How is TDS calculated for incentives

Care circular no. 01/2019 about services of the outpatient HzP according to §§ 61 SGB XII

The personal entitlement to benefits on HzP results from § 61 in connection with §§ 61a, 61bSGBXII. According to this, in addition to the need under social welfare law, there must be a need for care within the meaning of Section 61a SGBXII.

Since 01.01.2017, the concept of need for long-term care of the HzP has been identical to that of long-term care insurance (see § 14 SGB XI). It only experiences an extension to the extent that it does not exclude the granting of benefits if those affected are likely to require care for less than six months. In particular, however, it does not allow an expansion of benefits if the conditions specified by the long-term care insurance are not met. This means that HzP services below care level 1 are excluded.

People are in need of care if they have health-related impairments of independence or skills and therefore need outside help. The criteria from the areas mentioned in paragraph 2 are decisive

  • mobility
  • Cognitive and communication skills
  • Behaviors and psychological problems
  • Self-sufficiency
  • Coping with and independent handling of illness and therapy-related demands and stresses
  • Design of everyday life and social contacts

For the granting of benefits, the persons in need of care must be assigned to one of five care grades according to the severity of the impairment of independence or skills (Section 61b SGBXII; compare Section 15 SGB XI for insured persons).

For uninsured persons and people who do not meet the insurance-law performance requirements, the TdS must prepare or commission an expert opinion to determine the degree of need for care, which is based on the expert opinion form of the MDK in accordance with § 15 SGB XI and the expert opinion Guidelines according to Section 17 (1) SGB XI must be drawn up (Section 62 SGBXII). This is important for outpatient care because of the amount of the care allowance according to § 64a SGBXII as well as the allocation of further benefits according to §§ 64b - 66 SGBXII. The principle of avoiding multiple assessments must be taken into account as far as possible.

In the case of insured persons, the decision of the long-term care fund on the level of care based on the MDK's report is binding (Section 62a sentence 1 SGBXII).

Thus, the granting of HzP comes into consideration

  • as a supplementary help to the benefits of long-term care insurance, taking into account the subordination of social assistance and the needs-coverage principle
  • for people in need of care who are not entitled to long-term care insurance benefits because they
  • are not insured for long-term care (this also includes people who receive medical treatment from a health insurance company in accordance with Section 264 of the Book V of the Social Code)
  • do not meet the waiting period in accordance with Section 33 (2) SGB XI or