Helga S. is entitled to benefits from the nursing care insurance because of her illness. The nursing care insurance is always located at the health insurance with which one is insured. The long-term care insurance fund determines the severity of the need for care by assigning the person one of the five degrees of care.
Who is considered to be in need of long-term care?
The term “need for care” is defined in the German Social Code (SGB XI). This defines the criteria for entitlement to care benefits under long-term care insurance. According to this, persons in need of care are “those who have health-related impairments of independence or abilities and therefore require help from others. They must be persons who cannot independently compensate for or cope with physical, cognitive or mental impairments or health-related burdens or requirements.” In addition, the need for care must be permanent, expected to last for at least 6 months.
Legislative changes: More focus on independence
As part of the Second Care Strengthening Act (PSG II), care levels 1 to 5 were introduced on January 1, 2017. These replace the previous three care levels. The main purpose of the legal changes was to help better meet the care needs of dementia patients, the mentally handicapped and those suffering from mental illness. As a result, the degrees of need for care are no longer based solely on the physical limitations of those affected, but also on how independently they can still manage their daily lives.
Care at home: entitlement to care benefits
To assess the impairments and abilities of the person in need of care, there are various criteria. In detail, these criteria for a claim to care benefits under the SGB are defined as follows:
- Mobility: changing position in bed, maintaining a stable sitting position, transferring, moving around within the living area, climbing stairs.
- Cognitive and communication skills: Recognizing people from the immediate environment, local and temporal orientation, remembering significant events or observations, controlling everyday actions, making decisions in everyday life, understanding facts and information, recognizing risks and dangers, communicating elementary needs, understanding prompts, participating in a conversation.
- Behavioral and psychological problems: motor behavioral abnormalities, nocturnal restlessness, aggressive behavior, resistance to nursing and other supportive measures, delusions, fears, listlessness with depressed mood, socially inadequate behavioral patterns
- Self-care: Washing the front upper body, personal hygiene in the area of the head, washing the intimate area, showering and bathing including washing the hair, dressing and undressing, preparing food and pouring drinks, eating, drinking, using a toilet or a commode, coping with the consequences of urinary incontinence and dealing with indwelling catheter and urostomy, coping with the consequences of fecal incontinence and dealing with stoma, nutrition parenterally or through tube
- Coping with and independently dealing with disease- or therapy-related requirements and stresses.
- In relation to medication, injections, care of intravenous access, suction and oxygen administration, rubs and cold and heat applications, measurement and interpretation of body conditions, body-related aids
- In relation to dressing changes and wound care, care with stoma, regular disposable catheterization and use of laxative methods, therapy measures in home environment
- In relation to time- and technology-intensive measures in the home environment, visits to the doctor, visits to other medical or therapeutic facilities.
- In relation to adherence to a diet or other disease- or therapy-related behavioral requirements
Also to be considered is the extent to which household management can still be managed.
Determination of the degree of care
The care degree of an affected person is determined by an assessor of the Medical Service of the Health Insurance (for statutory insured) or MEDICPROOF (for privately insured) on the basis of a point system:
| Care degree | Number of points | Degree of impairment |
|---|---|---|
| 1 | 12.5 to under 27 | Low impairment of independence |
| 2 | 27 to under 47.5 | Considerable impairment of independence |
| 3 | 47.5 to under 70 | Severe impairment of independence |
| 4 | 70 to under 90 | Most severe impairment of independence |
| 5 | 90 to 1000 | Most severe impairment of independence with special requirements for nursing care |
“Conversion” of long-term care levels to long-term care grades
People in need of care who were already in one of the three care levels before 2017 were not reassessed, but transferred to the new care levels. Here, the so-called Bestandsschutz applied, meaning that no one was placed in a worse position. The transfer of the care levels into the care degrees took place according to this scheme:
- Care level 2: Care level “0” with limited everyday competence and care level 1.
- Care level 3: Care level 1 with limited everyday competence and care level 2.
- Care level 4: Care level 2 with limited everyday competence and care level 3
- Care degree 5: Care level 3 with limited everyday life skills.
