At the dentist: What does the health fund pay for children?

What causes dentist costs to the child?

The statutory health insurance (GKV) covers some costs for children at the dentist. However, the entire spectrum of modern and high-quality dentistry is far from being covered here. Additional costs can be in a variety of areas such as Orthodontics (braces), prophylaxis (professional teeth cleaning for children) and high-quality dentures (after caries or accidents) come to the parents. Therefore, it should always be clear that anyone who wants to protect themselves from the impending costs of using braces or high-quality dentures for children must take out additional dental insurance for children.

What does the statutory health insurance pay for children?

Prophylaxis for children – the GKV pays

– thus prevention and early detection of diseases in the oral cavity –

With § 22 SGB V an attempt was also made to create an individual prophylaxis system for all GKV insured children in the area of teeth, which at least guarantees a minimum level of prophylaxis for them too. These are 4 IP levels (IP1, IP2, IP4, IP5) that describe the different preventive steps at the dentist. These GKV teeth benefits apply to children from the age of 6 to the age of 17.

IP1 survey of oral hygiene status 1x per calendar half-year:

Examination of the oral cavity for caries etc.
Examine gums (gingiva) for diseases
Checking the oral hygiene performed for success
Checking for plaque infestation / plaque retention sites (incl. Staining of the teeth for plaque control)
Possibly. X-ray for caries diagnosis (X-ray in children under strict indication!)

IP2 consultation 1x per calendar half year:

Development and prevention of diseases in the oral cavity
Caries and periodontosis / gingivitis prevention and prevention
Healthy nutrition for healthy teeth
Improvement of oral hygiene (e.g. regular fluoridation at home)
Dental care Explanation and demonstration (proper brushing of teeth, interdental brushes, dental floss & Co.)

IP4 fluoridation of the teeth with varnish or gel should strengthen the enamel 1x per calendar half-year or, in the case of high caries risk, quarterly:

thorough cleaning of the teeth (soft deposits)
draining the teeth
Fluoridation of the teeth

IP5 fissure sealing:

however, only on the rear permanent molars (6 and 7 teeth) – molars
only on toothless teeth
if the permanent molars break before the age of 6, the GKV will also pay for them beforehand
thorough cleaning of the teeth (soft deposits)
draining the teeth
Sealed with hardened plastic

Outside the IP (individual prophylaxis) guidelines, the following costs for the following treatments are reimbursable by the SHI in the area of prophylaxis:

Filling children – cash benefit

In the case of children, plastic filling costs in the anterior region are reimbursed as a cash benefit. However, if plastic fillings in the posterior region are to be used, the parents must bear the costs themselves. Because in the posterior region, statutory health insurance only reimburses amalgam fillings for children. If a higher-quality denture is required, the additional costs incurred must be borne by yourself. There is an exception if there is a proven allergy to amalgam or chronic renal failure. Here, the GKV will also cover the cost of plastic fillings in the posterior region for children.

Dentures e.g. Children’s crown – GKV benefits

Even the smallest ones can have tooth gaps due to accidents or caries on the milk teeth. Under no circumstances should these remain unused for a long period of time, otherwise there will be problems with language development and especially can move or shift the other teeth. This can result in years of orthodontic treatment. Due to the variety of indications, dentures are not uncommon in children.

Children dentures cash benefit:

basically the same reimbursements as for adults
Regular care is reimbursed
Fixed grants are paid for by the health insurance fund, which corresponds to 50% of the costs for standard care
all additional costs incurred (e.g. general anesthesia for over 12 year old, high-quality dentures, more modern treatment methods are not subsidized)

Fixed braces & Co. – Health insurance benefits

Probably the largest and most important area where children can incur additional costs at the dentist is orthodontics (costs for braces). This area is very complex and the cost reimbursement for braces by the cash register varies depending on the severity of the misaligned teeth (KIG1, KIG2, KIG3, KIG4 and KIG5). In some cases, own contributions of € 1,000 and more can still arise here, despite the participation of the statutory health insurance.

KIG 1-2 orthodontics – no cost coverage

When assessing whether health insurance / statutory health insurance covers the cost of braces, KIG levels are used. The severity of the misaligned tooth is determined and divided into the corresponding KIG level. With KIG 1 and KIG 2, statutory health insurance does not bear any costs for braces for children. That If orthodontic treatment is required, all costs incurred must be borne by yourself. It is important to know that some treatment would make medical sense in KIG 2!

Kig 3-5 – Dental braces (standard care)

At KIG 3-5, the health insurance company pays for orthodontics. However, it is important to know that this is only a standard orthodontic treatment with the principle: expedient, adequate and economical. If sensible “better” materials or techniques are often used to make the braces treatment quicker, more aesthetically or more gently, this can lead to additional costs. Statutory health insurance does not pay for these additional costs in the context of treatment with braces and the costs must then be borne by the parents themselves.

Orthodontics – cash benefit or private benefit?
Degree	definition	cash performance
KIG 1	Very slight tooth misalignment e.g. Overbite up to 3mm, open bite up to 1mm, deep bite 1-3mm aesthetically, medical reasons for treatment are usually not given
KIG 2	Slight tooth misalignment e.g. Overbite 3 – 6mm, open bite 1-2mm, Cover bite up to 3mm orthodontic treatment can make sense for medical reasons
KIG 3	Clear misalignment e.g. open bite 2 – 4mm, Cover bite up to 3mm + mucosal injury Orthodontic treatment is medically indicated

KIG 4 Severe misalignment
e.g. Breakthrough disorder,
Overbite 6 – 9mm,
Unilateral cross bite Orthodontic treatment is urgently needed KIG 5 Extreme tooth misalignment,
Anomalies etc. e.g..
Cleft lip and palate,
Relocation of teeth orthodontist treatment inevitable

Misaligned teeth KIG 3-5 – here the GKV pays (Attention: only standard!)

The following diagnoses fall under the KIG 3-5 classification, which means that fixed or loose braces are a cash benefit. Only standard treatment, however. This means that materials or techniques that make the treatment faster, more aesthetic or less painful should be used, additional costs arise. These additional costs must then be borne by the parents themselves.

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