Procedure
There is no one standardized procedure for the provision of assistive products. Therefore, only a general guide can be given here.
Procedure for the supply of aids for private use
Procedure for the supply of aids for private use
This information relates to the provision of assistive products for the personal area or specifically to care within the meaning of §33 SGB V, i.e. when care is financed by statutory health insurance.
Based on the DVfR's proposal for an optimal care process, the following steps are relevant for individual and needs-based care.
Whether an assistive product is needed can be determined, for example, in an acute hospital, a rehabilitation clinic or by the family doctor. Ideally, several professional groups (e.g. doctor, occupational therapist, physiotherapist, nursing staff) as well as the affected person themselves and, if necessary, their relatives should advise on possible assistive products. Potential products should be selected as part of a detailed consultation and, if possible, tried and tested by the user in advance. This can be done in cooperation with specialist medical supply retailers or assistive technology advice centers.
In addition to the physical limitations of those affected, it is important to consider their personal life situation, abilities and expectations, the domestic situation, the environment and the general feasibility of the fitting in order to avoid incorrect fittings. If the willingness or ability to use a particular assistive product is not present or if the conditions in the environment are not met, the care will not fulfill its purpose.
Assistive products are prescribed by a doctor. Ideally, there should be consultation between the doctor, therapist and/or nursing staff, specialist medical supply retailer or assistive technology consultant and the person concerned.
The required assistive products should be described as precisely as possible on the prescription and any special functions required should also be described. It is also recommended that the doctor explains the necessity of the prescription in more detail on the prescription. The SHI-assistive product number for the specific product (if available) or an example product should also be listed.
Assistive products are among the mandatory benefits covered by statutory health insurance (GKV). They are not relevant to doctors' budgets and no reference values (monetary value of assistive products that a doctor can prescribe per quarter and patient) have been set for assistive products.
An entitlement to the provision of assistive products by the health insurance fund does not automatically arise from the prescription by a doctor! This is because the principle of the obligation to provide benefits is that the care must be economical, satisfactory, necessary and appropriate (see Section 12 SGB V). In addition, it must not be an item of daily use.
The statutory health insurance funds regularly approve assistive products that are listed in the Statuatory Health Insurance's Medical Technical Aids Register, provided that all the necessary requirements are met.
Important note on the medical technical aids register: As confirmed by various court rulings, however, the Statuatory Health Insurance's Medical Technical Aids Register is not exhaustive, but is merely an orientation and interpretation aid! It is therefore also possible for assistive products that are not listed in the Statuatory Health Insurance's Medical Technical Aids Register to be covered by the statutory health insurance funds. In this case, the treating physicians must usually provide detailed justification for the prescription.
Once the assistive products have been selected and prescribed, an application with a cost estimate from the service provider (e.g. medical supply store) must be submitted to the service provider (e.g. health insurance company) before procurement. This initiates the approval process. The prescribed assistive products cannot be received at the medical supply store with a prescription alone. Every supply of assistive products is subject to approval by the service provider. After the application and cost estimate have been checked by the service provider, the insured person will receive a confirmation of benefits in the best case scenario.
The following applies to the provision of assistive products by statutory health insurance: individual health insurance funds have concluded contracts with service providers such as medical supply stores. These must be named to the insured person so that they know where they can obtain the assistive products. As a rule, assistive products must be obtained from these contractual partners. In individual cases, another company can be commissioned on application. Any additional costs incurred as a result must be borne by the insured person. The health insurance company only pays the contractually agreed price for the assistive products and only the follow-up costs incurred. In principle, assistive products remain the property of the health insurance company and must be returned when they are no longer needed. Assistive products can also be loaned to insured persons by the health insurance fund.
The principle of benefits in kind generally applies to the provision of assistive products by the SHI (see SGB V § 2), i.e. the insured person receives the assistive product directly and not a sum of money to procure the assistive product.
In most cases, the actual supply of a specific assistive product is carried out by a medical supply store. This is then the service provider. There are also other service providers, for example pharmacies or orthopaedic shoemakers.
The provision of assistive products usually includes
- the purchase or loan of the assistive products
- the costs for the necessary modification, repair, maintenance and replacement
- the costs of vocational training in the use of the assistive products
- the costs for the company (e.g. charging current for an electric wheelchair, batteries for a hearing aid)
Whether an assistive product fulfills its purpose depends not only on the nature of the product but also to a large extent on the physical characteristics and abilities of the person using it and their knowledge of how to use it correctly.
For this reason, the respective assistive products should be individually adjusted to the user by therapists or specialist medical retailers. In addition, the user should be given detailed instructions on how to use the assistive products in order to avoid incorrect use and the associated incorrect postures or dangers.
Ideally, instruction should be provided by trained specialists (e.g. occupational therapists, physiotherapists, medical device consultants). Individual situations relevant to everyday life should be practiced in order to enable the people using the device to achieve a high degree of independence.
For example, many assistive products have to be adapted to the height of the people concerned in order to enable them to be used at all. In addition, certain illnesses require an assistive product to be fitted with specific equipment, e.g. a headrest or a suitable seat cushion for a wheelchair.
If an assistive product is not adapted or is adapted incorrectly, it may not be used or may lead to a worsening of the disability or illness.