“Need for long-term care” is interpreted uniformly in long-term care insurance. Legal criteria and a nationally coordinated assessment procedure guarantee the conditions under which this can be assumed for sick people. This ensures that benefits are granted and long-term care insurance funds are distributed fairly.
Standards for the need for care
The prerequisite for the need for long-term care is that there are health-related impairments to independence or abilities and the sick person therefore requires help from other people. The illness that causes the need for assistance is irrelevant. Restrictions due to physical illnesses are taken into account in the same way as impairments due to mental or psychological illnesses. For example, someone who has lost their independence due to dementia (e.g. Alzheimer’s disease) and therefore requires care, supervision and guidance in everyday life can also be classified as needing care, as can someone who has lost their physical mobility due to a physical illness (e.g. rheumatism, arthrosis, loss of sight) or due to an accident.
In the following six legally defined areas, the extent to which independence or abilities have been maintained despite impairment must be determined. This applies regardless of the respective living environment:
- Mobility,
- mental and communication skills,
- Behavioral and psychological problems,
- Self-catering,
- Coping with and independently dealing with illness- or therapy-related demands and stress, and
- Organization of everyday life and social contacts
For each of these six areas, there are legally described individual criteria for which the remaining independence or the remaining abilities are to be determined.
In addition, all six areas already take into account whether and to what extent the health restrictions on independence or abilities also require assistance with household management. A distinction is made between activities outside the home and the actual running of the household.
Note: If the need for assistance only exists for a short period of time, for example after a serious illness, this does not yet lead to a need for care. The requirement is a need for assistance for at least six months since the onset of the health impairment. This is assessed in advance. A shorter period only applies if an expected lifespan of less than six months is assumed. If therapeutic and rehabilitative measures are expected to reduce the extent of the need for care, recognition can be limited in time.
The assessment procedure
The six areas form the basis for the assessment procedure of the Medical Service or other experts commissioned by the long-term care insurance fund. Nationally applicable guidelines specify how the individual criteria in each area are to be assessed and what is relevant for determining the need for care. This is because, in addition to the duration of the required assistance, its extent also plays an important role. The combination of the partial results from the six areas results in the care degree. In future, there will be a total of five care levels. A need for assistance below the legally defined threshold does not lead to a need for care within the meaning of long-term care insurance. The need for assistance then falls under the personal responsibility of the person with long-term care insurance. However, there may be an entitlement to benefits from social welfare or other service providers.
The application for care services
Anyone applying for long-term care insurance benefits for the first time after December 31, 2016 should use the special form, which we will be happy to send you on request. The form asks for some data that we need for organizational reasons in order to process the benefit application quickly. A medical certificate confirming the need for care is not required.
Once we have received your application, we will offer you individual advice. We look forward to you taking advantage of our offer and will be happy to answer your questions in a personal meeting.
The appraisal
If long-term care insurance benefits are applied for for the first time, the severity of the health-related impairment of independence and abilities is determined as part of an assessment procedure. As a rule, we obtain an expert opinion from the Medical Service for this purpose. In order for the assessor (a doctor or care professional) to gain an accurate picture of the individual care needs of the person in need of care, they must also gain a personal impression of their social environment, e.g. their living and care situation. For this reason, the assessor must make a home visit, which is of course announced in advance. In the case of inpatient care, the assessor will visit the care home. Only in exceptional cases can the home or nursing home visit be waived.
There is a certain amount of time between your application for benefits and our decision on your entitlement to benefits because the assessment is processed carefully in the interests of the applicant. You will receive our written decision as soon as possible after your application. In particularly urgent cases (e.g. in the case of an initial application for full inpatient care), this will even take place within 25 working days of receipt of your application.
Assessment of the need for care
Depending on the severity of the health-related impairments to independence and abilities, each person in need of care is assigned to one of five care levels. The assessors from the Medical Service determine which level of care is appropriate in each individual case.
In a first step, a score is determined for each individual criterion separately for the six areas. In the second step, these scores are added up for each area and weighted according to a legally prescribed table. In the third step, the individual weighted total scores are added together. The result determines the extent of the need for care and the allocation to one of the five care levels.
At first glance, this procedure seems quite complicated. However, it is precisely the extensive individual assessments that generally guarantee the quality of the reports and lead to a fair allocation to the care level that actually applies.
Need for care for children
The basic principles for determining the level of care for adults also apply to children. However, there are some special features here. For example, the assistance required by the child in need of care must be compared with the assistance required by a healthy child of the same age. Only the additional need counts as a health-related impairment of independence or abilities. The points system is also different for children up to the age of 11.
Deviations also apply to children up to 18 months of age, as they naturally require all-round care. For this reason, only areas 3 “Behavior and psychological problems” and 5 “Coping with and independently dealing with illness- and therapy-related demands and stresses” are assessed for them. In addition, area 4 “Self-care” includes the question of whether there are serious problems with food intake that require exceptional care-intensive assistance in the area of nutrition. Finally, these infants are classified one care level higher across the board.
The degree of care awarded remains decisive up to the age of 18 months. After that, the regular classification is made without a new assessment. However, early applications for upgrading will be reassessed and appropriate reassessments will be arranged. The special features in the case of exceptional needs also apply to children. Our advisors will be happy to explain the details to you.
The expert opinion as a basis for decision-making
The assessor comments on the need for care and the level of care and also prepares a separate prevention and rehabilitation recommendation. We attach this to our benefit decision and also explain which prevention and rehabilitation measures are indicated. If the applicant agrees, we will contact the relevant rehabilitation provider, who will then take the necessary steps to implement the measure. We also explain the reasons for a negative rehabilitation recommendation from the assessor to the applicant in a comprehensive and understandable manner.
The BKK care insurance fund generally follows the recommendations of the assessor when deciding on the need for care and the degree of care. Every BKK policyholder who has applied for long-term care insurance benefits will receive a written decision from us with specific details of their entitlement to benefits. We also attach the expert opinion to the notification – unless the insured person has objected to this during the assessment.
A repeat assessment recommended by the Medical Service will be arranged by the BKK care insurance fund on its own initiative at the specified time. If a greater need for assistance arises beforehand due to a deterioration in the state of health, the person in need of care can of course also initiate an earlier reassessment.
Care advice
The BKK nursing care insurance fund evaluates each individual report from the medical service in detail. In particular, information on the assistance required and the provision of aids or measures to improve the living environment are also taken into account. The BKK advisors use this information to advise those in need of care and family carers personally on their care situation, to organize care and, if necessary, to help them apply for benefits from other service providers.
However, even before the assessment, the BKK offers all first-time applicants, as well as with each further application for special services, a consultation appointment regarding care within 14 days of receipt of the application. For example, questions about the scope of services of the long-term care insurance, the realization of the benefit claims, also considering necessary own contributions, and the organization of the care are answered.
We will be happy to meet your request if you would like to receive advice in your own environment or in the facility where you live. If you also wish, our counseling service is also available for your relatives or other people close to you. However, it can also be used at a later date.
This form of comprehensive care advice has been part of the BKK care insurance funds’ self-imposed standard for years. If the responsible state authorities deem it necessary, care advice can also be offered jointly with those involved in care provision in so-called care support centers. We will be happy to inform you personally whether this service is available in your region.
Start of services
Persons in need of care receive benefits from the long-term care insurance from the time of application to the BKK and at the earliest from the beginning of the need for care. This applies regardless of the duration of the assessment procedure. If the need for care already existed in the month before the application for benefits, the BKK long-term care insurance fund will provide benefits from the beginning of the month of application.
If a reassessment reveals that the requirements for a higher care level were already met earlier, BKK policyholders receive the higher benefits retroactively. If the state of health has improved and the applicable care level is therefore lower, the BKK care insurance fund will adjust its benefits for the future.
Quality and evaluation reports
Quality and evaluation reports on the individual programs can be found at www.bkk-medplus.de.
