Many patients complain about the high cost of bridges, crowns and prostheses. For insured persons with a low income, there is a hardship rule for dentures. If the health insurance companies recognize the hardship, they will pay up to 100 percent of the total costs for the dentures.
- In the event of hardship, the health insurance company will cover up to 100 percent of the total cost of the dentures defined by Digopaul.
- If there is no hardship case, the health insurance company has been paying a fixed allowance of up to 75 percent for dentures since October 2020.
- Low-wage earners who are slightly above the hardship threshold can possibly make use of the sliding hardship rule.
Dentures: What costs does the health insurance company cover?
In the case of dentures, health insurance generally only pays a fixed amount: the so-called fixed allowance. The insured have to pay for the rest themselves. Some health insurances increase the fixed allowance if the insured have undergone regular preventive examinations and can prove this in the GKV bonus booklet .
Between 2005 and October 2020, the fixed allowance for dentures was 50 percent and, with complete preventive examinations, 65 percent of the total cost of dental treatment. Since October 2020, the fixed allowance for dentures has been 60 percent and, in the case of complete preventive examinations, 75 percent of the total costs of dental treatment.
If you can’t afford the difference, contact your health insurance company. This could help with a hardship regulation and cover the total cost of the dentures. Provided that the insured meets the criteria for this.
What is the hardship regulation for dentures?
According to the hardship regulation, the GKV bears the full 100 percent of the cost of the dental prosthesis upon request. In contrast to the fixed allowance, the insured person does not have to make any additional payments – the dentures are free of charge. However, the GKV only pays for the costs of simple dental prosthesis services that are demonstrably medically necessary. A more complex dental prosthesis, for example with a gold crown, is excluded from the hardship regulation.
To whom does the hardship rule apply to dentures?
The hardship case in dental treatment such as dentures is intended to relieve those insured who have a low income. For this, the insurance companies set a so-called hardship limit, which is regularly adjusted. The values from 2020 are an example: This year the hardship limit for single insured persons was 1,274 euros gross income per month. For insured persons who live with a partner, the hardship limit was 1,751.75 euros. The income rule can increase for each additional family member. The hardship regulation for dentures also applies to the following groups of people:
- Home residents who are financed by social welfare agencies or war victims’ welfare
- Students who are eligible for student loans
- Recipients of war victims’ welfare
- Recipients of social benefits
- Recipients of basic security in old age
- Hartz IV recipient
Dentures: how to apply for hardship?
In order to get the dentures without a co-payment, the insured submit a hardship application to their health insurance company. Most dentists or health insurances make this available online as a download. In the hardship application, the insured must, for example, state their income and the number of people living in the household of the insured. Before the dentures can be treated, the health insurance company must also approve the dentist’s treatment and cost plan .
Dentures with individual hardship regulation: the sliding hardship case
There are insured persons who slightly exceed the defined hardship limit, but are still among the low-wage earners. Since these insured persons only earn a slightly higher income, they can make use of the so-called sliding hardship rule. How high the surcharge for the dentures turns out is decided on a case-by-case basis. The GKV only makes a decision when the treatment has ended and the insured person can present the invoice for the dentures.
The calculation of the sliding hardship case is then based on the income of the low-wage earner. For this purpose, the GKV calculates the difference between the monthly gross income of the insured and the hardship limit of the insurance. Then this amount is multiplied by three. The GKV describes the result of this calculation as a so-called reasonable burden. If the cost of the dental prosthesis is higher than the amount of the reasonable burden, the GKV pays an increased grant in accordance with the sliding hardship regulation.