🩺 Care level in cases of disability
In brief
Disability and need for care are legally two separate determinations with different procedures and bases for entitlement: the degree of disability is determined by the Versorgungsamt, the care level (Pflegegrad) by the Pflegekasse on the basis of an assessment by the Medical Service (Medizinischer Dienst, MD) under the New Assessment Instrument (Neues Begutachtungsassessment, NBA). Both procedures can run side by side independently of each other – a high GdB does not automatically mean a high care level, and vice versa.
After the application, the Pflegekasse generally has 25 working days for the assessment and decision; if this deadline is exceeded without an agreed extension, a compensation payment may become due.
Step by step
- Apply to the PflegekasseAn informal application to the Pflegekasse (usually housed at the health insurance fund), even by phone, is initially enough and secures the start of benefits.
- Attend the assessment appointmentThe Medical Service arranges an appointment, usually at your home, and assesses your independence in 6 areas of life under the NBA.
- Wait for the report and decisionThe Pflegekasse generally has 25 working days for the assessment and decision.
- Check the decisionCheck whether the care level granted reflects your actual impairment appropriately.
- Lodge an objection if neededIf the care level is too low or was rejected, lodge an objection within one month.
Deadlines
- An informal application is enough to secure the deadline and the start of benefits – do not wait until all documents are complete.
- Prepare for the assessment appointment: a care diary covering typical days helps the assessor realistically gauge the actual need for support.
- An objection can initially be lodged informally; the detailed reasons can generally be submitted within a few weeks – what matters is not to miss the one-month deadline itself.
- If you receive integration assistance at the same time in certain forms of housing, under § 103 SGB IX the Pflegekasse can pay a flat-rate amount to the integration assistance provider instead of providing the care benefit in kind directly – the practical delimitation is complex and, if in doubt, should be clarified with both providers.
In depth · legal basis, figures and practice – for advisers and professionals
Assessment procedure
The Medical Service assesses independence in the 6 modules of the New Assessment Instrument (mobility, cognitive and communicative abilities, behaviours and psychological problems, self-care, coping with and independent handling of illness- or therapy-related demands and burdens, organisation of everyday life and social contacts) and from this determines a care level from 1 to 5.
Deadlines and consequences of delay
Under § 18 Abs. 3 SGB XI the Pflegekasse must decide within 25 working days of receiving the application. If this deadline is exceeded for reasons the Pflegekasse is responsible for, a compensation payment may arise for the insured person; the details are regulated in § 18 Abs. 3a SGB XI.
Relationship to integration assistance
§ 103 SGB IX regulates the interplay of long-term care insurance and integration assistance: if a person with disabilities in need of care receives integration assistance in certain forms of housing, a flat-rate amount can flow to the integration assistance provider, which then also provides the care, instead of the care benefit in kind.
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