The long-term care insurance fund is obliged to offer you a counselling appointment within two weeks (on request also at your home). If this is not possible, it must issue you with a voucher for a consultation at another suitable counselling centre.
• The long-term care insurance fund collects your specific data and forwards your application immediately to the Medical Service (MD) or to the Social Medical Service (SMD) in the case of those insured under the miners' insurance scheme.
• The MD or SMD will draw up a care assessment to determine the need for care and the level of care required. This takes place during a previously notified home visit.
• The long-term care insurance fund must generally make a decision within 25 working days of receiving your application, unless the shortened assessment period of one week applies. You will receive written notification of this. If the long-term care insurance fund does not make a decision within this period, you will receive EUR 70.00 for each week or part thereof that the deadline is exceeded. The deadline regulation does not apply if the care insurance fund is not responsible for the delay or if the person in need of care is in full inpatient care and is already recognised as care grade 2.

The private compulsory long-term care insurance companies commission Medicproof GmbH, which was founded specifically for this purpose, to carry out the assessment.

General assessment:

• Decision notice: no later than 25 working days after receipt of the application by the long-term care insurance fund
• initial benefits: from the start of the month of application at the earliest

Assessment when applying for care leave:

• for inpatient stays in a hospital or rehabilitation clinic: within one week of receipt of the application
• for stays in a home environment: within two weeks of receipt of the application

The MD must inform the applicant immediately in writing which recommendation he or she will forward to the long-term care insurance fund.

Objection (details in the notification)