Standard supply
Under standard care are in the health insurance statutory understood those medical services that over the collective bargaining agreement are entitled to all statutory insurance schemes.
In the context of dental care, the term input in § 75 f. of SGB V found. Here, standard care refers to those dental prostheses that are medically necessary and that are carried out according to a method recognized in accordance with Section 135 (1) SGB V. The Federal Joint Committee (G-BA) adopted guidelines for this on January 1, 2005. The patient can choose whether he wants to take standard care, or whether he prefers a similar type of treatment or a different type of treatment than dentures. The patient is entitled to a fixed allowance for standard care - regardless of the type of care chosen.
Principles for a dental prosthesis
The aim of providing dentures is to restore adequate functionality of the chewing organ or to prevent its impairment. Dentures is displayed when a tooth or several teeth are missing or destroyed and if thereby the functionality of the masticatory system is impaired or is liable to be impaired, such. B. by tooth migration or tilting. When supplying dentures, there should be functionally adequate opposing teeth or should be created during the course of the treatment. A new denture is not indicated if the existing denture is still functional or the functionality can be restored (e.g. by expanding ). (Dental prosthesis guidelines of the Federal Joint Committee, Section C, No. 6, 7.)
Insured persons are entitled to the medically necessary supply of dental prostheses including dental crowns and superstructures (dental and dental technical services) in those cases in which dental prosthetic care is necessary. The quality and effectiveness of the services must correspond to the generally recognized state of medical knowledge and take into account medical progress. This also applies to similar and different types of supplies. (Guidelines Section B, No. 3.)
Participation of the patient
The cooperation of the patient is an essential prerequisite for achieving the treatment goal. Regular dental care and evidence of dental examinations in accordance with Section 55 (1) SGB V are important criteria for determining the type of dental prosthesis that is necessary in individual cases. Evidence of these must be provided in a bonus booklet . If the patient's oral hygiene is inadequate and / or if the patient refuses to participate in any necessary periodontal treatment, the treatment goal must be redefined. (Guidelines Section C, No. 9.)
Cooperation of the health insurance companies
The dentist applies for the diagnosis-based fixed allowance for standard care from the responsible health insurance company by means of a treatment and cost plan. The health insurance company can have the findings, the need for care and the planned care assessed. (Guidelines Section C, No. 10.)
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Standard supply
As part of the health reform “Health System Modernization Act” (GMG) , subsidies for dentures were reorganized from January 1, 2005. Since then, the decisive factor has been the dentition diagnosis, from which the fixed contribution from the health insurance company to the dentures considered appropriate for this diagnosis is derived. The decisive factor is the usability of abutment teeth as bridge or prosthetic anchors, which depends on the value of the abutments . The health insurance benefits are therefore called findings- oriented fixed allowances . This dental prosthesis, which is considered appropriate, sufficient, economical and necessary for the respective condition of the teeth, is called standard care. Over 40 definitions for destroyed or lost teeth (findings) are cataloged. For each finding, an amount is set that is adjusted every year. The relevant guidelines adopted by the joint federal committee (G-BA) were described for the individual types of care as follows:
Dental crowns
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Dental crowns can be indicated:
- to preserve a tooth that is capable of being preserved and is worth preserving, if preservation of the tooth by other measures is no longer possible or not possible in the long term,
- to support a dental prosthesis when support and retention is not possible in any other way.
- Dental crowns are not indicated for teeth that remain without antagonists in the long term and are not required for anchoring dentures.
- Prefabricated crowns may only be used in pediatric dentistry .
- For the restoration with a provisional crown, a provisional restoration produced in a direct process is generally sufficient.
- Metallic full and partial crowns are part of the standard care. Also at standard care include vestibular veneers in the upper jaw up to and including tooth 5, in the lower jaw up to and including tooth 4. In the area of the teeth 1 to 3 vestibular veneer includes the cutting edge. (Guidelines Section C, No. 16-20.)
Bridge supply
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Bridges are indicated
- when this restores the closed row of teeth in a jaw .
- End pier bridges are usually indicated.
- Cantilever bridges are only indicated up to the width of the premolar and including at least two abutment teeth; The replacement of molars and canines with cantilever bridges is excluded in gaps .
- To replace an incisor, if there is sufficient oral enamel on one or both abutment teeth, a single-span adhesive bridge with a metal framework with one or two wings may be indicated. In the case of single-wing adhesive bridges to replace an incisor tooth, the tooth adjacent to the pontic of the adhesive bridge, which is not the carrier of a wing, should not need a crown and should not be provided with a crown that needs to be replaced.
- Adhesively fixed single-span bridges in the anterior region with metal frameworks are only part of the standard care for insured persons between the ages of 14 and 20. The abutment teeth should be free of caries and fillings . The span to be bridged should in principle not include more than one tooth.
- Metallic full and partial crowns are part of standard bridges. Vestibular veneers in the upper jaw up to and including tooth 5 and in the lower jaw up to and including tooth 4. In the area of teeth 1 to 3, the vestibular veneer also includes the incisal edges.
- In the case of disparallel abutments, the contract dental care also includes the attachments required as a result. (Guidelines Section C, Nos. 22-26.)
Removable dentures
- In the case of partial dentures, a periodontal (on the teeth) supported model cast construction is usually indicated.
- In the case of residual dentition without the possibility of periodontal support, a plastic prosthesis without complex retaining elements is usually indicated.
- With full dentures , the base is usually made of plastic. A metal base is only part of the standard care in justified exceptional cases (e.g. torus palatinus and exostoses ).
The necessary holding and supporting devices belong to the dentures. Intraoral support pin registrations to determine the central position are only part of the standard care in addition to the full denture or cover denture prosthesis, also on implant-supported full dentures in the upper and lower jaw, if the positional relationship between the lower and upper jaw cannot be determined reproducibly using simple methods.
Functional analytical and functional therapeutic services are not part of contract dental care. (Guidelines Section C, Nos. 27–30, 33–34.)
Combination supply
A combination supply is understood to be a dental prosthesis in which fixed and removable dental prostheses are combined to form a functional unit using connecting elements.
Combination supplies are indicated
- if a static and functionally more favorable loading of the remaining teeth and a favorable retention can be achieved compared to other types of dentures.
- As part of standard care (with the exception of cover denture prostheses), only telescopic / conical crowns on canines and the first premolars belong to the connecting elements. With a remaining tooth stock of up to three teeth, in addition to the initial periodontal situation of the remaining teeth, the gap topography with regard to the type of anchoring and support must be critically assessed. In this case, standard care includes both cover denture prostheses and periodontally supported prostheses with a model cast base and, as connecting elements, resilience telescopic crowns and root post caps or telescope / conical crowns. (Guidelines Section C, No. 35.)
Dentures on implants
Implants are not part of standard care. The dental prosthesis built on implants (superstructure) is part of the standard care in the following exceptional cases:
- for tooth-limited individual tooth gaps (switching gap), if
- there is no need for periodontal treatment,
- the neighboring teeth free of caries and
- are not in need of crowning or crowned as well
- with atrophied toothless jaw
In the case of single tooth gaps, the superstructure is limited to a single crown.
If the toothless jaw is atrophied, the superstructure is limited to the full denture. (Guidelines Section C, No. 26–39.)
Similar care
If insured persons choose a dental prosthesis of the same type that goes beyond the standard care according to Section 56 (2) SGB V, they have to bear the additional costs compared to the services listed in Section 56 (2) sentence 10 SGB V themselves. Similar dentures exist if they include the standard benefit and additional benefits are added. Examples are a full veneer of crowns, which in the posterior area of certain teeth consist only of metal as a standard restoration (see illustration) or a partial denture that is attached to your own crowned teeth with invisible fasteners instead of brackets. (Guidelines Section B, No. 4.) The statutory health insurance companies pay the subsidy for standard care for this, but not for the additional services, neither the fee nor the associated material and laboratory costs.
Different care
Insured persons are entitled to the reimbursement of approved fixed allowances in accordance with Section 55 (5) SGB V if a different type of care is provided that deviates from the standard care. A different type of restoration exists if a different form of restoration (bridges, removable dentures, combination restoration, superstructures) than that described in the standard benefit for the respective diagnosis is selected. (Guidelines Section B, No. 5.) For example, instead of a partial prosthesis, an implant is provided. The same applies if the diagnosis-oriented fixed allowance provides for a removable dental prosthesis, but instead fixed bridge dentures are made. In these cases, too, the patient receives the fixed allowance for standard care. The additional costs, both the additional fee costs and the additional material and laboratory costs, must be borne by the patient.
Reward
Standard care is billed according to the assessment standard of dental services (BEMA), the list of fees for those with statutory health insurance. For this, the patient receives a diagnosis-based fixed allowance , the amount of which depends on the bonus booklet or, in cases of hardship, covers the total costs. In the case of similar care, the BEMA as well as the private fee schedule for dentists (GOZ) issued by the federal government, and in the case of different care, only the GOZ is charged. The patient must bear the difference to the fixed allowance for standard care himself.
Non-contractual services
For all three types of supply, additional non-contractual services according to the GOZ can be agreed. Non-contractual services are excluded services of the GKV, regulated in § 28 SGB V.
Billing
The dentist bills the fixed allowance for standard care via the Association of Statutory Health Insurance Dentists , which in turn bills the costs of the respective health insurance company. The payer receives an invoice directly from the dentist for the co-payment. In the event that the insured person has chosen to reimburse the costs , he pays the full amount of the invoice to the dentist and submits the treatment and cost plan for reimbursement of the fixed allowance to his health insurance company.
See also
Web links
Bonus smile , information page on standard care and fixed subsidies from the dental associations, Kdö.R.
Individual evidence
- ↑ a b c d e f g h i j k Dental prosthesis guidelines of the Federal Joint Committee (PDF; 59 kB)
- ↑ proDente, fixed grants (PDF; 552 kB)
- ↑ Dental prosthesis guideline: Adaptation in Section D. II. Numbers 22 and 24 - Adhesive Bridge , Federal Joint Committee, entry into force on May 3, 2016. Accessed on February 7, 2017.
