Eligibility Requirements for Benefits

To be eligible for long-term care insurance benefits, your family member in need of care must have paid into the social long-term care insurance system for at least two years during the past ten years or have been covered under a family policy.

People with private health insurance are generally also covered for long-term care by their insurance provider, although a separate insurance policy is taken out for private long-term care insurance. The benefits provided by private long-term care insurance are virtually identical to those provided by public long-term care insurance.

Keep in mind that statutory long- term care insurance always covers only a portion of the costs incurred. Long-term care insurance provides social protection against the risk that arises when a family member requires long-term care. Many expenses must also be paid out of pocket or, if necessary, by social welfare agencies.

Assessment of the Need for Care

The assessment of the need for long-term care is conducted during a visit by the local Medical Service (MD) or, for privately insured individuals, by Medicproof, a subsidiary of the Federal Association of Private Health Insurers.

The assessment focuses on the individual’s ability to manage daily life independently. A person is considered independent even if they perform an activity with the aid of an assistive device, such as walking with the help of a walker.

Submitting an Application to the Long-Term Care Insurance Fund

Anyone who wishes to receive benefits for the first time must submit an application to the health insurance provider or private health insurance company of the person in need of care. The application is then forwarded to the appropriate long-term care insurance fund. This can also be done by phone. You will then be sent the appropriate forms. This form must be completed and signed by the person in need of care or by an authorized representative.

If your family member is already receiving similar benefits from the workers’ compensation insurance association, the pension office, or the social services office, you should submit copies of those documents along with the application. This will help us process your application more quickly.

Long-term care insurance providers are required to offer personalized long-term care counseling to both the insured person and their family members. If desired, the consultation can also take place at home. In addition, your nearest care center can also provide assistance. A care resource center is a neutral, free point of contact for people in need of care and their family members, offering advice on all matters related to care, long-term care insurance benefits, and support services.

After you have submitted your application to the long-term care insurance fund, the Medical Service will contact you to schedule an appointment for the assessment. You must ensure that communication in German is possible. Otherwise, in addition to translators, friends or family members are also permitted to assist with the translation. The review will then generally take place within 20 days. If it takes too long, it’s best to call the Medical Service and explain your situation.

Evaluation by the Medical Service

The assessment usually takes place in the home of the person in need of care. As a family member, you have the right to be present during a visit by the Medical Service or Medicproof.

Here’s how the review process works:

• An introductory conversation describing the care situation. If there are several caregivers present, your family member may, if they wish, speak with the assessor alone at first.
• Review external findings relevant to nursing care , such as physicians’ reports, nursing documentation, transfer reports, notes made by nursing staff, and findings from previous assessments, if available.
• Document the patient’s nursing history (medical history) . In this context, the personal assessment of the person concerned is decisive. This includes current health problems, needs, specific stressors, as well as the onset and progression of illnesses that led to the disability.
• Identify existing assistive devices —that is, all care aids or technical aids that are available, even if they are not being used.
• Describe the healthcare and housing situation . Are there any circumstances related to your living situation that hinder your independence? What facilities are used? Does the care take place at a facility that provides a structured daily routine (school, workshop, day care)? The nursing staff’s on-duty hours are documented here, such as the distribution of nursing tasks among different staff members, including the type, frequency, and timing of each task. They also ask to what extent a caregiver is involved, whether the caregiver must remain within calling distance, or whether the person in need of care can be left alone.

It is helpful to provide a detailed description of your daily routine and to take a tour of your living space together. You should point out any special features.

Other questions that are not used to determine the care level relate to activities outside the home and household management.

When it comes to activities outside the home, it is important to consider, for example, to what extent the person in need of care can move from their apartment to the building’s entrance. Can she do this on her own, or does she need assistance? In addition, an assessment is made to determine whether the person in need of care can move about independently outside the home within a 500-meter radius. Is it possible to use public transportation or get into a car? Is it possible to participate in activities with other people?

In household management, the degree of independence in various household activities is assessed on a scale ranging from fully independent to completely dependent. The activities to be assessed include: shopping for daily necessities; preparing or reheating meals; light household chores such as washing dishes, setting the table, or folding laundry; and more strenuous household chores such as mopping, vacuuming, or cleaning windows.

Other questions include: Can household-related services or care provided by a home care agency be planned independently? To what extent can the person in need of care handle day-to-day financial and administrative matters?

Following the assessment, the evaluator provides recommendations on how to handle the care situation. The evaluation report, the resulting conclusion, and the specific recommendations are sent to the long-term care insurance fund. The assessor will not provide you with direct information about the outcome of the assessment . You must wait for the written notice of benefits (see below).