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Under certain conditions, statutory health insurance companies cover the costs of medically necessary orthodontic treatment for children and adolescents. You can have your own contribution reimbursed by your health insurance company after treatment.
Statutory health insurance companies pay for orthodontic treatment for insured persons who have not reached the age of 18 at the start of treatment, if the treatment is medically necessary.
The orthodontist will assess whether the treatment is medically necessary for your child based on so-called orthodontic indication groups (KIG) and their 5 degrees of severity. The statutory health insurance companies will pay for your child's orthodontic treatment from severity level 3, which means, for example, that a jaw or tooth misalignment already significantly impairs your child's biting, mouth closure or joint function, or threatens to do so in the future.
The orthodontist will bill the Kassenzahnärztliche Vereinigung directly for the orthodontic treatment, minus your own contribution. Your co-payment amounts to 20 percent of the SHI-accredited costs. If you have more than one child undergoing orthodontic treatment, your co-payment for the second and each additional child is reduced to 10 percent of the SHI-accredited costs. The prerequisite is that they live in the same household.
Once the treatment has been successfully completed, the statutory health insurance will reimburse your own contribution. To do this, you must submit an application to your health insurance company or your child's health insurance company and submit some documents, such as the final report from the orthodontist or orthodontist and the co-payment invoices with corresponding proof of payment.
Cost absorption for adults
The costs for orthodontic treatment started at the age of 18 can only be covered by the statutory health insurance in very few exceptional cases. These include, for example, severe jaw anomalies where surgical corrections are also necessary. In these cases, your orthodontist will create a coordinated oral surgery and orthodontic treatment concept.
For reimbursement of copayments for orthodontic treatment, proceed as follows:
Standard care for children and adolescents:
Exceptional indications for adults:
As a rule, you do not have to observe any deadlines.
Processing usually takes about 2 to 5 working days.
For rapid processing and decision-making, the 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, while adhering to the statutory processing time limit 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 the health insurer by mail. An expert opinion may be required. This takes up to an additional 6 weeks.
Outpatient or inpatient preventive care can help you avert the threat of illness or the need for long-term care. You apply for the preventive care benefit from your health insurance fund.