Calculating the care level - Which care level am I entitled to?

The care assessment determines the extent to which care is required. As soon as you have submitted an application for care benefits to your care insurance fund, they will arrange an appointment with you for the assessment by the MD (medical service).

You submit this application either directly to your care insurance fund or to the care insurance fund of the person for whom you wish to apply for benefits. The long-term care insurance fund then commissions the medical service to draw up an expert opinion. This report clarifies whether and to what extent there is a need for care, i.e. whether or not an official care degree can be assigned.

Classification: The path to a care level

In order to benefit from long-term care insurance, you need a care degree. You can apply for this by submitting a simple application to your long-term care insurance provider. A care assessment will then be drawn up to evaluate your care situation. Once this process has been completed, the insurance company will send you a notification of your care level.

The application

Regardless of whether you are submitting an initial application or would like to increase your current care level, it is necessary to submit an application for a care level to your care insurance provider. The date on which the application is submitted is important as, if approved, your entitlement to benefits will apply retroactively from this date.

In acute situations, it is possible to obtain a rapid provisional care assessment within just 5 - 10 days by means of an urgent application.

The expert opinion

A care assessor from the medical service visits your place of residence, be it your home or the care home if you live there. They will assess the care situation on site, ask questions and may give initial advice on care or recommend aids.

In some situations, the assessment can also be carried out by telephone, either through a structured telephone interview or by video call.

The care assessment is then drawn up, which uses a standardized procedure to determine which level of care you should receive.

The decision

Although the expert opinion makes a recommendation, it is not the final decision, as this is made by the long-term care insurance company. Normally, however, the recommendation of the expert opinion is accepted. You will then receive your care degree decision together with the written report.

If you have been granted a care degree, your benefit entitlements apply. entitlement to benefits retroactively from the date of application.

However, it is possible to lodge an objection within 30 days if, for example, the care degree has not been recognized or you are not satisfied with the classification.

How points are assessed for a care level

The assignment of a care level determines which care services care services you are entitled to and is determined with the help of an expert opinion based on a points system.

In the event of a need for care, whether for you or one of your family membersthe type and amount of care benefits depends on the care level assigned, which ranges from 1 to 5, depending on the type of insurance. For people covered by statutory health insurance (GKV), compulsory social long-term care insurance (SPV), also known as long-term care insurance, is responsible. Those with private health insurance (PKV), on the other hand, are covered by private compulsory long-term care insurance (PPV) and receive their long-term care benefits through this.

The degree of care is calculated on the basis of a maximum score of 100, which is awarded by assessors. These assessors use a comprehensive list of questions and various criteria to evaluate the extent to which everyday activities can be carried out independently or what support is required. This concerns areas such as food intake, personal hygiene and mobility. The greater the restrictions in coping with everyday life, the more points are awarded and the higher the care level assigned.

Classification of the care level according to points

During the care assessment, assessors evaluate the level of support required and award points ranging from 0 (no care level) to 100(care level 5). These points serve as the basis for determining the level of care and enable people in need of care to claim financial benefits or care assistance.

Since the introduction of the second Care Strengthening Act [mfn]das zweite Pflegestärkungsgesetz[/mfn], people in need of care with mental impairments, such as dementia sufferers, receive the same level of benefits as applicants with physical impairments, depending on their level of care. The assessors indicate the degree of impairment as a percentage: The more points achieved, the higher the level of care.

A maximum total of 100 points can be achieved by meeting various criteria. The exact calculation procedure is complex, but care degree calculators can help to obtain a preliminary assessment.

The allocation of the care degree based on the points is shown below.

Degree of care: points table

No care level: 0 points - 12.5 points

Care level 1: 12.5 to under 27 points

Care level 2: 27 to under 47.5 points

Care level 3: 47.5 to under 70 points

Care level 4: 70 to under 90 points

Care level 5: 90 to under 100 points

The total score of 100 is made up of a large number of individual points in different modules, which together give the score.

There are also some special cases to consider:

1. Special needs constellation: An individual regulation applies here for people with special care requirements.
2. Degree of care for children: The assessment procedure and classification differ in part from those for adults.
3. Degrees of care for dementia: The assessment procedure takes appropriate account of people with dementia.

The special needs constellation

Sometimes, despite a high need for care, not enough points are achieved in the assessment for care grade 5. In such situations, however, the expert opinion can still award care level 5 due to a special constellation of needs and for care-related reasons.

This exception applies to people who can no longer use their arms or legs, meaning that they can no longer reach, stand or walk, even with aids. However, there may be a minimum level of mobility.

Degree of care in childhood

Also Children with special care needs also have the option of receiving a care degree. This must be applied for by the parents. The assessment process is similar to that for adults, but the special features of children are taken into account.

There are special regulations for different age groups:

1. Children under 18 months: As even healthy children of this age require comprehensive care from their parents, a natural need for care is assumed. For this reason, a higher level of care is always assigned during the assessment.
2. Children under the age of 11: At this age, many skills only develop over time and independence is naturally limited. For this reason, the assessment is not based on adults, but on the age-appropriate developmental stages of children.

Degree of care for dementia

When a person develops dementia, they soon need support in everyday lifeespecially with cognitive, emotional and social challenges. Physical limitations only occur in the later stages of the disease.

In the past, it was often difficult for people with dementia to be classified appropriately in the old system of care levels, as the focus was on daily care requirements in minutes. However, this was corrected with the comprehensive reform of the assessment process and the introduction of care levels in 2017.

The decisive criterion for the care grades is no longer the amount of care required, but the degree of independence. This means that dementia and mental illnesses no longer disadvantaged compared to physical limitations.

How the points for the care level are calculated

The assessment of your care needs is based on six different areas, which are reviewed by assessors to determine how independent you are in everyday life and which care level corresponds to your condition. No distinction is made as to whether you are in need of physical care or suffer from a long-term mental illness.

To determine your care level, an independent assessor will be sent to your home by the care insurance company.

If you have social long-term care insurance, i.e. are a member of statutory health insurance (GKV), the Medical Service (MD) will carry out this assessment. If you have private health insurance, the company MEDICPROOF will issue the relevant reports.

Depending on how severely your independence is restricted, an assessor will determine the appropriate care level, regardless of whether you are an adult or a child in need of care. If you are in need of long-term care (at least six months or longer), you will receive cash benefits or care benefits in kind from the long-term care insurance fund. Please note, however, that benefits from compulsory long-term care insurance are only paid after an application has been submitted.

Modules and criteria for the assessment

The total score of 100 in the care assessment is made up of various criteria in six modules. Different scores are awarded in each module. These evaluate different aspects of need for care and have different effects on the overall result:

1. Mobility: This assesses how independently the person being assessed can move around and change their posture.
2. Cognitive and communicative abilities: These criteria assess spatial and temporal orientation as well as the ability to make decisions, hold conversations and communicate needs.
3. Behavioral and mental health problems: It is determined how often the person concerned is affected by mental health problems. psychological problems such as aggressive or anxious behavior.
4. Self-care: The independence of the person being assessed with regard to daily personal hygiene is assessed here.
5. Coping and independent handling of illness- or therapy-related requirements and burdens: It is determined how often the applicant requires support in dealing with the illness and medical treatments, such as dialysis or changing dressings.
6. Organization of daily life and social contacts: These criteria assess the assessed person's ability to plan their daily routine and maintain social contacts.

In addition to these six modules, there are two further care degree modules: Activities outside the home and Household management. However, these two modules are not taken into account when determining the care degree.

Module 1: Mobility

Module 1 for determining the level of care deals with mobility and comprises five different criteria. These include, for example, repositioning in bed, the ability to maintain a stable sitting position and the ability to transfer or climb stairs. These criteria are assessed using a four-level scale:

• Self-employed (0 points)
• Predominantly independent (1 point)
• Predominantly dependent (2 points)
• Self-employed (3 points)

Module 2: cognitive and communication skills

Module 2 for determining the level of care relates to a person's cognitive and communicative abilities. Eleven different criteria are taken into account. These include the ability to orient oneself in time and place, to recognize people, to remember important events, to identify risks and dangers and to participate in conversations. These abilities and impairments are assessed on a scale with four levels:

• Ability present/unimpaired (0 points)
• Ability largely present (1 point)
• Ability available to a small extent (2 points)
• Ability not available (3 points)

Module 3: Behavioral and psychological problems

The scale for assessing the frequency of observed behaviors and mental health problems in Module 3 for determining the level of care usually comprises four levels. These levels could be defined as follows:

1. Never or rarely: The observed behavior occurs only occasionally and does not pose a significant challenge to care. (0 points)
2. Occasional: The behavior occurs from time to time, but can usually be managed by appropriate measures. (1-3 times within two weeks 1 point)
3. Frequent: The behavior occurs regularly and requires repeated measures to be taken by the nursing staff. (2 to several times a week, but not daily 3 points)
4. Very frequent: The behavior occurs very often and poses a considerable challenge for care, requiring continuous monitoring and intensive care. (5 points)

This scale enables a differentiated assessment of the severity and frequency of the observed behaviors, which in turn is helpful in determining the level of care.

It is noticeable that a higher score is awarded for more pronounced behaviors compared to other modules. This ensures appropriate consideration of the particular significance for everyday care, as the scale accurately captures the severity and frequency of the observed behaviors.

Module 4: Self-sufficiency

Module 4 looks at 13 different sub-criteria in the area of self-care. These include various personal hygiene activities such as washing, brushing teeth and shaving. Dressing, preparing and eating food and using the toilet or incontinence are also covered. incontinence are also taken into account.

The assessment is based on a scale with four different levels, with scores from 0 to 3 being used in certain cases. The scores are higher for meals (0 to 9 points) and for drinking, toilet use and tube feeding (0 to 6 points). This emphasizes the additional care required when these activities are particularly challenging.

The following ratings apply to the other criteria:

• Self-employed (0 points)
• Predominantly independent (1 point)
• Predominantly dependent (2 points)
• Self-employed (3 points)

Module 5: Coping with - and independently dealing with - illness- or therapy-related demands and stresses

Module 5 assesses a person's ability to deal independently with the treatment of an illness and the corresponding therapeutic measures. Here, 16 different individual criteria are included in the assessment to determine a care level. The points awarded depend on how much help the person concerned needs to implement various measures.

The scoring in Module 5 may seem a little complicated at first, as various criteria are multiplied by a certain factor. But don't worry, the MDK staff will guide you through these questions and ensure that you answer them correctly.

Module 5 looks at various aspects such as taking medication, injections, monitoring body values, changing dressings and managing catheters. The frequency of visits to the doctor and other therapeutic measures are also taken into account.

Module 6: Organization of everyday life and social contacts

The 6th module deals with the organization of everyday life and maintaining social contacts. Six different criteria are taken into account in the care assessment. These include the organization of the daily routine, resting phases and sleeping habits, employment opportunities, planning for the future and interaction with other people. The assessment is again based on a four-point scale:

• Self-employed (0 points)
• Predominantly independent (1 point)
• Predominantly dependent (2 points)
• Self-employed (3 points)

Weighting of the modules and calculated points

The assessors first calculate the sum of the individual points for each module. The modules are included in the overall assessment with a different weighting; the weighting depends on the amount of care required, with less heavily weighted modules the amount of care required is correspondingly lower. The individual modules are therefore subsequently weighted. This is used to calculate the total number of points for classification into a care level.

This means that the person in need of care receives certain points for each module depending on their need for assistance. This total number of points per module is then weighted as a percentage in a second step and included in the calculation.

The individual points per module are not simply added together, but their weighting ensures that the area of self-sufficiency has the strongest influence on the evaluation with 40 percent.

It is important to note that in the two main categories of cognitive/communicative abilities and behavior/psychological problems, only the higher of the two values is included in the assessment result at 15%. The weighting of the points per module isdefined in the Social Code § 15SGB X I [mfn]Social Code § 15 SGB XI[/mfn].

Objectivity in the assessment based on the modules

Over time, the medical service's assessment procedure has improved significantly. In the past, people with cognitive impairments such as dementia were at a particular disadvantage compared to physically impaired people, but this is no longer the case.

Nevertheless, there is still a challenge in the assessment process: people in need of care and their relatives often present the care situation better than it actually is. It is not easy to disclose all deficits to a stranger. Thorough preparation for the care assessment is therefore particularly important.

It is very important to realize that there is no reason to be ashamed in front of the medical service employee, as they see people in need of care every day and are there to classify you or your relatives appropriately. Concealing the situation will only result in the appropriate level of care not being achieved.

It can also be very helpful to keep a care diary. This can be used to record all daily care activities over a longer period of time, as well as the time spent and the type of help required. In this way, you can ensure that the individual modules of the care level are recorded correctly and that the actual applicable care level is determined.

Objection in the event of rejection or downgrading

If you disagree with your care degree decision, be it due to a rejection, a downgrading or a care degree that you feel is too low, you should consider lodging an appeal. It is important to check in advance whether your arguments have a chance of success. You can always use the support of care advice agencies for this.

An appeal is promising if you can convincingly demonstrate in which points the expert opinion has incorrectly assessed the care situation and how this would justify a different level of care overall.

By lodging an objection to the care degree, you can ensure that a new report is drawn up that addresses the disputed points in more detail. In this way, there is hope that the appropriate care degree will be determined at the second attempt.