Apply for a subsidy for dentures or assumption of costs for a different type of dental prosthesis for people with statutory health insurance

You receive subsidies from your statutory health insurance for dentures. Only in exceptional cases will the health insurance fund cover the cost of implants. Insured persons with a low income may receive financial support.

If you need dentures, your dentist will advise you on the most suitable treatment. He or she will draw up a treatment and cost plan for dentures required for dental treatment. This documents the expected material and laboratory costs as well as the dentist's fee. The treatment and cost plan also serves as an application to your statutory health insurance provider for reimbursement of the costs of dentures.

Subsidy for dentures

Your statutory health insurance company will provide you with fixed subsidy amounts for your dentures. These are called fixed allowances based on the diagnosis, because their amount depends on the diagnosis - for example: "missing tooth". The amount of the subsidy is the same for all insured persons with the same diagnosis. The subsidy from your health insurance company is 60 percent and can increase if you have had regular check-ups and the check-ups are documented in your bonus booklet.

The amount of the subsidy is based on the so-called standard care. Standard care is something like standard or basic treatment.

• The subsidy from the health insurance company can increase to 70 or 75 percent if you have had regular dental check-ups in the last 5 or 10 years before the start of treatment and can prove this with your bonus booklet.
• Depending on the amount of the treatment costs, the co-payment may represent an unreasonable burden for you. People with a low income then have the option of applying to their health insurance provider to have a case of hardship assessed. If the hardship case is approved, the subsidy from the health insurance companies can increase to up to 100 percent of the costs of standard care.

Costs that exceed the statutory fixed reimbursement amount must be borne by you as your own contribution.

Similar and different dentures

If your treatment differs from the standard treatment, this is referred to as similar or dissimilar dentures.

A "similar restoration" is when additional elements are added to the actual standard restoration. These can be additional ceramic veneers, for example. These elements are not included in the fixed allowance. You must therefore pay for the additional services yourself.

The fixed allowance system also includes the term "different treatment". This refers to a deviation from the standard treatment. Here is an example: If you have 5 missing teeth in the upper jaw, the standard treatment includes a partial denture. If you opt for two bridges instead of the partial denture, this is considered a different type of restoration.

Billing is then carried out as follows: Your dentist will invoice you for the dentures based on the scale of fees for dentists (GOZ). Your health insurance company will then pay you the subsidy on application, which is based on the costs of standard care.

Exceptional indications

The statutory health insurance companies will cover the costs of a dental implant and the implant operation for so-called exceptional indications in particularly severe cases. These are severe jaw diseases such as jaw defects caused by accidents or cancerous tumors as well as genetically caused missing teeth. In order to check whether such an exceptional case exists and whether the costs can be covered as part of overall medical treatment, the health insurance company must have an assessment carried out.

• Treatment and cost plan
• Bonus booklet, if applicable (copy)
• If applicable, invoices from the dentist including laboratory invoices
• Cost estimate, if applicable

In case of hardship:
Proof of your monthly income, if applicable, proof of income of other relatives living in the same household.

• You have statutory health insurance.
• The treatment and cost plan was approved by the health insurance company before the start of treatment.

• Objection
• Complaint
  

You can submit your application for a subsidy and cost coverage for dentures by post or - with many statutory health insurance companies - in person at the office or online.

Standard care and subsidy for dentures:

• Your dentist will draw up a treatment and cost plan for you.
• If available, you submit this to your health insurance company together with your bonus booklet.
• Your health insurance company will check the treatment and cost plan and send you a decision.
• Treatment can only begin once your health insurance company has approved the treatment and cost plan.
• Once the treatment has been completed, your dentist will settle the fixed allowance directly with your health insurance company. You will receive an invoice from your dentist for your own contribution.

Other types of treatment:

• Your dentist will draw up a treatment and cost plan for you.
• If available, you submit this to your health insurance company together with your bonus booklet.
• Your health insurance company will check the treatment and cost plan and send you a decision.
• Treatment can only begin once your health insurance company has approved the treatment and cost plan
• After treatment, you will receive a private invoice from your dentist for the total cost of the dentures. You submit this to your health insurance company for reimbursement of the fixed allowance (direct billing).
  • Exceptional indication: For implants in connection with exceptional indications, your dentist will prepare a treatment and cost plan including a treatment and cost plan for dentures.
  • Your dentist will either send the treatment and cost plan directly to your statutory health insurance fund or give it to you for submission to your statutory health insurance fund.
  • Your statutory health insurance company will check the application and inform you.

In case of hardship:

• To receive dentures with no or a lower co-payment, apply to your health insurance company for a so-called hardship case.
• Fill out the form to apply for a hardship case for dentures. You can obtain this from your health insurance company.
• In the hardship application, you must, for example, state your income and the number and income of people living in your household. Your health insurance company will check your application and send you
  • an approval or
  • a rejection notice.

As a rule, you can start dental treatment up to a maximum of 6 months after the health insurance company has approved the treatment and cost plan.

Processing normally takes around 2 to 5 working days.

In order to process and decide quickly, your health insurance fund must have the necessary information and any required documents in a complete and meaningful form.
The health insurance company decides on applications promptly, whereby the statutory processing period is adhered to in order to protect patients' rights.
Please note that the processing time stated is an average value for all health insurance companies. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and may be longer. The same applies if documents or records are sent to you or your health insurance company by post.

An expert opinion may have to be obtained. This will take up to an additional 6 weeks to process your request.

• You do not have to pay anything for applications to your statutory health insurance provider.
• As a rule, you are responsible for any costs that exceed the fixed allowance based on the findings. Hardship regulations may reduce or eliminate the personal contribution.