Content

Procedure

There is no standardised procedure for the provision of assistive products. Therefore, only a general guide is provided here.

Steps: 1. Requirement 2. Prescription 3. Cost Estimate 4. Cost Coverage 5. Delivery 6. Evaluation Procedure for the Provision of Assistive Products for Private Use Steps: 1. Requirement 2. Prescription 3. Cost Estimate 4. Cost Coverage 5. Delivery 6. Evaluation Procedure for the Provision of Assistive Products for Private Use

This information refers to the supply of assistive products for personal use or specifically for care in the sense of §33 SGB V, i.e. when the 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 required, can be determined, for example, in an acute care 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 person concerned and, if necessary, his or her relatives should be advised about possible assistive products. Products that come into question should be selected in the course of a detailed consultation and, if possible, tried and tested by the users in advance. This can be done in cooperation with the specialist medical supply trade or the advice centres for assistive devices.

In addition to the physical limitations of those affected, 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 care in order to avoid incorrect care. If the willingness or the ability to use a certain product is not present or the conditions in the environment are not available, then the care does not fulfil its purpose.

Assistive products are prescribed by a doctor. Ideally, there should be coordination between the physician, therapist and/or nursing staff, medical supply retailers or assistive product consultants and the person affected.

The required assistive product should be described on the prescription, as accurately as possible, special functions required should also be described. It is also advisable that the physician 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 compulsory benefits of the statutory health insurance (GKV). They are not budget-relevant for doctors and there are no guidelines (monetary value of assistive products, that a doctor can prescribe per quarter and patient) for assistive products.

An entitlement to be supplied with an assistive product by the health insurance company does not automatically result from the prescription by a doctor! The principle of the obligation to provide benefits is that the care must be economical, satisfactory, necessary and appropriate (see § 12 SGB V). Furthermore, it must not be a commodity of everyday life.

The statutory health insurance funds regularly approve assistive products that are listed in the GKV list of assistive products, provided that all necessary requirements are met.

Important note on the list of medical aids: As confirmed by various court decisions, the GKV-Registration of Medical Devices does not have a conclusive character, but is only an orientation and interpretation aid! Therefore, it is also possible that aids that are not listed in the SHI list of aids are covered by the statutory health insurance funds. For this purpose, the treating physicians must usually provide a detailed explanation of the prescription.

Once the assistive product has been selected and prescribed, an application with the cost estimate of the service provider (e.g. medical supply store) must be submitted to the service provider (e.g. health insurance company) prior to procurement. This initiates the approval procedure. The prescribed medical aid cannot be received at the medical supply store with a prescription alone. Every supply of an assistive product is subject to approval by the service provider. After examination of the application and cost estimate by the service provider, the insured person will receive a benefit commitment in the best case.

The following applies to the provision of aids 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 medical aid. As a rule, aids must be obtained from these contractual partners. In individual cases, another company can be commissioned upon request. 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 medical aid as well as the follow-up costs incurred. In principle, aids remain the property of the health insurance company and must be returned when they are no longer needed. Insured persons can also borrow aids from the health insurance company.

When the SHI system provides aids, the principle of benefits in kind (cf. SGB V § 2) usually applies, i.e. the insured person receives the aid directly and not a sum of money to procure the aid.

In most cases, the actual provision of a specific aid is provided by a medical supply store. This is the service provider. There are also other service providers, for example pharmacies or orthopaedic shoemakers.

The provision of an aid usually includes

  • the purchase or loan of the aid
  • the costs for the necessary modification, repair, maintenance and replacement
  • the cost of training in the use of the aid
  • the costs of operation (e.g. charging current for electric wheelchair, batteries for hearing aid)

Whether an assistive device fulfils 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, as well as their knowledge of the correct use of the assistive device.

For this reason, the respective aid should be individually adjusted to the user by therapists or by the medical supply trade. In addition, detailed instructions on how to use the aid should be given in order to avoid incorrect use and the associated bad posture or dangers.

Ideally, the instruction should be given by trained specialists (e.g. occupational therapists, physiotherapists, medical product advisors). Individual situations relevant to everyday life should be practised in order to enable the users to achieve a high degree of independence.

Many aids have to be adapted to the height of the person concerned, for example, in order to make their use possible at all. In addition, certain illnesses require specific equipment of an assistive device, e.g. a headrest or a suitable seat cushion in the case of a wheelchair.

If an assistive device is not or incorrectly adapted, it may not be used or may lead to a worsening of the disability or illness.