For crowns, bridges, and prostheses, the statutory health insurance companies cover part of the costs. However, this so-called fixed allowance does not cover everything for dentures – it remains a personal contribution that you as the patient must pay yourself. But how much does the health insurance company pay?
- The finding is the condition of your teeth as determined by your dentist.
- The fixed allowance (officially “findings-oriented fixed allowance”) paid by the statutory health insurance for your dental treatment. The fixed allowance covers 50% of the costs of standard care.
- You must pay the co-payment yourself. It is the difference between the cost of your dental treatment and the fixed allowance from the health insurance fund.
- The dentist identifies a dental diagnosis as a molar tooth with large substance defects that are worth preserving.
- The standard supply is a crown made of non-precious metal without ceramic veneer. Cost: around 300 euros.
- The fund’s fixed allowance is 50%, in this example, it is around 150 euros.
- Your contribution is around 150 euros.
The treatment and cost plan
Before making the dentures, the dentist must prepare a free treatment and cost plan for you. In this, the patient’s dental findings are displayed with a tooth diagram. For each tooth, there is a line with “Findings”, “Standard care” and “Therapy planning”.
The current findings of the dentition and the planned standard care are entered into the treatment and cost plan. If the patient wishes another treatment, this is noted under “Therapy planning”. The dentist also records the estimated material and laboratory costs. For complex work, a cost estimate is requested from the dental laboratory.
The treatment and cost plan should represent the therapy planning and break down the detailed costs for the patient. With the signature, the patient declares that he has been informed about the alternative care, knows the costs, and agrees with the treatment.
The fixed grant: how much is paid?
As a legally insured person, you will receive a 50% subsidy from your health insurance company. But there are certain exceptions:
The hardship regulation
Statutory health insurance exempts the insured from their contribution if this represents an unreasonable burden. The hardship case comes into force if the monthly gross income does not exceed EUR 1,218 or if the patient receives certain social benefits.
In this case, it doubles the fixed allowance, which means that it fully covers the treatment costs of standard care. We can make the necessary dentures despite the low income.
The income limit is not rigidly regulated. This means that you can also receive a grant if you have a slightly higher gross income. The examination of this so-called “individual hardship rule “can be requested from the health insurance company with the treatment and cost plan.
The fixed grant: examples
The performance of the health insurers varies according to the findings, and the planned standard care. The more complex the desired dental prosthesis, the higher the self-contribution that remains.
If, for example, instead of a bridge for 700 euros, an implant is placed for 2,300 euros, you will still only receive the grant for the bridge (in this case 350 euros). Your contribution is then 1,950 euros (over 80% of the costs!).
The more complex the treatment and the desired care, the greater the portion that you must bear. Let your dentist explain the standard care to you and weigh up the advantages of an alternative and therefore more expensive care. You can use the bonus booklet to improve the performance of statutory health insurance.