Die gesetzliche Krankenkasse zahlt einen Festzuschuss zu Zahnersatz. Darauf haben Versicherte Anspruch.
Die gesetzliche Krankenkasse zahlt einen Festzuschuss zu Zahnersatz. Darauf haben Versicherte Anspruch. Die restlichen Kosten für Zahnersatz tragen gesetzlich Versicherte selber.
„Die Gesamtkosten bei Zahnersatz wie Kronen, Brücken oder Prothesen richten sich danach, welche Behandlung der Versicherte in seinem persönlichen Fall wählt“, erklärt Dr. Erling Burk, Zahnarzt aus Wesel und Vorstandsmitglied der Zahnärztekammer Nordrhein. „Die Kosten für Zahnersatz sind somit immer individuell.“ Die Gesamtkosten setzen sich aus dem sogenannten befundorientierten Festzuschuss der Krankenkasse und dem vom Versicherten zu tragenden Eigenanteil zusammen.
Das zahlt die Krankenkasse – befundbezogener Festzuschuss
Wird bei der Behandlung Zahnersatz notwendig, übernimmt die gesetzliche Krankenkasse (GKV) einen genau festgelegten Betrag, den befundorientierten Festzuschuss. Der Festzuschuss deckt 60 Prozent der Kosten einer sogenannten Regelversorgung (Stand Oktober 2020), also einer medizinisch zweckmäßigen und wirtschaftlichen Basisversorgung als Behandlung. Durch ein lückenloses Bonusheft entsteht Anspruch auf einen höheren Zuschuss. Das Bonusheft dokumentiert die zahnärztlichen Vorsorgeuntersuchungen. Für zerstörte oder fehlende Zähne haben Krankenkassen und Zahnärzte insgesamt über 40 Befunde definiert, welche die Regelversorgung einer Behandlung festlegen. Ein Beispiel: Fehlt im Oberkiefer ein Schneidezahn, gilt der Festzuschuss 2.1 „Zahnbegrenzte Lücke mit fehlendem Zahn“. Die Krankenkasse zahlt als Festzuschuss immer 460,60 € (Stand 1.1.2021) – unabhängig davon, ob sich der Versicherte für eine festsitzende Brücke (Regelversorgung) oder für eine aufwändigere Versorgung, z.B. ein Implantat mit einer Krone, entscheidet. Bei geringem Einkommen übernimmt die Krankenkasse im Rahmen der Härtefallregelung die Kosten für eine Regelversorgung sogar komplett. Bei Privatversicherten hingegen bestimmt der bei der privaten Krankenversicherung abgeschlossene Tarif die Höhe der Erstattung für Zahnersatz wie Kronen, Brücken, Prothesen, Teilprothese oder Implantate.
Über die Regelversorgung hinaus: gleichartiger oder andersartiger Zahnersatz
Bei aufwändigeren Behandlungen, die über die Regelversorgung hinausgehen, spricht der Zahnarzt von gleichartigen oder andersartigen Versorgungen. Gleichartige Versorgungen beinhalten die Regelversorgung und zusätzliche Leistungen wie z.B. eine zahnfarbene Verblendung im nicht sichtbaren Bereich der Zähne. Andersartige Versorgungen enthalten hingegen nicht die Regelversorgung, sondern sind komplett andere Versorgungsformen wie z.B. Implantate. Die durch eine aufwändigere Versorgung entstehenden Mehrkosten tragen gesetzlich Versicherte selbst.
Eigenanteil des Versicherten – so errechnet er sich
Gesetzlich Versicherte können die Art der Versorgung mit Zahnersatz frei wählen. Der Zuschuss der Krankenkasse ändert sich hierdurch nicht. Jedoch ist bei einer aufwändigeren Versorgung mit höheren Gesamtkosten zu rechnen als bei einer Regelversorgung. Der Eigenanteil steigt. Denn er ist die Differenz zwischen den Gesamtkosten der Versorgung mit Zahnersatz und dem Festzuschuss der gesetzlichen Krankenkasse. Entscheidet sich der Versicherte für die Regelversorgung, ist davon auszugehen, dass der Eigenanteil 40 Prozent der Gesamtrechnung beträgt. Mehrkosten, die für eine aufwändigere Versorgungen entstehen, tragen gesetzlich Versicherte selber. Sie erhöhen somit die Kosten für den Patient.
proDente-Tipp: Je höherwertiger die Versorgung, desto höher in der Regel auch der Eigenanteil, den der gesetzlich Versicherte zahlen muss. Lassen Sie sich die verschiedenen Versorgungsformen vom Zahnarzt ausführlich erklären und wägen genau ab, welche Versorgung für Sie im individuellen Fall die richtige ist. Zudem: Ein lückenlos geführtes Bonusheft kann den Zuschuss der Krankenkasse auf 70 bzw. 75 Prozent erhöhen.
Download proDente-Infoblatt
„Zuschuss zum Zahnersatz? Das sollten Sie wissen!“
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