Requesting orthodontic treatment and reimbursement of the co-payment for orthodontic treatment from the statutory health insurance fund Unfortunately this specification of service has not yet been completely translated.
Under certain conditions, statutory health insurance companies cover the costs of medically necessary orthodontic treatment for children and adolescents. You can have your own contribution reimbursed by your health insurance company after treatment.
Statutory health insurance companies pay for orthodontic treatment for insured persons who have not reached the age of 18 at the start of treatment, if the treatment is medically necessary.
The orthodontist will assess whether treatment is medically necessary for your child based on so-called orthodontic indication groups (KIG) and their 5 degrees of severity. The statutory health insurance companies will pay for your child's orthodontic treatment from severity level 3, which means, for example, that a jaw or tooth misalignment already significantly impairs your child's biting, mouth closure or joint function, or threatens to do so in the future.
The orthodontist will bill the Kassenzahnärztliche Vereinigung directly for the orthodontic treatment, minus your own contribution. Your co-payment amounts to 20 percent of the SHI-accredited costs. If you have more than one child undergoing orthodontic treatment, your co-payment for the second and each additional child is reduced to 10 percent of the SHI-accredited costs. The prerequisite is that they live in the same household.
Once the treatment has been successfully completed, the statutory health insurance will reimburse your own contribution. To do this, you must submit an application to your health insurance company or your child's health insurance company and submit some documents, such as the final report from the orthodontist or orthodontist and the co-payment invoices with corresponding proof of payment.
Cost absorption for adults
The costs for orthodontic treatment started at the age of 18 can only be covered by the statutory health insurance in very few exceptional cases. These include, for example, severe jaw anomalies where surgical corrections are also necessary. In these cases, your orthodontist will create a coordinated oral surgery and orthodontic treatment concept.
- Orthodontic treatment plan
For the reimbursement of the co-payment, the final certificate of the orthodontist and the invoices for your co-payment are also required
- Forms: yes
- Online procedure possible: Many statutory health insurers offer an online procedure.
- Written form required: yes
- Personal appearance required: no
Zur Kostenübernahme für kieferorthopädische Behandlung über den Kassen-Navigator des GKV-Spitzenverbands
- You are a member of a statutory health insurance fund.
- For reimbursement of the co-payment, your child must have successfully completed the treatment
§ 29 Fünftes Buch Sozialgesetzbuch (SGB V)
§ 8 Zweites Gesetz über die Krankenversicherung der Landwirte (KVLG 1989)
Richtlinien des Bundesausschusses der Zahnärzte und Krankenkassen auf der Internetseite des GKV-Spitzenverbands
For reimbursement of copayments for orthodontic treatment, proceed as follows:
Standard treatment for children and adolescents:
The orthodontist identifies a malocclusion in your child's teeth from severity level 3 and creates an orthodontic treatment plan. The orthodontic treatment plan contains
- the planned therapeutic measures,
- the expected duration of treatment, and
- the expected costs.
- The orthodontic practice submits the findings and the treatment plan to your statutory health insurance fund or to the health insurance fund with which your child is insured.
- Treatment begins when the relevant health insurance company has approved the treatment plan.
- During the treatment, the orthodontic practice settles 80 percent of the statutory health insurance costs (in case of several children from the 2nd and for each additional child 90 percent) directly with the responsible health insurance company. The practice sends you an invoice for the remaining 20 percent (or 10 percent in the case of several children) per quarter.
- You pay the invoice amount to the orthodontic practice.
- Keep the orthodontic practice's invoices and the accompanying payment receipts.
- The orthodontic practice will issue a certificate of completion for you upon successful completion of treatment.
- You apply for reimbursement of the co-payment made to the relevant health insurance fund and submit the necessary documents. You can submit the application by mail and - for many statutory health insurance companies - in person at the office or online.
- Your statutory health insurance fund will transfer the co-payment to you.
Exception indications for adults:
- Your orthodontist submits the coordinated oral surgery and orthodontic treatment plan directly to your statutory health insurer.
Responsible for the content
Federal Ministry of Health
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