Long-term care and applying for a Pflegegrad

If you need substantial help with everyday life, you can apply for long-term care benefits. Contact the Pflegekasse attached to your statutory health fund, or your private compulsory-care insurer. Having care insurance does not automatically start the payments.

In short

• Care insurance supports people of any age; it is not only for older people. The assessment considers physical, cognitive and psychological limitations and the help needed in daily life.
• A Pflegegrad measures care needs. It is separate from a disability degree, a sick note or an earning-capacity pension.
• Apply promptly and retain the application date. Membership, qualifying insurance periods and an assessment still have to be checked.

Request benefits and advice

1. Contact the care fund through your health fund’s official contact details. Say that you are applying for Pflegeleistungen; an initial informal oral or written request is possible. Keep a dated written copy or ask for confirmation of the telephone application, then complete the fund’s form.
2. Ask the fund to check the qualifying insurance history. In social care insurance, section 33 normally requires two insured years in the preceding ten; family-insurance periods count. There are rules for children. Have the fund assess prior periods rather than assume that a newly issued health card proves entitlement.
3. Request Pflegeberatung under section 7a. Prepare questions about support at home, relief for relatives, care services and residential care. If discharge from hospital is imminent, tell the hospital’s discharge team and the fund immediately; ask about the applicable urgent assessment route.

Prepare for the care assessment

Under section 14, the limitations must be expected to last at least six months. You do not have to wait six months to apply; the assessment considers how long they are expected to last. Section 15 assesses independence in areas including mobility, communication and cognition, behaviour, self-care, handling treatment and organising everyday life. The grades run from 1 to 5.

Keep recent medical and discharge reports, the medication list, aids and a record of the help actually needed, including at night. Describe ordinary difficult days and what another person does for you. Ask a relative or carer who knows your routine to attend. Do not hide difficulties to appear independent. The statutory fund commissions the Medizinischer Dienst or another independent assessor; private insurance uses its assessment service.

Read the decision before arranging paid care

Keep the written decision and request the assessment report. Check the recorded needs, Pflegegrad, benefit start and what was approved. Ask the care adviser to compare cash benefits, services and combinations for your grade and situation, and what your carers would need to do. Care insurance does not necessarily meet the whole care bill: get a written cost estimate and ask which items remain yours before signing a service or home contract.

Arrange home care and support for relatives

In social care insurance, people with grades 2 to 5 can request Pflegegeld when they arrange appropriate care themselves under section 37. This is not an automatic wage for every relative. Ask the adviser to compare cash, care services and combinations and identify the required counselling visits; missing those visits can reduce or end care cash payments.

If you are the caring relative, tell the fund how many hours and days you provide care and about any paid work. Ask it to assess social-insurance support under section 44; being a relative alone does not establish eligibility. Ask about respite or backup care if you become ill, and talk to your employer about leave before changing your hours or giving up work.

If the decision seems wrong or needs change

For a statutory care-fund decision, read the remedy notice immediately. A domestic Widerspruch under SGG section 84 is ordinarily due within one month of notification; notification abroad has a three-month rule. Use an accepted signed written or qualifying electronic channel, or a statement recorded at the fund, and retain proof of receipt. Explain overlooked limitations with evidence and request help if the deadline is close. Ask for a higher-grade reassessment if needs have increased. A private insurer’s review and dispute routes follow that system; do not assume the statutory objection procedure applies to it.