When a loved one becomes in need of care, many relatives and those affected are suddenly faced with a mountain of questions: Who actually decides on the level of care? How does the application process for private long-term care insurance work? And what should I be prepared for when the assessor visits?
This is exactly where Medicproof comes into play. As the medical service of private long-term care insurance (PKV), Medicproof takes on the important task of professionally assessing the need for long-term care of insured persons. In this comprehensive magazin , you will learn everything you need to know about Medicproof, the care assessment, the role of the assessors, the requirements for care benefits and how you can best prepare for the assessment.
What is Medicproof?
Medicproof is the medical service of private long-term care insurance (PKV). Medicproof was founded as a subsidiary of the Association of Private Health Insurers (PKV Association) to take on the task of assessing the need for long-term care for privately insured persons.
Medicproof works independently and neutrally, but ensures that the need for long-term care is determined according to the same criteria as for those with statutory insurance - namely on the basis of the Eleventh Social Security Code (SGB XI). ([mfn]SGB XI[/mfn])
The tasks of Medicproof
The tasks of Medicproof are varied and serve the purpose of objectively and comprehensibly determining the need for care of privately insured persons. In detail, the range of tasks includes
- Assessment of the need for care: home visits to determine the degree of care.
- Preparation of care assessments: Systematic assessment based on legal criteria and documentation in the report.
- Quality control: Ensuring uniform assessment quality through training and internal standards.
- Advice for private long-term care insurers: Support with technical questions on care assessments.
- Further development of the assessment procedures: Participation in the conceptual improvement of the assessment guidelines.
- Carrying out second opinions: Preparation of supplementary assessments in opposition proceedings.
These tasks help to ensure a fair and objective assessment of the need for care based on individual needs.
What does "in need of care" mean? - The concept of the need for care
The term "in need of care" is legally defined in Section 14 of the Eleventh German Social Code (SGB XI) [mfn]Section 14 of the Eleventh German Social Code (SGB XI)[/mfn]. Accordingly, people in need of long-term care are those who have health-related impairments to their independence or abilities and therefore require long-term help and support in everyday life, i.e. for at least six months.
The decisive factor here is that the limitations can be of a physical, cognitive or psychological nature. It is therefore not just about traditional physical care needs, but also about assistance and support in coping with cognitive challenges such as dementia or mental illnesses.
The so-called "New Assessment Assessment" (NBA) is used to assess the need for care. Six areas of life - also known as "modules" - are assessed to determine the extent to which independence is restricted. These areas include, for example, mobility, cognitive abilities, self-care and dealing with illness-related requirements.
The definition of the need for long-term care is therefore deliberately broad in order to do justice to all people who are dependent on support in everyday life, regardless of age, the cause of the impairment or the form of insurance. It forms the basis for the decision on the level of care and therefore the benefits provided by long-term care insurance.
The importance for people in need of care and their relatives
The Medicproof report is of central importance for people in need of care and their relatives. This is because they can only access long-term care insurance benefits if they have a recognized care level. These benefits can take the form of care allowance, benefits in kind for outpatient services, support with inpatient care or subsidies for measures to improve the living environment are provided. The assessor's assessment therefore has a direct impact on the quality of life and everyday life of those affected.
The path to a care degree: application and assessment
The path to care level is a decisive step for all those who are entitled to care services care services. Especially in the private insurance sector, it is important to know the individual steps well and use them in a targeted manner. Because only those who have a recognized care level can claim the care insurance benefits to which they are entitled.
The application process for private long-term care insurance
The application process for private long-term care insurance comprises several steps that should be completed carefully in order to achieve a quick and targeted classification in a suitable care degree:
- Applying to the private long-term care insurance fund: The first step is for the insured person or their relatives to apply in writing or by telephone.
- Note early timing: The application should be submitted as soon as a permanent impairment of independence or abilities is recognizable.
- Commissioning Medicproof: Once the application has been received, the private long-term care insurance fund commissions Medicproof to carry out a long-term care assessment.
- Appointments: An appointment for the assessment is usually arranged within around 14 days of the application being submitted.
- On-site or telephone assessment: The assessment usually takes place in the applicant's home. In exceptional cases, it may take place by telephone or video.
- Preparation of the assessment: The assessor documents the results using legally defined modules and forwards the assessment to the long-term care insurance company.
- Notification of the decision: The private long-term care insurance company informs the insured person of the result and the degree of care determined.
Requirements for the application
The basic requirement for submitting an application is a physical, mental or psychological illness. mental illness or disabilitywhich means that the person concerned is dependent on help to cope with everyday life.
This need for assistance must be expected to last for at least six months. It is important that applicants document their situation comprehensively and enclose all relevant medical documents to enable Medicproof to carry out a quick and fair assessment.
The role of the experts
The Medicproof assessors have the task of home visit to gain a comprehensive picture of the individual care situation.
They take into account both objective information (such as medical reports) and subjective impressions from discussions with the person in need of care and, if applicable, their relatives. They systematically document the areas in which the person concerned needs support, how often help is required and to what intensity.
Qualifications and tasks of the Medicproof experts
All Medicproof experts have in-depth medical training and comprehensive knowledge of care requirements. They regularly take part in further training to ensure that the assessments comply with current legal requirements and scientific standards.
In addition to collecting data on site, their tasks also include the structured evaluation of the information and the creation of an easily comprehensible care report.
The care report: Procedure and contents
Once the application has been submitted and the private long-term care insurance has been commissioned, perhaps the most important part of the process begins: the preparation of the long-term care assessment by Medicproof.
This assessment forms the basis for the assignment of a care level by care professionals - and thus for all benefits that privately insured persons can receive to maintain their independence.
To ensure a fair and objective assessment, the individual care situation is assessed using six modules. These modules cover key areas of life and take into account physical, mental and psychological impairments.
Module 1: Mobility
This assesses the extent to which a person can move independently:
- Changing position in bed
- Standing up and sitting down
- Moving around within the home
- Climbing stairs
This module records whether everyday movements are possible without assistance or whether support is required.
Module 2: Cognitive and communicative skills
Among other things:
- Orientation to person, time and place
- Understanding and communication
- Memory
- Recognizing risks and dangerous situations
The module is particularly relevant for dementia or neurological diseases.
Module 3: Behavioral and psychological problems
The following aspects, among others, are taken into account here:
- Restlessness, anxiety or aggressive behavior
- Nocturnal restlessness
- Repeated running away
- Self-harming behavior
Mental impairments can also contribute significantly to the need for care.
Module 4: Self-sufficiency
The assessment is based on how independently a person can care for themselves:
- Personal hygiene (washing, showering, dental care)
- Dressing and undressing
- Food and drink
- Going to the toilet
Everyday basic care is an essential part of the need for care.
Module 5: Coping and independent handling of illness- or therapy-related requirements
These include:
- Taking medication
- Organize visits to the doctor
- Handling aids (e.g. prostheses, oxygen equipment)
- Wound care or injections
This module is particularly relevant for people with chronic illnesses or complex care needs.
Module 6: Organization of everyday life and social contacts
The following are assessed:
- Daily structuring
- Participation in social life
- Ability to maintain social contacts
Psychosocial aspects also play a role in the assessment of the level of care.
Weighting of the modules
Each module is given a certain percentage weighting in the overall assessment:
| Module | Area of life | Weighting |
|---|---|---|
| Module 1 | Mobility | 10 % |
| Module 2 | Cognitive and communication skills or Module 3 | 15 % |
| Module 3 | Behavioral and psychological problems or Module 2 | 15 % |
| Module 4 | Self-sufficiency | 40 % |
| Module 5 | Need for support due to illness/therapy | 20 % |
| Module 6 | Organization of everyday life and social contacts | 0 % (for documentation purposes only) |
Note: During the assessment, either module 2 or module 3 is evaluated - depending on which is more relevant for the assessment of the need for care.
Awarding points and care level
In each relevant module, individual aspects are rated with points from 0 to 3:
- 0 points: no impairment
- 1 point: minor impairment
- 2 points: significant impairment
- 3 points: severe impairment
These points are weighted and result in a total score of 0 to 100 points. This total score determines the care level:
| Total score | Degree of care |
|---|---|
| 12,5 – <27 | Care level 1 |
| 27 – <47,5 | Care level 2 |
| 47,5 – <70 | Care level 3 |
| 70 – <90 | Care level 4 |
| 90 - 100 | Care level 5 |
The importance of the care protocol
A care diarywhich documents the support needed in everyday life over several days is a valuable tool for the assessment. It helps the assessor to validate the information provided by the person concerned and to obtain a realistic picture of the care situation. Relatives or care services can help with the creation of such a protocol.
Influence of the corona pandemic on the assessment
The coronavirus pandemic has also led to adjustments at Medicproof. In order to protect vulnerable groups of people, telephone or video-based assessments have been temporarily introduced. This form of assessment is still an option if an on-site assessment is not possible or justifiable.
Nevertheless, a personal assessment on site is still preferred, as it provides a more comprehensive picture of the care situation.
Care services and benefit entitlements
If a care level has been determined by Medicproof, those insured under private long-term care insurance are entitled to various benefits designed to make life with a need for long-term care easier. Which benefits which benefits are granted and to what extent depends largely on the level of care determined.
The amount of benefits and their requirements
Private long-term care insurance provides different benefits depending on the level of care determined. For care level 1 those affected primarily receive access to counseling services and preventive measures.
From care level 2 can care allowance, care benefits in kind, allowances for day and night care as well as benefits for short-term care or respite care can be applied for. The financing of a place in a nursing home is also possible from care level 2 is also possible.
Aids and support in everyday life
Aids such as wheelchairs, care beds, home emergency call systems or hygiene products can be applied for to make everyday care easier. The costs are covered by private health insurance if they are medically necessary. There are also options for adapting living space, such as stair lifts or barrier-free conversions.
Such measures contribute significantly to increasing the independence and safety of those in need of care.
What to do if the application is rejected?
If an application for care services is rejected or a care level is determined to be too low, there is the option of lodging an appeal. It is important that this is well justified. It can be helpful to submit an extended care record or request a new assessment. Medical opinions can also help to strengthen the application.
Objection and further steps
An objection must be received by the long-term care insurance company within one month of receipt of the decision. In many cases, it is worth seeking professional help. Our care advisors will support you in formulating your appeal, work with you to gather suitable evidence and guide you through the entire process.
Frequently asked questions about Medicproof and care levels
How long does the Medicproof assessment procedure take?
The assessment usually takes place within 14 days of the application being submitted. The care assessment is usually sent to the care insurance fund one week later.
How do I prepare for the expert's visit?
Have medical documents ready, keep a detailed care log and, if necessary, ask relatives or caregivers to be present at the appointment.
What role do relatives play in the assessment?
Relatives can provide valuable information and supplement the information provided by the person in need of care. Their perspective is particularly important if there are cognitive limitations.
What is the difference between Medicproof and the MDK?
Medicproof is responsible for privately insured persons, the MDK for those with statutory insurance. Both work according to the same SGB XI criteria and prepare comparable care assessments.
Who pays for the Medicproof?
The costs for the assessment are covered by the respective private long-term care insurance. There are no additional costs for the insured person.
