Apply for orthodontic treatment and reimbursement of the co-payment for orthodontic treatment at the statutory health insurance
Statutory health insurance companies pay for orthodontic treatment for insured persons who have not reached the age of 18 at the beginning of treatment, if the treatment is medically necessary.
The orthodontist assesses whether the treatment for your child 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 or threatens to affect your child's biting, mouth closure or joint function in the future.
The orthodontist settles the orthodontic treatment minus your own contribution directly with the Association of Statutory Health Insurance Dentists. Your own contribution is 20 percent of the contract medical costs. 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 contract medical costs. The prerequisite is that they live in a common household.
If the treatment has been successfully completed, the statutory health insurance will pay you back 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 and the co-payment invoices with corresponding proof of payment.
Coverage 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, which also require surgical corrections. In these cases, your orthodontist will create a coordinated oral surgery and orthodontic treatment concept.
For the reimbursement of co-payments for orthodontic treatment, proceed as follows:
Standard care for children and adolescents:
- The orthodontist detects a malocclusion in your child from severity 3 and draws up an orthodontic treatment plan. The orthodontic treatment plan includes
- the planned therapeutic measures,
- the expected duration of treatment, and
- the estimated costs.
- 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 competent health insurance fund has approved the treatment plan.
- During the treatment, the orthodontic practice settles 80 percent of the contract medical costs (for several children from the 2nd and for each additional child 90 percent) directly with the responsible health insurance company. The practice will send you an invoice per quarter for the remaining 20 percent (or 10 percent if there are several children).
- You pay the invoice amount to the orthodontic practice.
- Keep the invoices of the orthodontic practice as well as the corresponding payment receipts.
- The orthodontic practice will issue a certificate of completion for you after successfully completing the treatment.
- You apply for reimbursement of the co-payment paid to the competent health insurance fund and submit the necessary documents. You can submit the application by post and – with many statutory health insurance companies – in person at the office.
- Your statutory health insurance company will transfer your own contributions.
Exceptional indications in adults:
- Your orthodontist transmits the coordinated oral surgery and orthodontic treatment concept directly to your statutory health insurance company.
- You are a member of a statutory health insurance fund.
- For the reimbursement of the co-payment, your child must have successfully completed the treatment.
Which documents are required?
- Orthodontic treatment plan
- For the reimbursement of the own contribution, the certificate of completion of the orthodontist or the orthodontist as well as the invoices for your own contribution 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 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.
Processing usually takes about 2 to 5 business days.
For a quick processing and decision, the health insurance company must have the necessary information and, if necessary, necessary documents complete and meaningful.
The health insurance company decides on applications promptly, whereby the statutory processing deadline is observed 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 documents are sent by post to you or the health insurance company. Where appropriate, an expert opinion is required. This takes up to 6 weeks in addition.
§ 29 Fifth Book of the Social Code (SGB V)
Applications / forms
- Forms available: yes
- Written form required: no
- Informal application possible: no
- Personal appearance required: no
- Online service available: no
The text was automatically translated based on the German content.
Technically approved by
Federal Ministry of Health (BMG)
Professionally released on