Long-term care insurance; application for arbitration proceedings

In certain cases provided for by law, service providers and cost bearers in long-term care can appeal to the Arbitration Board in accordance with Section 76 SGB XI (Social Long-Term Care Insurance Arbitration Board) if they cannot reach agreement in negotiations.

If service providers and cost bearers fail to reach an agreement in negotiations, either party can appeal to the Social Care Insurance Arbitration Board regarding the points in dispute. Its office is located at the State Office for Long-Term Care. The Arbitration Board decides upon application and determines the content of agreements in the absence of agreement.

The Social Long-Term Care Insurance Arbitration Board is responsible in the following cases:

• Failure to reach agreement on inpatient care fees (= care rates) and outpatient care fees as well as on fees for accommodation and meals in care homes.
• Non-agreement on inpatient and outpatient framework agreements in accordance with § 75 SGB XI
• Reduction of care remuneration due to breach of duty in the provision of high-quality services.
• If, in the case of decisions to be taken jointly by the state associations of long-term care insurance funds with the working groups of the local social welfare providers or the supra-local social welfare providers, no agreement is reached with the representatives of social welfare in two consecutive resolutions (e.g. conclusion or termination of care contracts or conclusion of framework agreements in accordance with Section 75 SGB XI).

The following are not subject to arbitration

• the remuneration of additional services in accordance with § 88 SGB XI and
• investment costs in accordance with § 82 Para. 2 SGB XI.

The following information is required:

The parties to the proceedings before the arbitration board must be named, stating the respective long-term care insurance fund/working group or the respective supra-local social welfare provider with a summonable address.
The declaration that contract negotiations have definitively failed and therefore no agreement has been reached after one of the contracting parties has requested the corresponding negotiations in writing.
Information must be provided on the individual matters on which no agreement could be reached. The application must describe the results of the previous negotiations. The application should contain a specific request. This must be substantiated by submitting the relevant documents.

• Power of attorney, if applicable
• Additional documents may be required depending on the individual case. Please contact the State Office for Nursing Care.

It must be a matter for which the SGB XI provides for a decision by the arbitration board and the requirements set out in the respective facts must be met.

• 75 Para. 4 SGB XI: A framework agreement is not concluded in whole or in part within six months after one of the contracting parties has requested contract negotiations in writing (this also applies to contracts with which existing framework agreements are to be amended or replaced by new contracts).
• 85 Para. 5 SGB XI: A care rate agreement (nursing home) is not concluded within six weeks after one of the contracting parties has requested in writing that care rate negotiations take place or both contracting parties submit a joint application (possible before the end of the six weeks).
• 89 Para. 3 Sentence 4 SGB XI: A remuneration agreement for outpatient care services is not concluded within six weeks after one of the contracting parties has requested negotiations in writing or both contracting parties submit a joint application (possible before the end of the six weeks).
• 87 sentence 3 SGB XI: An agreement on fees for board and lodging in a nursing home is not reached within six weeks after one of the contracting parties has requested negotiations in writing or both contracting parties submit a joint application (possible before the end of the six weeks).
• Section 81 para. 2 sentence 2 SGB XI: If two resolutions are passed in succession, no agreement is reached between the state associations of long-term care insurance funds and the working groups of social welfare providers.
• § Section 115 (3) SGB XI: No agreement on the amount of the reduction in care remuneration due to a breach of duty in the provision of high-quality services.

Legal recourse against the Arbitration Board's decisions on remuneration issues is open to the social courts without the need for preliminary proceedings. The action must be brought against the Arbitration Board. The action only has a suspensive effect in the event of a reduction in remuneration.

The application to initiate arbitration proceedings must be submitted in writing to the State Office for Care together with the necessary documents. It must be signed by the requesting party/parties or by the respective legal representative or by a representative authorized by the respective party.

The Arbitration Board shall decide on the application. In an oral hearing, the arbitration board will first attempt to reach an amicable agreement between the parties. If this is not successful, a decision is made by resolution. If the parties agree, a decision can also be made in writing.

In the case of remuneration negotiations, the request for arbitration can be made at the earliest six weeks after a written request for negotiations, unless the contracting parties submit the request jointly (in which case the six-week waiting period does not apply); in cases of Section 85 Para. 7 SGB XI or Section 89 Para. 3 sentence 4 in conjunction with § 89 para. 3 sentence 4 SGB XI (unforeseeable significant changes to the assumptions on which the agreement or determination of the care rates or outpatient care remuneration was based), a determination of the care rates or outpatient care remuneration can be applied for after just one month.

In the case of framework agreement negotiations, the application can be submitted after six months at the earliest; in the case of decisions by the state associations of long-term care insurance funds together with the social welfare providers, as soon as no agreement is reached after two successive resolutions.

There is no time limit for the reduction of care remuneration in accordance with Section 115 Paragraph 3 Sentence 3 SGB XI.

Fees of EUR 260.00 to EUR 7,700.00 and the expenses pursuant to Art. 10 of the Costs Act are charged for the proceedings of the Arbitration Board