Care level 4: Requirements, benefits and tips

Care Level 4 is the second-highest of a total of five care levels into which insured individuals requiring care have been classified since the 2017 care reform (previously, there was a single care level). Care Level 4 describes the most severe impairment of independence. The care level determines which benefits and support services the person in need of care can receive from the responsible long-term care insurance fund.

The Home Care Agency explains: What is Care Level 4? What requirements must be met? What services are available? Learn more now!

Definition and Eligibility Criteria: Care Level 4 – Severe Impairment of Independence

Care Level 4 is a classification within the German long-term care insurance system assigned to people with the most severe limitations in their ability to function independently. Individuals classified at this care level generally require comprehensive assistance with daily living activities and all-around care, including personal hygiene, nutrition, mobility, and household tasks.

Classification into care levels (formerly care levels) is carried out by the Medical Service of the Health Insurance Fund (MDK) or other independent experts who assess the individual care requirements and the need for care using a points system. The long-term care insurance fund helps those with care level 4 and offers extensive benefits to ensure the necessary care, whether through outpatient care services, inpatient care or Care allowance for family carers.

What requirements must be met for care level 4?

To be classified as Care Level 4, certain requirements must be met, based on a comprehensive assessment of a person’s independence and abilities. The assessment and classification into the appropriate care level are carried out by the MD (the Medical Service, formerly MDK: the Medical Service of the Health Insurance Funds).

The assessment by the MD takes place after the application for a care degree from the responsible long-term care insurance company. The following criteria are taken into account:

Mobility

The "Mobility" module in the assessment by the Medical Service of the Health Insurance Fund (MDK) evaluates a person's physical mobility and ability to move independently in everyday life. Various aspects of mobility are considered in order to determine the degree of impairment.

The assessment typically covers the following areas:

1. Changing position in bed: The ability to turn over independently in bed and change lying position.
2. Standing up and sitting down: The ability to get out of bed or a chair independently and sit down again.
3. Mobility within the home: The ability to move around the home without assistance, including walking and the use of aids such as walkers.
4. Stair climbing: The ability to climb stairs if required in the home environment.
5. Transfer: The ability to move independently from one place to another, such as from the bed to the wheelchair or from the wheelchair to the toilet.

Cognitive and communicative skills

The "Cognitive and communicative abilities" module in the assessment by the Medical Service of the Health Insurance Funds (MDK) assesses a person's mental abilities and communication skills. This module is crucial in determining the extent to which a person is able to cope with everyday life and interact with others.

The assessment typically covers the following areas:

1. Recognizing people and objects: The ability to recognize and name familiar people and everyday objects.
2. Spatial and temporal orientation: The ability to orient oneself in time and space, i.e. to know what day it is or where one is.
3. Memory: The ability to recall important information, such as one's own name, address, or current events.
4. Making decisions: The ability to make independent decisions in everyday life, such as what to eat or what to wear.
5. Understanding and speaking: The ability to understand spoken information and express oneself verbally in order to communicate needs and wishes.
6. Perceptiveness: The ability to recognize connections and process information.

Behavioral and psychological problems

The “Behavioral Patterns and Mental Health Issues” module in the assessment conducted by the Medical Service of the Health Insurance Fund (MDK) assesses behavioral abnormalities and mental health issues that may interfere with a person’s daily life. This module helps determine the additional support needs arising from such behaviors or mental health issues.

The assessment typically covers the following areas:

1. Nocturnal restlessness: Frequent waking or wandering during the night that disturbs sleep.
2. Anxiety and aggression: Occurrence of anxiety or aggressive behavior towards oneself or others.
3. Delusions and hallucinations: Experiencing unrealistic ideas or perceptions that do not correspond to reality.
4. Depressive moods: Persistent sadness, listlessness or loss of interest that interferes with everyday life.
5. Social inadequacy: Difficulties in social interaction, such as inappropriate behavior in social situations.
6. Self-harming behavior: Behavior that is harmful to one’s own health or safety, such as refusing food or medication.

Self-sufficiency

The "self-care" module in the assessment by the Medical Service of the Health Insurance Fund (MDK) evaluates a person's ability to carry out basic everyday activities independently. This module is crucial in determining the level of support a person needs in everyday life.

The assessment typically covers the following areas:

1. Personal hygiene: The ability to wash, shower or bathe oneself and to carry out oral and dental hygiene independently.
2. Dressing: The ability to dress and undress independently, including selecting and putting on clothing.
3. Nutrition: The ability to eat and drink independently, including preparing meals when possible.
4. Excretion: The ability to use the toilet independently, including intimate hygiene and the use of incontinence products if required.

Coping with and independently managing challenges related to illness or treatment

The module "Coping and independent handling of illness- or therapy-related demands and burdens" in the assessment by the Medical Review Board of the German Statutory Health Insurance (MDK) evaluates how well a person is able to cope with the demands and burdens caused by their illness or therapy. This module is important for determining the additional support required as a result of medical and therapeutic measures.

The assessment typically covers the following areas:

1. Taking medication: The ability to take medication independently and correctly, including the dosage and schedule.
2. Injections and infusions: The ability to self-administer injections or handle infusions if necessary.
3. Wound care: The ability to care for wounds independently and change dressings.
4. Handling medical aids: The ability to use and care for medical aids such as prostheses, wheelchairs or respiratory equipment independently.
5. Medical appointments and therapies: The ability to attend medical appointments and to carry out or organize therapeutic measures independently.
6. Recognizing and responding to symptoms of illness: The ability to recognize and respond appropriately to symptoms of illness to avoid complications.

Organization of everyday life and social contacts

The module "Organization of everyday life and social contacts" in the assessment by the Medical Service of the Health Insurance Fund (MDK) evaluates a person's ability to organize their everyday life independently and maintain social contacts. This module is important for determining the need for support in the social and organizational areas of daily life.

The assessment typically covers the following areas:

1. Daily structuring: The ability to plan and organize the day independently, including carrying out activities and errands.
2. Leisure activities: The ability to independently initiate and carry out leisure activities that correspond to personal interests.
3. Maintaining social contacts: The ability to cultivate and maintain social relationships, including communication with friends, family and acquaintances.
4. Participation in social life: The ability to participate in social activities, such as attending club meetings, cultural events, or community gatherings.

These aspects are assessed using a point system that measures the degree of independence or the level of support required in each area. The results of these modules contribute to the overall care level assessment and help determine an individual’s specific support needs.

Care level 4: Benefits for care level 4

Individuals with a care level of 4 are affected by the most severe impairments of independence and require intensive care and support several times a day to manage their daily lives. Accordingly, care for care level 4 is significantly more demanding than for care levels 1–3. To provide optimal support to those with a care level of 4, all care services are available to them.

Benefits for care level 4:

• Care allowance
• Relief amount
• Care benefit in kind
• Preventive care
• Day and night care
• Short-term care
• Care aids for consumption
• Home emergency call
• Technical care aids
• Adaptation of living space

Care allowance for care level 4

Care Level 4 indicates a severe impairment of independence or functional abilities. Individuals with this care level require comprehensive support in their daily lives. The care allowance, which is paid when care is provided at home by family members or volunteer caregivers, currently amounts to 800 EUR per month. This allowance is intended to provide financial support to family caregivers and to promote home care.

Relief amount for care level 4

For Care Level 4, individuals in need of care are entitled to a monthly relief allowance of 131 EUR. This amount is earmarked for a specific purpose and is intended to relieve the burden on family caregivers and promote the independence of those in need of care.

The relief amount can be used for various support services, such as:

• Offers for support in everyday life, such as care groups or everyday companions.
• Services provided by recognized care services by nursing staff that are not covered by regular care benefits in kind.
• Day or night care to relieve the burden on family carers.
• Household care (domestic help)

ATTENTION: The relief amount is not paid out directly, but is granted as a reimbursement for services used. Unused amounts can be carried forward to the following calendar half-year.

Long-term care benefits in kind for care level 4

Individuals with a care level of 4 are entitled to in-kind care benefits of up to 1,859 EUR per month. These benefits are intended to cover the use of professional nursing and care services that assist with home care. These include:

• Basic care by an outpatient care service, such as help with personal hygiene, nutrition and mobility.
• Domestic care, such as assistance with shopping, cooking and cleaning.
• Care services that promote social participation and the organization of everyday life.

Long-term care benefits in kind are paid directly to the approved care services that provide the services. People in need of care can use the benefits in kind flexibly in order to cover their individual care needs in the best possible way. If the benefits in kind are not fully utilized, it is possible to convert the unused portion into care allowance.

Preventive care for care level 4

People with care level 4 are entitled to respite care if the regular caregiver is temporarily unavailable, for example due to vacation, illness or other reasons. Preventive care can be claimed for up to 6 weeks per year.

The annual amount available for respite care is up to €1,685. In addition, up to 50% of the unused portion of the short-term care allowance (up to €842.50) can be transferred to respite care, which can increase the maximum amount to €2,418 per year.

Respite care can be provided by professional care services, other private individuals, or in an inpatient facility. If respite care is provided by close relatives, reimbursement is limited to the amount of documented expenses, such as travel costs or loss of earnings.

Day and night care for care level 4

At care level 4, people in need of care are entitled to partial inpatient care services, which can be provided as day and night care are referred to as day and night care. These services provide valuable support by looking after those in need of care during the day or night in special facilities while they otherwise live at home.

For Care Level 4, up to 1,685 EUR per month is available for day and night care. These services include:

• Support and care during the stay in the facility.
• Meals and social activities that promote participation in community life.
• Support with personal hygiene, mobility and other daily activities.

The costs for accommodation, meals and investment costs usually have to be borne privately, but can be covered by additional services or private funds. The use of day and night care has no influence on the care allowance or care benefits in kind, so that these can be used in parallel to optimize care.

Short-term care for care level 4

At care level 4, people in need of care are entitled to short-term care, which can be used if temporary inpatient care is required. This may be the case after a stay in hospital or in crisis situations, for example, if care at home cannot be provided temporarily.

Up to €1,854 per year is available for short-term care. These benefits can be used for a maximum of 8 weeks per year. In addition, unused funds from respite care (up to €1,685) can be transferred to short-term care, which can increase the maximum amount to €3,539 per year.

Short-term care covers the costs of nursing, care and medical treatment in an inpatient facility. Costs for accommodation and meals usually have to be borne privately, but can be covered by additional benefits or private funds.

Care aids for consumption with care level 4

At care level 4, people in need of care are entitled to care aids for consumption that make home care easier and improve hygiene. These aids are specifically intended for daily use and are usually provided on a monthly basis.

The monthly amount for these medical aids is up to 42 EUR. Typical medical aids include:

• Disposable gloves
• Disinfectant for hands and surfaces
• Disposable bed protection pads
• Face mask
• Protective aprons

These aids can be obtained from approved providers, who often also take care of billing the care insurance fund directly. People in need of care or their relatives simply have to select and order the aids they require.

Home emergency call for care level 4

For care level 4, people in need of care are entitled to a home emergency callwhich offers them additional security in everyday life. The home emergency call is a technical system that makes it possible to call for help quickly in an emergency by pressing a button that is connected to an emergency call center.

The care insurance fund covers the costs of setting up and operating the home emergency call system, provided that the requirements are met.

These include:

• The person in need of care lives alone or is alone for large parts of the day.
• There is an increased risk of falls or other emergencies.
• There is no other person in the household who can provide help quickly in an emergency.

The home emergency call usually comprises a basic device with a portable transmitter that can be worn as a bracelet or necklace. In an emergency, a connection is established to the emergency call center, which then initiates the necessary measures, such as informing relatives or alerting the emergency services.

Technical care aids for care level 4

At care level 4, people in need of care are entitled to technical care aids that make home care easier and promote independence. These aids are designed to make care safer and more efficient.

Technical care aids include, among others:

• Care beds: Electrically adjustable beds that make it easier to get up and lie down.
• Lifting aids: Devices that support the lifting and moving of people in need of care.
• Wheelchairs: mobility aids that can be adapted to individual needs.
• Commode chairs: Make toileting easier for people with limited mobility.
• Anti-decubitus mattresses: Special mattresses that prevent pressure sores.

The cost of technical assistive devices is generally covered by the long-term care insurance fund, though beneficiaries are often required to pay a copayment of 10% of the purchase price, up to a maximum of 25 EUR per device. In certain cases, such as financial hardship, this copayment may be waived. The devices must be prescribed by a doctor and approved by the long-term care insurance fund.

Home adaptations for care level 4

For care level 4, people in need of care can receive financial support for home adaptations to adapt their home environment to their individual care needs. These adaptations are intended to make care easier and increase independence and safety in everyday life.

Possible measures include:

• Installation of ramps: To overcome barriers and facilitate access.
• Adaptation of the bathroom: installation of level-access showers, grab rails or special toilet seats.
• Door extensions: To allow access for wheelchairs or walking aids.
• Stairlifts: For more mobility between different floors.
• Adaptation of the kitchen: To enable use while seated.

The long-term care insurance fund may provide a subsidy of up to 4,180 EUR per measure. An application must be submitted to and approved by the long-term care insurance fund before the modifications are made.

Care level 4 - application and assessment

The Application and assessment for care level 4 takes place in several steps and is crucial in order to receive the corresponding care benefits. Here is an overview of the process:

1. Application: The first step is to apply to the relevant long-term care insurance fund, which is usually affiliated with the health insurance fund. The application can be made informally in writing, by telephone or online.
2. Care assessment by the MDK or MEDICPROOF: After receiving the application, the care insurance fund commissions the Medical Service of the Health Insurance Fund (MDK) or, in the case of privately insured persons, the company MEDICPROOF to carry out an assessment. An assessor visits the applicant at home to determine the level of care required.
3. Assessment of independence: The assessor evaluates independence in six areas of life, including mobility, cognitive and communication skills, behavior and mental health problems, self-care, coping with illness or therapy-related requirements, and organization of everyday life and social contacts.
4. Points system: Each area is awarded points, which are then added together to give a total score. For care level 4, 70 to under 90 points are required.
5. Decision of the long-term care insurance fund: Based on the assessment, the long-term care insurance fund decides on the allocation of the care degree. The applicant receives a notification with the decision and the reasons.
6. Right of appeal: If the applicant does not agree with the decision, there is the option of lodging an appeal within one month.

It is advisable to prepare well for the assessment appointment by, among other things, keeping a care diary to document the actual care needs.

Upgrading to a higher care level

If the state of health of a person in need of care deteriorates and the current care level 4 no longer covers the actual need for care, a upgrade to care level 5 can be applied for.

How to apply for a higher care level:

1. Application for upgrading: The person in need of care or their relatives must submit an application for upgrading to the relevant long-term care insurance fund. This can be done informally in writing, by telephone or online.
2. Reassessment: After receiving the application, the long-term care insurance fund commissions the Medical Service of the Health Insurance Fund (MDK) or, in the case of privately insured persons, the company MEDICPROOF to carry out a reassessment. An assessor visits the person in need of care at home to determine their current care needs.
3. Assessment of independence: The assessor again assesses independence in the six areas of life, as in the original assessment. Points are awarded according to the same scheme.
4. Decision by the long-term care insurance fund: Based on the new assessment, the long-term care insurance fund decides whether to upgrade the care level. The person in need of care receives a notification with the decision and the reasons.
5. Right of appeal: If the applicant does not agree with the decision, there is the option of lodging an appeal within one month.

It is helpful to provide a thorough justification for the request for a higher care level and to submit current medical records or a care log to document the increased need for care.