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Benefits due to long-term care from long-term care insurance (SGB XI) if necessary from social assistance funds

The risk of becoming in need of care can affect anyone. In principle, therefore, everyone is obliged to insure themselves against this risk with a social or private care fund.

Under the current legal situation, there is a need for long-term dependency on the part of persons who, because of illness or disability, need substantial assistance for the ordinary and regularly recurring daily activities. However, it is not illness or disability that determine the need for care that is decisive, but rather the resulting need for help in day-to-day operations.

As of January 1, 2017, the current care levels "0", 1, 2 and 3 for the classification of the care-deprivedness of persons affected have been replaced by the five new care levels 1, 2, 3, 4 and 5.

The medical service of the Health Insurance (MDK) is responsible for determining whether and to what extent there is a need for care. The MDK is commissioned by the responsible nursing care fund when an application for long-term care insurance benefits is submitted.

With the new NBA assessment instrument, the MDK uses the new nba assessment instrument to determine how independent a person is according to a points system. The following applies: The more points the person receives, the higher the level of care and the more care and care services the respective care fund approves.
The following classification of the care levels with the respective required scores applies:

  • Care level 1: Low impairment of self-employment (12.5 to less than 27 points)
  • Care level 2: Significant impairment of self-employment (27 to less than 47.5 points)
  • Care level 3: Severe impairment of self-employment (47.5 to less than 70 points)
  • Care level 4: Severe impairment of self-employment (70 to less than 90 points)
  • Care level 5: Severe impairment of self-employment with special requirements for nursing care (90 to 100 points).

The social assistance institution is also bound by the findings of the MDK. If someone is not covered by care insurance, the social assistance institution will call in the respective health authority with a request for an opinion on the need for care.

Patients are entitled to basic care and home care in kind (home care assistance)
Alternatively, it is possible to receive a care allowance if patients can use it to provide basic care and home care themselves.
A combination of money and benefits in kind (combined service) is possible.

The scope of care insurance also includes offers in case of prevention of the caregiver (home care), day or night care (partial inpatient care) as well as short-term care (temporary inpatient care).
Patients in need of care are entitled to care in full-time care facilities if home or semi-stationary care is not possible or is not considered because of the specificity of the individual case.
In addition, care aids and technical assistance, grants for measures to improve the individual living environment as well as care courses for relatives and volunteer carers can be granted.
Carers or caring neighbours and friends may, where appropriate, receive social security benefits for the carer in the form of contributions to the relevant pension insurance institution.

The long-term care insurance benefits are covered by the long-term care insurance depending on the type of benefit up to certain limits that you will receive from your care fund in the specific case. In the case of full-time care, the costs of accommodation and meals, which you would also have to bear in the home environment, are not covered.
If patients are unable to cover uncovered residual costs, social assistance benefits (SGB XII) may be eligible.
However, social assistance as state aid only occurs if and to the extent that self-help and the help of dependants – usually relatives in a straight line or spouse – are not sufficient.

Source: Serviceportal Niedersachsen (Portalverbund des Bundes und der Länder)

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