Pflegegrad-Antrag

The Pflegegrad application and the long-term care insurance benefits that follow rest on the Eleventh Book of the German Social Code (SGB XI), originally promulgated on 26 May 1994 and amended many times since. The central provisions are § 14 SGB XI (definition of need of care), § 15 SGB XI (determination of the grade) and the benefit-granting rules in §§ 36 ff. SGB XI.

Long-term care insurance was introduced in 1995 as the fifth branch of social insurance and follows the principle "long-term care insurance follows health insurance" (§ 1(2) SGB XI). Anyone with statutory health insurance is automatically also covered by social long-term care insurance; people with private health insurance take out a private compulsory long-term care policy.

With the Second Long-Term Care Strengthening Act (PSG II), on 1 January 2017 the previous three care levels were replaced by five care grades (Pflegegrade) and a new definition of need of care was introduced — moving away from the purely deficit-based "in minutes" approach toward the question of how independently a person can manage their daily life. The Assessment Guideline (Begutachtungs-Richtlinie, BRi) of the Federal Association of Long-Term Care Funds is binding alongside the statute.

Since 1 January 2017 there are five care grades. They derive from the score of the New Assessment Instrument (NBA, § 15 SGB XI). The higher the score, the more severely independence is impaired.

• Care grade 1 — minor impairment of independence (12.5 to under 27 points).
• Care grade 2 — substantial impairment (27 to under 47.5 points).
• Care grade 3 — severe impairment (47.5 to under 70 points).
• Care grade 4 — most severe impairment (70 to under 90 points).
• Care grade 5 — most severe impairment with special demands on care provision (90 to 100 points).

Care grade 1 does not entitle to care allowance (Pflegegeld) but entitles to the monthly relief amount of €131, to consumable care aids, a grant for home adaptation and free care courses for relatives. From care grade 2 onwards, full entitlements arise: care allowance, in-kind care benefits, day care and respite care.

The assessment follows the New Assessment Instrument under § 15 SGB XI with six modules that flow into the total score with different weights. The instrument captures how much help the person needs in each module — no longer how many minutes of care are required per day.

• Module 1 — Mobility (weight 10%): standing up, climbing stairs, moving around.
• Module 2 — Cognitive and communicative abilities: orientation, recall, decision-making.
• Module 3 — Behaviour and psychological problems: aggression, restlessness, lack of drive, anxiety. Modules 2 and 3 are jointly weighted at 15%; the higher of the two scores counts.
• Module 4 — Self-care (weight 40%): washing, dressing, eating, using the toilet. Carries the highest weight.
• Module 5 — Coping with illness- and treatment-related demands (15%): taking medication, dressing changes, doctor visits.
• Module 6 — Daily life and social contacts (15%): structuring the day, maintaining contact.

Modules 7 (activities outside the home) and 8 (housekeeping) are recorded but, under the current BRi, do not enter the score.

After the application is received, the long-term care fund commissions the Medical Service (Medizinischer Dienst, MD) — for those with private insurance, the company Medicproof — to carry out the assessment. The assessor, usually a nursing professional or physician, gives written notice and visits the applicant at home or in the care facility at the agreed time.

According to consumer-advice centres, the assessment interview lasts about 60 to 90 minutes. It systematically asks how daily life is managed, what assistance is needed and how independent the person is — for example when dressing, washing or taking medication. Family caregivers should definitely be present and submit a care diary (Pflegetagebuch) covering the past few weeks.

The long-term care fund must decide within 25 working days of receiving the application (§ 18(3) SGB XI). For inpatient care or hospice care, shorter deadlines apply (one or two weeks). If the fund misses the deadline, it owes €70 for every commenced week of delay (§ 18(3b) SGB XI).

From care grade 2 onwards, those needing care can choose between care allowance (Pflegegeld) (§ 37 SGB XI) and in-kind care benefits (Pflegesachleistungen) (§ 36 SGB XI), or combine both (§ 38 SGB XI). Care allowance is paid to those cared for by relatives, friends or acquaintances, with the family organising the care. In-kind benefits are billed directly between the outpatient care service and the long-term care fund.

The care allowance amounts in force from 1 January 2025, as announced by the Federal Ministry of Health (BMG), are:

• Care grade 2 — €347 per month
• Care grade 3 — €599 per month
• Care grade 4 — €800 per month
• Care grade 5 — €990 per month

In-kind benefits are significantly higher because they are intended to fully fund professional services; in 2025 they range from around €796 (grade 2) to €2,299 (grade 5) per month. If combined, the unused share of in-kind benefits can be drawn proportionally as care allowance.

Alongside care allowance and in-kind benefits, long-term care insurance offers a whole bundle of further benefits that may be drawn independently or in addition:

• Relief amount under § 45b SGB XI — €131 per month from care grade 1 onwards; earmarked for supervision, household help or day/night care.
• Substitute care (Verhinderungspflege, § 39 SGB XI) and short-term care (Kurzzeitpflege, § 42 SGB XI), together up to roughly €3,500–€3,700 per year depending on the combination.
• Day and night care (§ 41 SGB XI) as additional partial-inpatient benefit alongside care allowance or in-kind benefits.
• Consumable care aids, currently a flat-rate of up to €40 per month (§ 40(2) SGB XI) for disposable gloves, bed protectors, disinfectants and similar.
• Living-environment improvements — grant of up to €4,000 per measure, for example for a barrier-free bathroom or stairlift (§ 40(4) SGB XI).
• Care courses for relatives (§ 45 SGB XI), free of charge and usually organised by the long-term care fund.

The application is filed without any specific form at the long-term care fund. A phone call, a short e-mail or a one-page letter is enough; the sentence: "I hereby apply for benefits from long-term care insurance under SGB XI" suffices. What matters is that the date the application was received is documented — from that day later benefits relate back.

There are three practical routes:

• By telephone at the long-term care fund — staff will record the application informally and send the detailed application form.
• Online through the portal of your health insurance fund (e.g. AOK, Barmer, Techniker, DAK, BKK).
• In writing by letter or fax; the form can also be picked up at branch offices.

The fund will then send out a questionnaire about your current care situation. Fill it in carefully — it is the basis for the assessment appointment and shapes how purposefully the assessor probes. Professional preparation of the questionnaire and the care diary is, in practice, decisive for an outcome that fairly reflects the points.

A care diary is not legally required, but in the advisory practice of consumer centres, social associations and care support points it is the most important tool for a realistic assessment outcome. It typically documents — over one to two weeks — at which points in the daily routine which assistance is needed.

What to record includes:

• When and how long does help with getting up, washing, dressing or eating last?
• What cognitive issues occur — confusion, day-night reversal, orientation problems?
• What falls or self/third-party endangerment situations occurred?
• How often were wound dressings changed, medications prepared, insulin injected or inhalations performed?
• How much help is needed when leaving the home, at doctor visits or for social contact?

The diary is presented at the assessment appointment. Assessors have very different professional backgrounds — a documented diary protects against an assessment carried out on a "good day" producing a distorted picture.

The 2017 reform integrated two groups systematically into the assessment system for the first time: people with geriatric psychiatric conditions, especially dementia, and children in need of care.

For people with dementia, modules 2 (cognition) and 3 (behaviour and psychological problems) feed weighted into the score. Someone still physically robust may, due to advanced dementia alone, reach care grade 2 or 3 — in the previous care-level system this was often impossible (the so-called "care level 0 problem").

For children up to age eleven there are separate assessment rules. Independence is compared with that of a healthy child of the same age. A special rule applies to infants: until the age of 18 months, all children needing care automatically receive a care grade one level higher than calculated from the NBA points. From age 11 the adult NBA applies.

The role of child and adolescent psychiatry and of social-paediatric centres is described separately in the BRi.

Depending on region and year, long-term care funds reject a substantial share of first-time applications or grant a lower care grade than applied for. The advisory offices of consumer centres, social associations (VdK, SoVD) and care support points see recurring patterns:

• Poorly prepared assessment: without a care diary and without the family caregiver present, many applicants come across in the 60-minute interview as more independent than they actually are in everyday life.
• Existing diagnoses are not mentioned: a dementia diagnosis, advanced Parkinson's disease or severe polyneuropathy colour the entire assessment — they need to be actively presented.
• Observation period too short: the assessment is a snapshot. Those who do not document variability (good and bad days) risk an overly favourable picture.
• Wrong assumptions about insurance status: anyone who has not paid in (or been covered as a dependant) for at least two of the past ten years receives no benefits, § 33 SGB XI.
• Application to the wrong fund after a change of health insurance — competence lies with the current long-term care fund.

An objection (Widerspruch) is admissible against a rejection or against a decision granting too low a care grade. The deadline is one month from notification of the decision (§ 84 SGG). If the legal-remedies notice is incorrect or missing, the deadline extends to one year.

The objection should be lodged in writing with the long-term care fund. Stating reasons is not mandatory but strongly recommended. It makes sense to request the full MD assessment report (§ 18(3) SGB XI grants a right to be handed it) and check point by point in which NBA modules the assessment diverges from reality. An additional medical statement or an updated care diary often helps.

If the objection is unsuccessful, an action before the Social Court (Sozialgericht) is possible (§ 51(1) no. 2 SGG). The deadline for filing suit is also one month from service of the objection decision. The first-instance proceedings are free of court costs; advice from a social association or specialist lawyer for social law is often advisable.

Today's care grades are the result of three reforms that came into force as the Long-Term Care Strengthening Acts (PSG I–III) between 2015 and 2017:

• PSG I (1 January 2015): increase of benefit amounts, extension of substitute care, introduction of care leave for relatives.
• PSG II (1 January 2017): new definition of need of care (§ 14 SGB XI), replacement of the three care levels by five care grades, introduction of the NBA with six modules.
• PSG III (1 January 2017): improved interlinking with assistance for care under SGB XII, strengthened role of municipalities in care advice.

Building on these, further amending acts came into force, including the Long-Term Care Support and Relief Act (PUEG) 2023, which raised long-term care insurance contributions and, among other things, expanded wage-replacement benefits for caregivers. As of 1 January 2025, all cash and in-kind benefits were raised by a flat 4.5% — hence the currently valid figures (care grade 5: €990 care allowance per month).

The long-term care fund (Pflegekasse) is organisationally part of the health insurance fund. So if you are insured with AOK, you are also insured for long-term care with AOK; the same applies to Barmer, DAK, Techniker, BKK Mobil Oil, Knappschaft and all other statutory funds. Privately insured persons are covered by the private compulsory long-term care insurance; assessments run through Medicproof.

Those needing care and their relatives have a right to free care advice under § 7a SGB XI. This can take place:

• directly at the long-term care fund,
• at a care support point (Pflegestützpunkt) — present in most federal states, run jointly by funds, the state and municipalities (§ 7c SGB XI),
• or by an independent care-advice service recognised by the fund.

Advice covers the choice of benefits, the combination of care allowance and in-kind benefits, care courses and aids. It is also relevant for the arrangements of outpatient and partial-inpatient care (day and night care).

One often-underestimated peculiarity of the Pflegegrad application is its retroactivity: benefits are paid from the first day of the month in which the application reached the long-term care fund (§ 33(1) SGB XI). Anyone who calls on the 30th of a month and files an informal application secures the entitlement for the entire month — even if the assessment process is concluded only weeks later.

After a positive decision, the long-term care fund transfers the care-allowance amounts that have accrued since the application month as a back payment; from the following month, regular monthly payments begin. In-kind benefits are settled directly between the care service and the fund; family caregivers receive no money in their own account under this model but benefit from the professional support.

The care grade is in principle open-ended — a deterioration in the need of care does not automatically lead to reclassification; that requires a request for upgrading. If the need of care permanently improves, the fund may downgrade ex officio, which in practice rarely happens.