List of resources of the statutory health insurance
The aids directory of the statutory health insurance in Germany contains a list of those aids , the costs of which must be borne by the German statutory health insurance according to the Aids Directive of the Federal Joint Committee .
basis
It is intended to create comprehensive product transparency for insured persons, service providers, contract doctors and health insurance companies. It includes all aids (technical aids) that are prescribable due to their functionality and their medical benefit, including their quality standards, descriptions and indications for which they can be used in accordance with the statutory health insurance.
In addition to the aids (rehabilitation), the aids directory also contains a list of the nursing aids in accordance with the statutory long-term care insurance.
The directory is created by the National Association of Health Insurance Funds and is continuously adapted to the medical and technical progress. In February 2019, the National Association of Statutory Health Insurance Funds reported : "The list of medical aids includes around 32,500 products in around 2,600 product types."
New products will be added after the medical service of the National Association of Health Insurance Funds (MDS) has checked the requirements.
The basis of the aids directory is § 139 of SGB V , which is implemented with the creation of the directory.
Legal character and binding effect
With the creation of the list of aids, the health insurance companies intended to create an exclusive "positive list" of those aids for which the health insurance companies are obliged to provide benefits. Products that are not listed should be exempt from the obligation to perform, regardless of whether they meet the quality criteria of the directory.
This legal opinion and the corresponding practice of the health insurance companies to only approve the assumption of costs for an aid if it is listed in the list of aids, contradicts the constant case law of the Federal Social Court (BSG):
- "According to this, the central associations of the health insurance funds have not received any legal authorization to finally define their service obligations towards the insured in the sense of a" positive list "through the list of aids. The medical aids guidelines of the Federal Committee of Doctors and Health Insurance Funds of June 17, 1992 (BAnz Supplement No. 183b) in the version of the announcement of October 19, 2004 (BAnz 2005 No. 2 S 89), which under No. 8 still prohibits the contracting doctor from auxiliary aids to prescribe at the expense of the health insurance companies, unless they are listed in the list of resources of the central associations of the health insurance companies, contradict the legal situation, which the BSG has also repeatedly pointed out. "
If an aid fulfills the criteria to correspond to the generally recognized state of medical knowledge and if it is necessary, sufficient, functional and economical, it can be granted even if it is not listed in the list of aids. As a mere administrative regulation for a legal entitlement norm, the list of aids does not have a normative effect. The list of aids should therefore summarize relevant information on aids in a list and give an overview suitable for comparison purposes.
Other legislation
in connection with the preparation of the list of aids in SGB V are important
- Section 33 Aids
- § 34 excluded drugs, remedies and aids
- Section 126 Supply by contractual partners
- Section 127 contracts
- § 213 Resolution by the umbrella organizations of the health insurance companies and
- § 302 Billing of other service providers.
Performance overview
The following (product) groups of aids are listed in the GKV list of aids:
- 01 suction devices
- 02 Adaptation aids
- 03 Application aids
- 04 bathing aids
- 05 bandages
- 06 Radiation devices
- 07 Aids for the blind
- 08 deposits
- 09 Electrostimulation devices
- 10 walking aids
- 11 aids against pressure ulcers
- 12 tools for tracheostomy
- 13 hearing aids
- 14 inhalation and respiratory therapy devices
- 15 incontinence aids
- 16 Communication aids
- 17 Aids for Compression Therapy
- 18 Ambulance / Disabled Vehicle
- 19 nursing items
- 20 positioning aids
- 21 measuring devices for body conditions / functions
- 22 mobility aids
- 23 orthoses / splints
- 24 prostheses
- 25 visual aids
- 26 seating aids
- 27 Speaking aids
- 28 standing aids
- 29 ostomy items
- 31 shoes
- 32 Therapeutic Movement Devices
- 33 toilet aids
- 34 hair replacement
- 35 epitheses
- 36 eye prostheses
- 37 breast prostheses
- 50 care aids to facilitate care
- 51 Care aids for personal hygiene / hygiene
- 52 Nursing aids for more independent living / mobility
- 53 Care Aids to Relieve Discomfort
- 54 Consumable care aids
- 98 Other care aids
- 99 miscellaneous
Aid position numbers
Every aid in the GKV list of aids has a unique identification number. This 10-digit number is made up of "Product group" (2), "Application location" (2), "Subgroup" (2), "Application type *" (1) and "Product" (3). The individual groups are separated by dots.
For example, the aid item number "18.46.05.0.001" corresponds to the "Compact 920 power wheelchair".
- The term "product type" is used for the term "application type" in the 7th position in the current publications (Rehadat / GKV directory)!
Admission procedure
In principle, only products can be included that meet the quality requirements of the corresponding product groups. The prerequisite for the inclusion of new aids in the list of aids is that the manufacturer proves the functionality, safety, the indication-related requirements and the medical benefit of the aid.
Start-up address
According to § 139 SGB V, the GKV-Spitzenverband (GKV-SV) of the health insurance funds is responsible for creating and updating the list of aids. If a manufacturer or distributor wishes a product to be included in the list of aids, a written application must be submitted to the GKV-SV. Appropriate, product group-specific application forms are available for this purpose. The GKV-SV forwards the applications for the purpose of medical and technical evaluation to the medical service of the Central Association of Health Insurance Funds (MDS).
Individual evidence
- ↑ Updated list of resources brings numerous improvements for those insured with statutory health insurance , press release from the National Association of Health Insurance Funds from February 26, 2019; Link checked on March 18, 2019
- ↑ BSG · Judgment of August 3, 2006 · Az. B 3 KR 25/05 R https://openjur.de/u/169002.html
