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Submit costs for implants or orthodontic treatment for adults to the statutory health insurance in cases of special exceptions

In special or severe exceptional cases, the statutory health insurance contributes to orthodontic treatment of adults or implants.

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Procedure details

If you have statutory health insurance, many services provided by your dentist are free of charge for you and are billed via your electronic health card (eGK): This applies, for example, to the removal of caries and the filling of holes.

Additional cost regulation for dental fillings

You are entitled to fillings made of the least expensive material. In addition to this standard treatment, you can also choose other materials. In these cases, you will only have to pay the additional costs incurred privately.
If you choose a more expensive material, for which you pay part of the costs yourself, you conclude a so-called additional cost agreement with your dentist. Your dentist settles with the health insurance company the benefits to which you are entitled according to the standard care. You will receive an invoice from your dentist for any additional services.

Allowance for dentures

For dental prostheses (e.g. crowns or bridges), your health insurance fund will provide you with precisely defined amounts as fixed allowances. The amount of the fixed subsidy is 60 percent of the average costs for standard care and can increase to 70 or 75 percent if you have had regular checkups in the last 5 or 10 years before treatment begins and the checkups are documented in your bonus booklet.

Costs that exceed the legally regulated reimbursement amount must be borne by you. Your health insurance company may cover a further amount of the costs if you have only a low income or receive certain social benefits (for example, BAföG, social assistance or unemployment benefit II).

If you have private supplementary dental insurance, you may - depending on the contract - be able to submit additional cost invoices, co-payment invoices and private invoices there. In any case, it is recommended that you inform your private supplementary insurance company before treatment begins and clarify what must be taken into account for any possible reimbursement or which documents are required for this.

Orthodontics

You or your child are entitled to orthodontic treatment if there is a medically justified indication and you or your child have not yet reached the age of 18 when treatment begins. Adults usually have to pay for orthodontic treatment themselves. Only in medically justified exceptional cases, for example in the case of severe jaw anomalies where surgical corrections are also necessary, can insured persons over the age of 18 also be entitled to benefits.

Dental implants

You must also bear the costs of a dental implant and the implant surgery yourself. Only in severe and special exceptions does the health insurance fund contribute to implants, for example as part of an overall medical treatment after a tumor operation.

  • You are a member of a statutory health insurance fund.
  • The treatment and cost plan was approved by your statutory health insurer before the start of treatment.
  • The treatment and cost planning or the oral surgery and orthodontic treatment concept has been approved by your statutory health insurer.

  • Required Documents

    Depending on the dental or orthodontic service you are receiving, your health insurance company may require the following documents in certain cases before treatment can begin:

    • Treatment and cost plan
    • Invoice from the dentist, if applicable, including laboratory invoices
    • If applicable, a copy of your bonus booklet
    • in particularly severe cases (exceptional indications):
      • Cost estimate
    • for adult orthodontic treatment:
      • maxillofacial and orthodontic treatment concept

    Please contact your health insurance company to clarify which documents are required.

For exceptional indications:

You can submit the treatment and cost plan together with the treatment and cost plan for prosthetic treatment by mail and - for many statutory health insurance companies - in person at the office.

  • In the case of implantological or orthodontic services for exceptional indications, your dentist will prepare a cost estimate.
  • Your dentist sends the cost estimate directly to your statutory health insurance fund.
  • Your statutory health insurance fund reviews the application and informs you of approval or rejection.

Additional costs, private billing, co-payment:

  • You will receive an invoice from your dentist and pay the invoice amount.
  • If you have private supplementary insurance, you can ask them whether the costs you have incurred will be reimbursed and which documents are required for this.
  • If your private supplementary insurance requires a rejection letter from the statutory health insurance fund, submit the invoice to your statutory health insurance fund.
  • Your statutory health insurance fund will review the application and send you a rejection notice.
  • You submit the rejection to your private supplementary dental insurance.
  • Depending on the contract, your private supplementary dental insurance will reimburse you for the agreed share of the total bill.

  • You will not incur any costs for the application to your statutory health insurance.
  • You will have to bear any additional costs yourself.

You do not have to observe any deadlines.

Processing usually takes 2 to 7 working days.

For rapid processing and decision-making, your health insurance fund must be provided with the necessary information as well as any required documents in a complete and meaningful manner.
The health insurance company decides on applications promptly, whereby the statutory processing period is adhered to in order to protect patients' rights.
Please note that the processing time indicated is an average value for all health insurance funds. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and may be longer accordingly. The same applies if documents or records are sent to you or your health insurer by mail.
If necessary, an expert opinion must be obtained. This takes up to an additional 6 weeks.

  • Objection
  • Action before the social court

Status: 09.03.2025
Editorially responsible for prodecure description: Bundesministerium für Gesundheit
Source: Federal Portal