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Dental Prosthetics: A Neutral Comparison of Benefits in Statutory and Private Health Insurance

Dental health plays a central role in well-being. When dental prosthetics become necessary, insured individuals face the question of which costs their health insurance will cover. The systems of statutory health insurance (GKV) and private health insurance (PKV) pursue fundamentally different approaches. This article examines the respective regulations and shows how insurance coverage can be supplemented through additional insurance.

1. The Dual System of Health Insurance in Germany

Statutory Health Insurance (GKV): The GKV is based on the principle of solidarity. Contributions are income-dependent, and benefits are based on medical need and are uniformly defined in the Social Code Book V (SGB V). They are subject to the principle of efficiency ("sufficient, necessary, economical").
Private Health Insurance (PKV): The PKV follows the principle of equivalence. Contributions are based on individual risk and the chosen tariff. Benefits are individually agreed upon by contract and cannot be unilaterally reduced by the insurer.

2. Dental Prosthetics in the GKV: The Fixed Amount Subsidy System

In the GKV, the benefit for dental prosthetics is based on a finding-oriented fixed amount subsidy. This means:

Basis is the finding: The health insurance fund pays a fixed amount based on the dental finding (e.g., "a missing tooth gap"), not on the actually chosen prosthetic.
Coverage of standard provision: The fixed amount subsidy covers 60% of the average costs for the medically necessary standard therapy (standard provision).
Bonus booklet: Through regular check-ups, the subsidy increases to 70% after 5 years and to 75% after 10 years of the costs of the standard provision.
Patient's share: If the patient chooses a higher-quality prosthetic (e.g., an implant instead of a bridge), they still only receive the fixed amount subsidy for the standard provision. The significant additional costs must be borne entirely by the patient.
Orthodontics: Treatments are generally only covered by the GKV for children and adolescents with pronounced malocclusions.

3. Dental Prosthetics in the PKV: Freedom of Contract and Tariff Dependency

In the PKV, the scope of benefits for dental prosthetics depends significantly on the chosen tariff.

Customizable scope of benefits: Insured individuals can choose a tariff that meets their needs – from basic to premium coverage.
Examples of tariff benefits:
- High percentage reimbursements (e.g., 80-100%) for crowns, bridges, and dentures.
- Coverage for implants and bone augmentation.
- Reimbursement for inlays or high-quality fillings.
- Coverage for orthodontics, even for adults.
Basis for billing: Billing is based on the scale of fees for dentists (GOZ).
Cost reimbursement principle: The insured person receives an invoice, pays it, and submits it for reimbursement according to the tariff.

4. Additional Insurance: Targeted Closure of Benefit Gaps

For GKV insured individuals: Private supplementary dental insurance is the most common way to increase the statutory fixed amount subsidy and reduce the patient's share. This can also cover the costs of implants or other higher-quality treatments.
For PKV insured individuals: In the PKV, dental services are already part of the main tariff. An "additional" insurance is usually not necessary here, as the scope of benefits is chosen directly at the time of contract conclusion.

Conclusion and Recommendations

The GKV offers a solid basic level of coverage for standard medical provision through its fixed amount subsidy system. For coverage beyond this, private supplementary dental insurance is a sensible addition.
The PKV offers the possibility to define the scope of benefits for dental prosthetics individually and with contractual guarantees. The amount of reimbursement depends directly on the chosen tariff.

When making your decision, you should consider the following points:

Your benefit entitlement: What type of prosthetic do you desire in case of need (standard or premium)?
Your financial situation: What is your budget for monthly premiums and a potential patient's share?
Your risk tolerance: Do you prefer a fixed subsidy (GKV) or a percentage-based cost reimbursement (PKV)?

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