Dentist: What does the health insurance pay for?

Dentist: What does the health insurance pay for?
Patrick Ott
Martina Martinez
Expert for insurance and finance
18. April 2023

First things first: for almost all dental complaints, there are treatment options that are paid for in full or in part by the statutory health insurance.

We will show you which health insurance benefits you are entitled to at the dentist and which costs are covered by law. Basically, treatment is carried out according to medical necessity, but also from an economic point of view.

The best and most modern treatment methods are usually also expensive options. There is not always room for them in the benefits catalog of the statutory health insurance. If you have a private health insurance, it depends on your contract what is covered.

With private supplementary dental insurance, you can close the gap in the benefits provided by statutory health insurance and reduce your own contribution to the dentist to as little as 0 euros. The selection of the right tariff is crucial.

What is paid: Benefits of the statutory health insurance

  • Preventive dental care
    • Check-up 2x per year
    • Tartar removal 1x per year
    • Early detection of periodontitis 1x every 2 years
    • Individual prophylaxis between the ages of 6 and 18 - e.g. sealing of the fissures of the molars (6 and 7)
    • Dental screening from the 30th to the 72nd month of life
  • Dental fillings
    • anterior teeth: plastic fillings in tooth color
    • posterior teeth: amalgam fillings
  • Root canal treatment
    • Root canal treatment and removal (resection)
    • Root canal treatment and measurement (X-ray)
      IMPORTANT: the tooth must be worthy of preservation, otherwise no services are provided
  • Periodontitis treatment
    • Systemic periodontitis therapy
    • Pre-treatment (e.g. removal of tartar)
      IMPORTANT: periodontitis must be in need of treatment = pocket depth greater than at least 3.5 mm
  • Orthodontics
    • Benefits for KIG classification 3 to 5, no benefit in KIG 1 and 2
    • Removable plastic braces
    • Fixed braces made of stainless steel brackets
    • Costs for stabilization phase
    • For adults only benefits for severe jaw misalignment
  • Dentures
    • Pulling teeth
    • Participation in dental prosthesis with fixed allowance = from 01.10.2020 60 percent of the standard supply
      IMPORTANT: A so-called standard care / standard therapy is defined for each finding. E.g. non-precious metal crown in the posterior region. Implants are not a standard treatment except after a severe accident.

You must pay these costs yourself: Additional private medical services

  • Preventive dental care
    • Professional teeth cleaning (some health insurances subsidize this measure)
    • Fissure sealing for adults or for children, if not tooth 6 or 7
    • Tongue hygiene, oral hygiene
    • Bacterial analysis and DNA test
  • Tooth fillings
    • Replacement of intact fillings
    • Additional costs for higher quality fillings (ceramic, gold)
  • Root canal treatment
    • Complete costs, if the tooth is not considered worthy of preservation
    • Additional costs for modern treatment methods (e.g. measuring or cleaning, laser treatment)
  • Periodontitis treatment
    • Long-term follow-up and preparation for treatment
  • Orthodontics
    • Benefits for children in KIG 1 and 2
    • Internal braces
    • Colorless arches, plastic and ceramic brackets
    • Fixed retainers on the inside of the teeth
  • Dentures
    • Own contribution for dental prosthesis = approx. 50 percent for standard treatment
    • Ceramic or precious metal for crowns and bridges
    • Implants including jawbone augmentation
  • Treatment methods
    • Laser treatment, e.g. for cleaning tooth pockets or root canals
    • Functional analysis and functional therapy measures
    • Naturopathic procedures (acupuncture, hynosis, etc.)
    • Aesthetic services: Veneers, ceramic veneers, bleaching.
    • Etc.

Health insurance benefit must be offered by dentist

Important to know: According to the Social Security Code, your dentist must offer a health insurance benefit if he or she is licensed to do so. This is because people with statutory health insurance have a right to such treatment and it may not be refused. It doesn't matter whether it's a simple filling or a complicated root canal treatment - your dentist is obliged to inform you of the statutory health insurance benefits and treat you accordingly.

Health insurance benefit offered by dentist in Germany
Your dentist must offer a health insurance benefit if he or she is licensed to do so.

In addition, the dentist may then offer additional private medical services and bill you according to the private fee schedule for dentists. These additional services may be of the same or different nature.

Similar additional service: The treatment method corresponds to the standard treatment, but an additional service is added: for example, a tooth-colored veneer is added to the crown in the posterior region.

Different type of additional service: The treatment differs from the standard treatment, e.g. a gap between the teeth is treated with an implant instead of a bridge.

Clarification and consultation

The dentist is also obligated to inform and advise you about all essential circumstances of the diagnosis or therapy. This includes, for example, the type and scope of a necessary measure and the associated risks of dental treatment.

You will find explicit regulations on this in §630 of the German Civil Code (BGB). The information also includes advice on the financial aspects of the treatment, i.e. also on the possible co-payment, e.g. for high-quality dentures.

Public health insurance benefits for dentures

Statutorily insured persons are entitled to a fixed allowance from the public health insurance fund for dental prostheses. The decisive factor is not the type of denture actually selected, but the dentist's findings in the treatment and cost plan. Depending on the findings, there is a medically necessary and financially economical standard provision. Since 01.10.2020, the health insurance company will pay 60 to 75 percent of this standard treatment in the form of a fixed allowance.

It does not matter whether you opt for this care option or want a higher-quality treatment by the dentist. The health insurance company always pays only the fixed allowance for dental prostheses. Anything above this standard treatment is billed privately and is your own contribution.

fixed allowance for dental prostheses
Health insurance pays only the fixed allowance for dental prostheses.

The standard treatment for dentures is usually a metal bridge in which the neighboring teeth are ground down. Many patients therefore opt for higher-quality treatment in the form of implantology. The treatment is gentler and does not damage neighboring teeth. However, the cost of dental implants is also many times higher than standard treatment.

Example: Cost coverage of the statutory health insurance for dental prosthesis.

Findings: Tooth gap in the posterior region (not visible).

TreatmentCosts covered by health insurancepayment
Bridge without veneer (standard treatment) Costs e.g. 660 Euro60 percent 396 Euro40 percent 264 Euro  
Ceramic implant Costs e.g. 3,000 Eurofixed allowance for standard treatment 396 Euro80-90 percent 2.670 Euro

Health insurance benefits for fillings and inlays

The health insurance company pays up to 100 percent of the dentist's bill for fillings. It depends on whether you opt for the standard treatment or want a higher-quality filling in the color of your teeth. The health insurance covers amalgam fillings for posterior teeth and plastic fillings for anterior teeth.

If you decide to have a tooth-colored filling in the posterior region as well, this is a similar higher-quality restoration: The health insurance fund will cover the cost of the amalgam filling. The difference of 40 to 100 euros to the more expensive option is your own contribution.

Another form of private medical care is a so-called inlay, which is specially developed as a filling in the laboratory. It is made of gold or ceramic. The health insurance does not cover any additional costs for inlays; you receive the normal allowance for the filling. The co-payment for an inlay is between 300 and 600 euros. Our current recommendations for dental tariffs cover up to 90 percent of these treatment costs.

Health insurance coverage for root canal treatment

The health insurance company will pay up to 100 percent of the dentist's bill for an apicoectomy or root canal treatment. The decisive factor is whether the tooth is classified as worthy of preservation or not - because only then is it a health insurance benefit.

root canal treatment in Germany
Up to 100% of the dentist's bill for an apicoectomy or root canal treatment in Germany is paid.

If the tooth is not classified as worthy of preservation, the treatments are 100 percent private benefits. In the case of private supplementary insurance, it is important that this covers the costs of root canal treatment even without SHI advance payment.

As with fillings and dentures, there are also different methods of root canal treatment. The health insurance company pays for the standard treatment, but the additional costs for a gentler or more modern method must be borne by the patient.

Health insurance benefits for preventive dental care

The most important preventive measure is the check-up at the dentist. This examination is covered by the health insurance once every six months. The dentist detects diseases at an early stage and can take measures in time. In addition, you increase your fixed cost allowance for dental prostheses through consistent preventive care and keeping a bonus booklet.

The health insurance also covers the costs of tartar removal once a year. Since 2004, periodontal screening has also been included in the benefits provided by the health insurance fund.

Professional dental cleaning (PZR), on the other hand, is not covered by the SHI benefits catalog and must be paid out of pocket. Dentists recommend that PZR be performed at least 1-2 times a year. A good supplementary dental insurance will cover the costs completely. There are also tariffs that cover up to 300 euros per year for bleaching.

Benefits of the health insurance for orthodontics

In 2002, the so-called orthodontic indication groups - KIG for short - were introduced. Here, the malocclusion of the teeth is divided into degrees of severity. Levels KIG 3 to KIG 5 refer to "considerable impairment" in biting, chewing, speaking or breathing. In these levels, the costs of orthodontic treatment are covered by the statutory health insurance. However, 20 percent of the treatment must initially be paid by you as your own contribution. After successful treatment, this will be reimbursed.

The statutory health insurance does not pay for additional private medical services such as internal braces, colorless arches or other modern and aesthetic treatment options. Likewise, there is no cost coverage for braces of the health insurance in the KIG levels 1 and 2. For adults from the age of 18, there are only in a few exceptional cases benefits of the GKV.

It is therefore particularly advisable to have supplementary dental insurance for children, which covers the costs of additional lines and also pays for medically necessary measures in the event of a classification in KIG 1 and 2.

Conclusion: What does the health insurance pay?

In principle, the statutory health insurance allows for a solid dental care. In many forms of therapy of the standard care, the health insurance benefits up to 100 percent, in dental prostheses about half. However, the keyword is standard care, i.e. medically necessary, simple and economical care.

If you want more and want to have access to modern, aesthetic treatment methods, you should think about private supplementary dental insurance in good time. Especially in the case of expensive dental prosthesis measures, e.g. with implants, the personal contribution can be significantly reduced in this way. We can help you find the best supplementary dental insurance for your individual needs.

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