In January 1995, the government of Helmut Kohl introduced the Social Law XI 1, the German long term care insurance. It is an independent part of the social security in Germany, in the Sozialgesetzbuch and provides financial provision for the risk of care necessity. Long-term care insurance was introduced as the fifth pillar of social insurance after health insurance, industrial injuries, pensions and unemployment insurance. This fifth pillar is financed by the care fund, which was built for all the individual health insurance policies.
Insurance is also provided for people who need care because of the severity of their long-term care. Old and sick people are no longer dependent on social security if in need of care. Statutory care insurance covers a portion of the home and residential care costs if an increased need for nursing or household assistance of at least six months is required. This will help the patient to lead an independent and self-determined life.GEK Info- Service: Die GEK- Pflegekasse, in o. O., o. J., Seite 4- 5
The insured person Both compulsory and voluntarily insured individuals in the statutory health insurance system are automatically covered by the social long-term care insurance. Voluntarily insured individuals, along with those who are fully privately insured, have the option to take out private long-term care insurance instead. Family members can also be covered under a regular member’s insurance through contribution-free family coverage. With this system, a cover for the entire population was introduced.Günther Merkens und Werner von Birgelen: Die private Krankenversicherung- die private Pflegeversicherung, eine Arbeitshilfe für die GKV, Sankt Augustin 1999, Seite 257
The benefit
The levels of care The care need people receive the benefits of insurance cover in three stages. The stages are referred to as levels of care and serve the classification of the claims of each care dependent person. The decision for the classification in the care insurance is made with substantial consideration of the nursing report. It is created by the medical service of health insurance, in which the insured is examined in his living area. The levels of care are organized as follows:
Care level I: a need for assistance for at least 90 min per day with basic care needs of at least 45 min per day. Care level II: a need for assistance must be at least 180 min per day with basic care needs of at least 120 min per day. Care level III: a need for assistance is required for at least 300 min per day with basic care needs of at least 240 min per day. Case of hardship: the care fund can provide more services in line with care benefits and inpatient care.GEK Info- Service: Die GEK- Pflegekasse, in o. O., o. J., Seite 6-8
If there is need of personal care below the required threshold of at least 90 min per day, there are no benefits. All services except for technical aids and care courses are budgeted. This is to prevent that the care insurance from being converted into full insurance. Thus, the contributions will be kept stable and the development expenditure can be controlled.Karl Jung (Hrsg.): Die neue Pflegeversicherung, Sozialgesetzbuch XI, Bonn 1995
The home care Like the levels of care, the services are categorized as well. On the one side there is the home care and on the other side there is the inpatient care. The home care can be divided into four categories:
The first group is the so-called care allowance, a monthly cash benefit for private organized caregivers, such as family members who are currently not employed. The cash amount in €235 in category I, €440 in category II and €700 in category III. In this scheme, there is no case of hardship arrangement.
The second option is the care benefit in kind. The ambulatory care service for the home care is subsidized, which is selected by the patient. These benefit have a maximum amount per month. In care level, I the amount is €450; in care level II, €1100; and in level III, €1,550. In special hardship cases, the care fund can cover operations with a total value of up to €1,918.
In addition, the combination of the care fund and care benefits is possible. In this case, the care benefits of the nursing for the home care can be charged as material costs. As well, the present share of the maximum amount can be claimed as cash benefit for caregivers.
Partial inpatient care is a temporary support during the day in an institution. The benefits are identical to those of the care in kind.Deutsche Rentenversicherung Bund (Hrsg.): Unsere Sozialversicherung, Wissenswertes speziell für junge Leute, Berlin 2007, Seite 167- 170
Inpatient care Inpatient care includes an accommodation in a home. This means that services are provided for the duration of care. The need for inpatient care is assumed. The care fund pays a fee to the nursing home. In care level I, the amount is €1023; in level II, €1,279; and in level III, €1,432. In extreme cases, up to €1,688 can be paid. The cash benefits are only for the cost of care and social support determined the home. If the income from all the family members required to pay maintenance is not sufficient to pay the remaining costs of the inpatient care, the appropriate social assistance institution can be requested.Deutsche Rentenversicherung Bund (Hrsg.): Unsere Sozialversicherung, wissenswertes speziell für junge Leute, Berlin 2007, Seite 170f
Financing With the introduction of the care insurance, the risk of nursing care case got recognition as a general life risk. This is a budgeting system. This means that depending on the level of care people get a fixed amount that is paid by the insurance as support, regardless of how high the prices for such services, such as by inflation, should rise over the years. The amount of the fee is based on the contribution rate and the assessable income of the members. For the publicly insured people, the contribution rate is 1.7%.
However, childless people who are 23 years or older have to pay a rate of 1.95%. This is paid from the gross amount of wages or pensions but only up to a maximum amount for health insurance from the current €4,012.50 per month. This regulation applies equally to all citizens of Germany since 1. July 1996. Family members are in a non-contributory insurance if the family coverage is eligible for the health insurance. However, the receipt of benefits from the long-term care does not absolve from payment of contributions.Gabler Wirtschaftslexikon, 16. vollständig überarbeitete und aktualisierte Auflage, Wiesbaden: Gabler 2005, Seite 2.324- 2.327
The gaps in the care insurance The care insurance is very complex so that few citizens have the necessary information to apply for the claim properly. Evaluators of the medical service test whether a person is entitled to have care. The patients are not prepared for the report. This creates a false impression of fitness and subsequently an incorrect (less comprehensive) classification of those people. This leads to the problem that the family and patient cannot cope with the situation financially.Thomas J. Kramer (Hrsg.): WISO Pflegeversicherung, Einstufungen, Leistungen, Streitfälle, Frankfurt/ Wien 2004, Seite13
In cases where patients or their families feel a claim was wrongly denied or classified, they can turn to the Insurance Ombudsman (Versicherungsombudsmann), an independent and free arbitration board that helps resolve disputes between consumers and insurance providers without going to court.
There are many ways to care for family members or to give assistance: the home emergency, the short-term and day care, the assisted living, the help for housekeeping, the meals being delivered to the house, the driving and escort services, and the nursing homes. This is only a small overview of the diversity of these opportunities. Because this issue is so complex, patients often do not receive assistance and private insurance for nursing care.Thomas J. Kramer (Hrsg.): WISO Pflegeversicherung, Einstufungen, Leistungen, Streitfälle, Frankfurt/ Wien 2004, Seite 17, 18
Furthermore, important factors in determining the time required for care are not taken into account in general. The emerging care reform includes the care of people suffering from dementia and need to get permanent presence from a person. In contrast, there is neither support in social areas of life nor help to manage crises and isolation nor dealing with dying and death. Equally nursing care cases of shorter duration than half a year get no payments from the original insurance.Karl Jung (Hrsg.): Die neue Pflegeversicherung, Sozialgesetzbuch XI, Bonn 1995
In principle, the legislature requires the combination of two conditions in the case of entitlement to benefit. On one hand, patients need to have assistance both in the nursing part and in the household. On the other hand, outside assistance is needed regularly and permanently. If any of these conditions is not met, there is no payment. The regular need for assistance means that care is needed at least once a week. Durable means that the need for care exists longer than six months. "The actual duration is not important, but the prognosis, the prospects for the future“.Thomas J. Kramer (Hrsg.): WISO Pflegeversicherung, Einstufungen, Leistungen, Streitfälle, Frankfurt/ Wien 2004, Seite 32, 33
Also, people needing care must meet formal requirements. The patients must be insured in the statutory or private health insurance as well as they have to be in the care insurance with contributions or non-contributory and apply for nursing care.Thomas J. Kramer (Hrsg.): WISO Pflegeversicherung, Einstufungen, Leistungen, Streitfälle, Frankfurt/ Wien 2004 To apply for this the concerned person must have a prior insurance of about five years in a care fund.Günther Merkens und Werner von Birgelen: Die private Krankenversicherung- die private Pflegeversicherung, eine Arbeitshilfe für die GKV, Sankt Augustin 1999, Seite 294
Meanwhile, the shortage of nurses has become an important topic as well. Nearly one in five employees in nursing would like to leave the profession because of excessive working hours. Mostly, this concerns younger and better qualified nursing staff. The time pressure that is put on professional nurses in difficult care situations usually affects the quality of care for people on need.Thomas J. Kramer (Hrsg.): WISO Pflegeversicherung, Einstufungen, Leistungen, Streitfälle, Frankfurt/ Wien 2004, Seite 29
The care reform
The membership rate Twelve years after its introduction, long-term care was reformed for the first time in 2008. The Act provides, inter alia, a broadening of services. The care reform provides various changes. The membership rate for the long term care was raised on 1 July 2008 by 0.25% so the care rate rose from 1.7% to 1.95%. For people without children, already at least 23, the nursing care rate rise up to 2.2% of the gross salary. The higher care premiums should be sufficient to 2014. After that, the maintenance care rates should adjusted for price increases every 3 years.Bundesministerium für Gesundheit: Das bringt die Reform der Pflegeversicherung, in: http://www.bmg.bund.de/cln_040/nn_604244/DE/Themenschwerpunkte/Pflegeversicherung vom 24.05.2008
Promotion of home care