Applying for care benefits

Anyone can need care at some point in their life. Many people find it difficult to care for themselves as they age. However, children, adolescents and those of middle age may also require care and support as a result of accidents, disabilities or chronic illnesses, for example.

To ensure that people in need of care are well looked after, they can apply for long-term care insurance benefits. These are called care benefits. They can include non-cash and financial benefits.

However, insured persons are only entitled to these benefits if they have been insured long enough in the social care insurance scheme. This required contributory period is at least 2 years within the last 10 years before the claim is submitted. In addition, the person must be determined to be “in need of care as defined by the long-term care insurance fund.”

Persons applying for care benefits for the first time, must first verify if there is such a need for care. An important part of this verification is an assessment performed by the medical review service or an assessor. This care assessment usually takes place at the applicant’s home. If an application is submitted for a higher care grade, this is also verified by a care assessment.

The application entitles the applicant to qualified care advice. It is advisable to take advantage of this support. Among other things, care advice helps the applicant complete the application and prepare for the care assessment. It also assists in selecting the services and support that are necessary for one’s own situation.

The application for care benefits can be made informally. This means that it is sufficient to communicate a sentence such as “I hereby apply for care insurance benefits” to your long-term care insurance fund or private long-term care insurance in writing or verbally.

You can submit the application by mail, telephone, fax or email. If you submit the application by telephone, you will have no record of when the application was made. It is therefore advisable to bring the application in person to a customer service center or to present it verbally and obtain confirmation of receipt there. If you make the request in writing, you can safeguard your application by sending it to the long-term care insurance fund by registered mail with a return receipt requested.

Submit the application as early as possible. The time of application is crucial because benefits will be made available from then on. No benefits will be paid retroactively, i.e. for a period prior to the application.

Persons with statutory health insurance can contact the long-term care insurance fund through their health insurance, as they are affiliated. Privately insured persons can submit an application to their private care insurance company.

If the person in need of care is unable to submit the application themselves, others can be granted power of attorney to submit it. Proof of authorization must be submitted to the long-term care insurance fund, otherwise the application will be deemed not submitted. For example, a copy of the power of attorney or the care certificate may fulfill this requirement. 

Next steps

The long-term care insurance fund will then send you the following documents:

• An application form
• An appointment for care advice or an advice voucher

In the application form, you must provide information about yourself and the care benefits you wish to receive.

Consumer advice centers offer a template form with explanations of essential terms and step-by-step instructions on how to fill out the application form.

The care assessment is mandatory, as it determines whether care benefits are necessary and, if so, to what degree. To do this, the long-term care insurance fund commissions an assessor, for example from the medical review service. Private long-term care insurance commissions the medical review service of the private health insurance companies, MEDICPROOF.

The assessor will offer you an appointment. You can postpone this appointment if you have or your caregiver has a scheduling conflict because of other appointments. It is advisable to do this only for very important reasons, because if you postpone, the long-term care insurance fund is no longer bound by the statutory assessment deadlines. You may then have to wait a very long time for a new appointment. If you refuse the assessment, the long-term care insurance fund can reject your application.

It is advisable to prepare thoroughly for the care assessment. This can help you to be correctly classified. Care advice can also provide support in this regard.

Since you must state on the application form the services you would like to receive, it makes sense to start thinking about how the care will be arranged early on.

Important questions include:

• Should care be provided at home or in an inpatient facility?
• Should and can relatives provide care at home for a longer period of time? To what extent might the help of outpatient care or support services be required?
• Should special needs be considered, for example, religion, ideology, culture, or same-sex care?
• Is special assistance needed because of an illness or disability, for example, for basic care, attending school, professional training or on the job?
• What services and offers are available for family caregivers to support and relieve them during periods of care giving?

It is usually a good idea to seek the support of a professional care advisor when answering these questions.

Qualified care advice is offered, for example, by care support points, care advice centers of the municipalities, social and welfare associations, as well as by the care insurance funds themselves.

The Center for Quality in Care Foundation (Stiftung Zentrum Qualität in der Pflege) provides a database of advice centers in your area.

It has also developed a checklist with criteria for recognizing good care advice.

People with private long-term care insurance can contact compass private pflegeberatung GmbH. It is an independent subsidiary of the German Association of Private Health Insurers (Verbands der Privaten Krankenversicherung) that provides advice on behalf of your private insurance company.

Legal entitlements

When you apply for care benefits, you are entitled to free and qualified care advice. Care insurance funds are obligated to offer you an appointment for care advice within two weeks of your application. Alternatively, you will receive an advice voucher that you can redeem at the advice center of your choice.

Relatives and other people, such as volunteer caregivers, are also entitled to free and qualified advice, provided the person in need of care has consented.

Topics of advice

Care advice centers advise you individually in order to adapt services and support as best as possible to your personal situation. Topics covered include:

• Benefits from care insurance, health insurance and other social insurance agencies: Which are possible and how can they be combined?
• Preparation for the care assessment: How does the home visit work? How can I help to ensure that all health conditions are properly recorded?
• Tips on care for specific illnesses: What are important precautions, for example, for dementia, stroke patients, or people with physical or mental impairments?
• Measures at home: Which aids, adjustments or renovations can be useful?
• Support for family caregivers: What are they entitled to? What relief and respite is available for them?

If desired, care advice can also be provided at home, in an inpatient care facility, in a hospital, in a rehabilitation facility or via a video call.

The long-term care insurance fund has 25 working days to process the application. Care advice is provided and the care assessment takes place within this period. By the end of this period, you will also receive the decision as to whether a need for care has been determined and the care grade that has been assigned to you.

Under certain circumstances, shorter deadlines also apply:

The long-term care insurance fund only has 5 working days from the date the application is submitted if the applicant is in hospital or in a rehabilitation facility and

• an assessment is required in order for the applicant to continue receiving care there, or
• the (future) caregiver has notified their employer that they are taking caregiver leave or family caregiver leave has been agreed.

In some cases, the long-term care insurance fund has a period of 10 working days from receipt of the application to complete processing of the application. This applies if the applicant is living at home without palliative care and if the (future) caregiver has notified their employer that they are taking caregiver leave or family caregiver leave has been agreed.

When the deadline is brought forward in such cases, the assessment must initially answer the following questions:

• Is the person in need of care?
• Are the conditions for assigning care grade 2 met?

The complete assessment must be carried out immediately afterwards.
In some cases, a stay in hospital or in a rehab facility is followed by a period of short-term care. The final assessment must then be carried out at latest on the tenth working day after the start of the short-term care period.

If the long-term care insurance fund does not meet these deadlines, it must pay 70 euros to the person making the application for each week that has begun.

However, this does not apply if

• the long-term care insurance fund is not responsible for the delay or
• the person is already residing in an inpatient care facility and is classified as care grade 2 or higher.

For more information, contact the long-term care insurance fund or the consumer advice centers.

If the application for care benefits has been rejected or the assigned care grade appears to be too low, it is possible to appeal the decision made by the long-term care insurance fund. The same rules apply as for the appeal against a decision by an insurance provider.

Reasons for appeal

To begin with, you only need to inform the long-term care insurance fund in a few sentences that you are lodging an appeal against their decision. You can use the sample letter provided by consumer advice centers for this purpose.

It is then important to carefully set out the reasons for your appeal. This is not mandatory, but increases the chance of success. The reasons do not have to be given within the appeal period. If the long-term care insurance fund sets a processing deadline, you can extend it in consultation with the long-term care insurance fund if, for example, you need more time to obtain medical documents.

The assessment is the basis for the decision made by the long-term care insurance fund. You should first read it and check whether its content is correct. If the long-term care insurance fund has not sent you the assessment together with their decision, you can request it from them. You are entitled to view it.

As with the assessment, when stating reasons for the appeal it is advantageous to have a rough understanding of the criteria used by the appraisers and how the care grade is determined.

Consumer advice centers offer an explanation of the process.

The care assessment may not be an accurate reflection of the reality of the care situation for one of the following reasons:

• Not all of the important issues were taken into account and recorded correctly and then weighted properly.
• The day of the assessment was not a normal care day because you were having an unusually good day.
• A particular support requirement may not have been noted.
• Your application was not accompanied by all important documents required (medication plan, doctor’s or hospital reports).

It is important that you give reasons for, or evidence of, each of your objections. Keeping a care diary can be helpful for this.

Care advice centers can also provide support in the event of an appeal.