Apply for orthodontic treatment and reimbursement of the co-payment for orthodontic treatment from the statutory health insurance company
Statutory health insurance companies pay for orthodontic treatment for insured persons who have not reached the age of 18 at the start of treatment if the treatment is medically necessary.
The orthodontist assesses whether your child's treatment is medically necessary on the basis of so-called orthodontic indication groups (KIG) and their 5 degrees of severity. The statutory health insurance companies pay the costs for your child from severity level 3. This means, for example, that a jaw or tooth misalignment already significantly impairs your child's biting, mouth closure or joint function or threatens to impair it in the future.
The orthodontist settles the orthodontic treatment directly with the Association of Statutory Health Insurance Dentists, minus your own contribution. Your own contribution amounts to 20 percent of the costs of the contract doctor. If you have more than one child undergoing orthodontic treatment, your own contribution for the second and each additional child is reduced to 10 percent of the costs incurred by the statutory health insurance doctor. The prerequisite is that they live in the same household.
If the treatment is successfully completed, the statutory health insurance will reimburse you for your own contribution. To do this, you must submit an application to your health insurance company or your child's health insurance company and submit some documents, for example the final report of the orthodontist as well as the co-payment invoices with corresponding proof of payment.
Reimbursement of costs for adults
The costs for orthodontic treatment, which is started from the age of 18, can only be covered by the statutory health insurance in very few exceptional cases. These include, for example, severe jaw anomalies that also require surgical corrections. In these cases, your orthodontist will create a coordinated oral surgery and orthodontic treatment concept.
To reimburse the co-payments for orthodontic treatment, proceed as follows:
Standard care for children and adolescents:
- The orthodontist will diagnose your child's tooth misalignment from severity level 3 and draw up an orthodontic treatment plan. The orthodontic treatment plan includes:
- the planned therapeutic measures,
- the expected duration of treatment, and
- the estimated cost.
- The orthodontic practice submits the findings and the treatment plan to your statutory health insurance company or to the health insurance company with which your child is insured.
- Treatment begins when the relevant health insurance company has approved the treatment plan.
- During the treatment, the orthodontic practice settles 80 percent of the costs of the contract physician (in the case of several children from the 2nd and for each additional child 90 percent) directly with the responsible health insurance company. The practice will send you one invoice per quarter for the remaining 20 percent (or 10 percent if you have several children).
- You pay the invoice amount to the orthodontic practice.
- Keep the invoices of the orthodontic practice as well as the associated payment receipts.
- The orthodontic practice will issue a certificate of completion for you after the treatment has been successfully completed.
- You apply for reimbursement of the co-payment from the responsible health insurance company and submit the necessary documents. You can submit the application by post or – in the case of many statutory health insurance companies – in person at the office.
- Your statutory health insurance company will transfer the co-payments to you.
Exceptional indications in adults:
- Your orthodontist will send the coordinated oral surgery and orthodontic treatment concept directly to your statutory health insurance company.
- You are a member of a statutory health insurance company.
- In order to be reimbursed for the co-payment, your child must have successfully completed the treatment.
Which documents are required?
- Orthodontic treatment plan
- In order to reimburse the co-contribution, the certificate of completion from the orthodontist and the invoices for your co-payment are also required
What are the fees?
- You will not incur any costs for the application to the statutory health insurance company.
- If your child is being treated with services that go beyond what is medically necessary, you will have to pay for it yourself. This applies, for example, to tooth-colored brackets, smooth surface sealing or highly elastic wires made of special alloys.
What deadlines do I have to pay attention to?
As a rule, you do not have to observe any deadlines.
It usually takes about 2 to 5 business days to process.
For a quick processing and decision, the health insurance company must have the necessary information and, if necessary, the necessary documents complete and meaningful.
The health insurance company decides on applications in a timely manner, whereby the statutory processing deadline is observed in order to protect patients' rights.
Please note that the stated processing time is an average value of all health insurance companies. It may vary in individual cases. The exact processing time also depends on the complexity of the individual case and can be extended accordingly. The same applies if documents or records are sent by post to you or the health insurance company. If necessary, an expert opinion is required. This requires an additional 6 weeks.
Applications / forms
- Forms available: yes
- Written form required: no
- Informal application possible: no
- Personal appearance required: no
- Online service available: no
For further information and, if applicable, forms for the assumption of costs for orthodontic treatment via the health insurance navigator of the National Association of Statutory Health Insurance Funds
Technically approved by
Federal Ministry of Health (BMG)
Professionally released on
The text was automatically translated based on the German content.