Dental implants: what does statutory health insurance pay?
People with statutory cover have no entitlement to implants, but there are exceptions.
Fixed subsidy and your own contribution
When it comes to the cost of an implant-supported restoration, the question of reimbursement plays a special part.
When and what does statutory health insurance pay?
As a rule, people with statutory cover have no entitlement to implants. The Federal Joint Committee has defined a small number of exceptional indications for particularly severe cases, for which an entitlement to implant services – the implant and the superstructure – can exist. These exceptions are set out in the guidelines of the Federal Joint Committee under section 91(6) and section 28(2) sentence 9 of Book V of the German Social Code. In these exceptional cases the implant and the prosthetic restoration on it are covered by the health insurer as a benefit in kind. Beyond that, dental implants are purely a private service and are not part of the statutory benefits catalogue. The Federal Joint Committee follows the legislature's intention: only in exceptional cases where it is medically imperative do the insurers cover the cost of implantology.
Exceptional indications:
Section 28(2) sentence 9 of Book V of the Social Code provides that exceptional indications can exist where a conventional prosthetic restoration without implants is not possible, or where the denture-bearing area cannot carry a mucosa-borne restoration.
The exceptions include:
- severe cases of jaw or facial defects caused by tumours, tumour treatment or accidents;
- muscular dysfunction in the mouth and face that cannot be controlled at will, such as spasticity;
- generalised, genetic absence of teeth.
These exceptions are always decided case by case, and the insurers commission expert opinions before deciding.
On this subject the Federal Ministry of Health states:
Private supplementary dental insurance offers members of statutory health insurers cover for restorations and particular dental treatments beyond what the statutory insurer pays. Whether a supplementary policy covers the cost of dental implants depends on the individual contract.
Fixed subsidies
Citizen information: fixed subsidies for dental restorations
As at 1 January 2010
Since 1 January 2005, people with statutory cover have been entitled to findings-based fixed subsidies within contracted dental care for restorations (crowns, bridges, dentures, implant-supported restorations). The entitlement is governed by section 55 of Book V of the German Social Code. Under the rules of the statutory health insurance modernisation act, the earlier percentage contribution by the insurers towards the cost of restorations was replaced by findings-based fixed subsidies towards the care needed in each case. Findings-based fixed subsidies relate not to the medically necessary care in the individual case but to standard prosthetic care for particular findings – the care suitable for treating the majority of cases with those findings.
Introducing findings-based fixed subsidies ensured that insured people can choose any medically recognised form of restoration without losing their entitlement to the subsidy. That applies, for example, to implant-supported restorations (superstructures).
Source: German Federal Ministry of Health
Download the full article: Citizen information: fixed subsidies for dental restorations (in German)
The key points at a glance
- People with statutory cover in Germany generally have no entitlement to implant services.
- For a small number of particularly severe cases, the Federal Joint Committee has defined exceptional indications.
- Since 1 January 2005 there have been findings-based fixed subsidies under section 55 of Book V of the Social Code.
- The subsidy depends on the findings, not on the restoration chosen.
Answered briefly