Upgrading the level of care

In January 2017, the care levels were replaced by care levels which represents a significant change for those in need of care represented. Since then, the need for care has been determined on the basis of these care levels. If a person's care situation changes and more external support is obviously required, it is advisable to apply for an upgrade to a higher level of care.

Today we would like to explain how an application for an upgrade of the care level is made. We will also provide you with information about the process, the duration and any possible appeal.

Good to know: How the care insurance fund assigns a care level to people in need of care

In Germany, the long-term care insurance fund actively supports people who are in need of care. Insured persons are entitled to various benefits such as care allowance, care benefits in kind, respite care, short-term care or the relief amount, which they can claim in order to cope with their everyday care needs. However, these benefits can only be claimed if the insured person has paid contributions into the social long-term care insurance scheme for at least two years in the last ten years. A further requirement is the existence of a recognized care degree.

As people in need of care are not automatically assigned a care level, they have to take action themselves. They can submit an application for long-term care insurance benefits to the long-term care insurance fund. As soon as the application has been received by the long-term care insurance company, it commissions the Medical Service (MD), formerly known as the Medical Service of the Health Insurance Medical Service (MDK)with the assessment of the care situation.

The assessor evaluates the applicant's independence in six different areas of life in the home environment. The assessor then forwards their observations to the long-term care insurance fund and makes a recommendation for a care level. The long-term care insurance fund then informs the person concerned by post about the care level assigned.

Tip: Check your care level

The transition from care levels to care grades took place on July 1, 2017. Since then, around one in five people may be entitled to a higher care level, even if their care situation has not changed. For this reason, we recommend that you check your options for upgrading. It could be worthwhile for you.

Was the changeover from care levels to care grades fair?

In 2017, around 2.7 million people in need of care in Germany received a notification from their care insurance fund. In this notification, they were informed that their care level had been changed to a care grade. Instead of the previous three care levels, there are now five care grades. For example, someone who was previously classified in care level 1 is now classified in care level 2 care grade. Anyone who was also affected by limited everyday competence now receives benefits of care level 3.

In recent years, the legislator and the health insurance funds have examined in detail whether the switch from care levels to care grades will actually lead to comparable benefits. benefits has actually led to comparable benefits. The result of these investigations was that every fifth person in need of care was classified either too high or too low. However, those who were classified too high are protected by law: They are grandfathered. This means that they continue to receive more benefits than they are entitled to under the new assessment system, but are not downgraded to a lower care level.

This is why it makes sense to upgrade to a higher care level

If you want a upgrade of the care level for your relative in need of care means a certain amount of effort at the beginning. Nevertheless, this step pays off in the truest sense of the word if it is approved, because raising the care level brings with it a number of benefits. With a higher care level, you may be entitled to additional benefits or a higher budget for care-related services.

This applies in particular to the care allowance and the care benefits in kind benefits. For care level 1 your family member receives neither care allowance nor care benefits in kind. From care level 2, the financial resources increase depending on the severity of the need for care. In this way, the care insurance fund aims to ensure that those affected receive sufficient support in their day-to-day care according to their care needs. As a general rule, the higher the care level, the higher the benefits provided by the long-term care insurance fund.

Who can apply for an upgrade of the care level?

People who apply to have their care level upgraded are not satisfied with their current care level. They are of the opinion that the care requirements of their relative in need of care exceed the benefits provided for the current care level.

This may be the case for various reasons:

1. The health of the person requiring care has deteriorated, particularly in the case of progressive illnesses such as multiple sclerosis. The current care level may then no longer adequately reflect the care situation.
2. The care level was too low from the outset. It can happen that the results of the care assessment lead to an inappropriate classification. Errors in the assessment are possible. It is conceivable that independence in certain areas, such as mobility, was assessed as being higher than it actually is.

When should you apply for an upgrade?

It is advisable to apply for an upgrade of the care level if you think that the current care level does not adequately reflect the actual care situation. There are various signs that may indicate this:

1. The benefits to which you are entitled according to your current care level do not correspond to your actual everyday needs. For example, you have care level 1 and you are not entitled to any care benefits in kind, although you are dependent on the daily support of an outpatient care service.
2. Although your level of care has not changed in the last few months, your independence has decreased considerably.
3. If you look at the assessment criteria for the care assessment, you believe that you would now receive significantly more points in each area of life. The areas of life include, for example, mobility, self-care and coping with everyday life as well as social contacts. A look at your previous care assessment can give you some orientation.

Is downgrading possible?

Many people who are in need of care are concerned that an application to upgrade their care level could ultimately lead to a lower care level. This is indeed possible, especially if the state of health has improved or the level of care required is no longer as high.

For example, a patient who has suffered a stroke and has become more mobile over time could be assigned a lower care level during a reassessment.

In general, it is important to know that the long-term care insurance fund examines the situation very carefully to ensure that those affected receive the right benefits they need.

People who already had a care level before the changeover to care levels are particularly protected. For them, so-called grandfathering applies. In this case, they are only downgraded to a lower care level if they no longer require care. This regulation is anchored in § 140 SGB XI.

How to apply for an upgrade of the care level

If you want your care level to be adjusted, you must always apply to your care insurance fund. They will also provide you with a form for upgrading your care level. Here is a step-by-step guide to get the process started quickly:

• Step 1: Check your current care level. To do this, compare your care situation at the time with your current situation. Have there been any fundamental changes in terms of your independence? It can be helpful to discuss the reasons for an upgrade with an expert such as your doctor, the care service or a care advisor. A care level calculator can also provide useful information.
• Step 2: Submit the application to your long-term care insurance fund. Request the application form for the care degree upgrade from your care insurance fund, for example as a PDF. Many long-term care insurance companies provide the form on their website. Fill out the form truthfully and completely, sign it and send it back. If you are unable to do this, a carer can do it for you.
• Step 3: Arrange an assessment appointment. The Medical Service (MD) will contact you. If the MD is unable to send an assessor within 20 working days, the long-term care insurance fund will provide you with a choice of three independent assessors.
• Step 4: Prepare for the care assessment. The assessor will come to your home and assess your independence using various instruments. Prepare important documents such as medical reports, medication schedules and hospital discharge reports. A care diary can also be helpful to document the amount of care you receive.
• Step 5: Wait for the decision from the long-term care insurance fund. The assessor summarizes his observations in an expert opinion and sends it to the care insurance fund together with a recommendation for a care degree. The latter makes the final decision.

Decision. It has a maximum of 25 working days to inform you whether the care degree upgrade has been approved or not.

Special features when upgrading the care level

The allocation of a care level depends on many different factors and may require special considerations in certain situations. One such case occurs, for example, when it comes to upgrading the level of care for children. Another special situation dates back a little further - in 2017, there was an automatic upgrade for people in need of care due to the changeover from care levels to care grades. The following section provides important information on these special situations and conversions.

Special features when upgrading the level of care for children

The care insurance fund determines whether a child is in need of care using the same procedure as for adults - a care assessment is therefore also decisive here. However, the child's existing independence is not compared with that of adults, but with that of children of the same age without impairments. Parents can also apply to have their child's care level upgraded. For children in need of care at a certain age, there is also an automatic increase in the level of care.

A special regulation states that children up to the age of 18 months generally receive a higher level of care. This level of care remains in place until the child reaches the age of 18 months and is then adjusted. Interestingly, children from the age of 11 are considered independent in all areas that are relevant to the level of care. This means that the care level for children from this age is determined in the same way as for adults.

What to do if the application for upgrading has been rejected?

Unfortunately, it often happens that the long-term care insurance fund rejects an application for a higher care degree. However, this does not mean that you simply have to accept it. You can lodge an appeal within one month, and this works as follows:

1. File an objection: Write an informal letter in which you make it clear that you object to the decision of the long-term care insurance fund. For example, you could write: "I hereby object to the decision dated DD.MM.YYYY and the rejection of my application for upgrading. A detailed explanation will follow in a separate letter."
2. Provide a justification: In another letter, explain why you think a higher care level is justified. It is best to refer to the expert opinion. If the report is not enclosed with the decision, be sure to request it from the long-term care insurance fund. It is often difficult for laypersons to understand the care assessment sufficiently and to react to it. We therefore recommend that you seek the support of a care expert or a care support center.
3. Be patient: You will need to be patient after you have lodged an objection to the higher care degree. The long-term care insurance fund will now check whether and to what extent your objection can be upheld. If your appeal is unsuccessful, your only option is to file a complaint with the social court or to submit a new application for upgrading after six months. Unless your health situation has deteriorated drastically.

Fill in the application for upgrading the care level

If you find that the care level you have been assigned is no longer sufficient to adequately cover your care needs, it is time to apply for an upgrade of your care level. This step paves the way for a new assessment of your situation and the possibility of receiving appropriate care benefits.

In contrast to the application for long-term care insurance benefits, the application for upgrading is less extensive and can be divided into five sections:

1. Personal details: Start by entering the required information about yourself and your long-term care insurance.
2. Authorized person: Here you can specify a trustworthy person who will support you in communicating and exchanging data with the health insurance companies. If your representative has changed since your last application, please add the relevant evidence.
3. Reason for upgrading: As you are applying for an increase in your care benefits, mark this section accordingly. Briefly state why your care situation has deteriorated and why you require a higher care level.
4. Appointment for the assessment: In order to achieve a higher classification, a further assessment by the Medical Service of the Health Insurance Funds (MDK) will be necessary. You can specify your preferred days for the appointment here, but there is no guarantee that these can be taken into account.
5. Signature and MDK report: Sign the application or have it signed by your authorized representative. Ask your care insurance company for the previous report on the application for care services to show any differences to the current situation. This will enable the MDK to get a more accurate picture of your care situation.

After you have submitted the application, the MDK will contact you to carry out a new assessment. Ideally, you will receive a higher care level with improved care services after a few weeks.