Procedure
There is no one standardized procedure for the supply of assistive products. Therefore, only a general guide can be given here.
Hifsmittel supply procedure for private use
Hifsmittel supply procedure for private use
This information relates to the provision of assistive products for personal use or, more specifically, to care within the meaning of §33 of the German Social Code, Book V, i.e. when care is financed by a statutory health insurance.
Based on the DVfR's proposal for an optimal supply process, the following steps are relevant for an individual and needs-based supply.
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, nurses) as well as the affected person him/herself and, if necessary, his/her relatives should discuss possible assistive products. Products that come into question should be selected as part of a detailed consultation and, if possible, tried and tested in advance by the users. This can be done in cooperation with medical supply stores or assistive device counseling centers.
In addition to the physical limitations of the people concerned, it is important to take into account 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, a supply does not fulfill its purpose.
Assistive products are prescribed by a physician. Ideally, there should be coordination between the physician, therapist and/or nursing staff, medical supply retailer or assistive device consultant and the person affected.
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 advisable for the doctor to explain 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 of the statutory health insurance (GKV). They are not budget-relevant for physicians, and no reference values (monetary value of assistive products that a physician can prescribe per quarter and patient) are defined for assistive products.
An entitlement to the provision of assistive products by the health insurance fund does not automatically result from the prescription by a physician! This is because the principle of the obligation to provide benefits is that the supply must be economical , satisfactory , necessary and appropriate (cf. § 12 SGB V). In addition, it must not be an object of daily use.
The Statuatory Health Insurance's Medical Technical aids register regularly approves assistive products that are listed in the Statuatory Health Insurance's Medical Technical aids register, provided that all necessary requirements are met.
Important note on the medical technical aids register: As confirmed by various court rulings, the Statuatory Health Insurance's Medical Technical Aids Register does not have a conclusive character, but is only an orientation and interpretation aid! Therefore, it is also possible that assistive products that are not listed in the Statuatory Health Insurance's Medical Technical Aids register are covered by the statutory health insurance funds. In this case, the attending physician must usually provide a detailed justification for the prescription.
After selecting and prescribing the assistive products, an application with the 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 procedure. 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 the cost estimate have been reviewed by the service provider, the insured person will, in the best case, receive a confirmation of benefits.
The following applies to the provision of assistive products by the statutory health insurance: Individual health insurance companies have concluded contracts with service providers such as medical supply stores. The insured person must be informed of these so that he or she knows where to obtain the assistive products. As a rule, assistive products must be obtained from these contractual partners. In individual cases, another company can be contracted upon 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 also only the follow-up costs incurred for them. 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.
When assistive products are provided by the SHI, the benefit-in-kind principle usually applies (cf. SGB V § 2), i.e. the insured person receives the assistive product directly and not an amount of money to procure the assistive product.
In most cases, the actual provision 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 orthopedic shoemakers.
The supply of an assistive product usually includes:
- the purchase or loan of the assistive products
- the costs for the necessary modification, repair, maintenance and replacement of the device
- the costs of vocational training in the use of the assistive products
- the costs for the company (e.g. charging current for electric wheelchair, batteries for 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 the product, as well as on their knowledge of the correct use of the assistive product.
For this reason, the assistive products should be individually adjusted to the user by therapists or medical supply stores. In addition, detailed instruction in the use of the assistive products should be provided in order to avoid incorrect use and the associated incorrect postures or dangers.
Ideally, the instruction should be given by trained specialists (e.g. occupational therapists, physiotherapists, medical product 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 a specific fitting of an assistive product, e.g. a wheelchair with a headrest or a suitable seat cushion.
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.