Level of care in Germany – how is it awarded?

The level of care in Germany reflects a person’s need for care services and determines eligibility to receive benefits from the care insurance fund. It is awarded after a thorough assessment of the applicant’s health status. How does such a procedure work? What costs can be reimbursed? This is the subject of today’s article.

Who is awarded care grades?

Care grades are awarded to persons who because of various health impairments have limited independence and ability in daily life. This applies both to physically disabled persons and to persons with dementia, chronic mental illness, or intellectual disability. Until 2016, three different care grades applied in Germany.

In 2017, changes were introduced by the Second Act to Strengthen Long-Term Care, under which, depending on the degree of impairment, one of the care grades is awarded following prior assessment: 

• care grade 1,
• care grade 2,
• care grade 3,
• care grade 4,
• care grade 5.

How is the level of care assessed?

All persons applying for nursing care must undergo a special assessment procedure that determines the need for assistance. Taking into account many factors, the intensity and duration of care can be established. Individual cases differ greatly – in some situations, occasional visits to the patient are sufficient; in others, the permanent presence of a qualified nurse is required. 

Ultimately, approval of the care grade and the associated funding is decided by the applicant’s care insurance fund.

Who carries out the assessment of the level of care?

Who carries out such an assessment? Usually, these are experts from the medical service employed by the long-term care funds. The assessment takes place at the applicant’s home and consists of checking all aspects related to daily functioning and the obstacles faced by the person in meeting basic needs.

In addition to assessing the level of care, the tasks of medical service staff also include providing advice on caring for the patient, valuation for long-term care insurance, and ensuring high-quality services. How is the level of care assessed?

Care assessment criteria

The person responsible for determining a person’s independence takes the following criteria into account:

• mobility – it is important to what extent the assessed person is able to move around the apartment independently and whether changes of position can be made freely,
• cognitive and communication skills – communication with the surroundings and the ability of the ill person to make decisions are assessed in order to determine whether orientation in place and time in everyday life is possible,
• behavioural and psychological problems – checking whether psychological problems such as aggressive behaviour or states of anxiety occur, and determining how often assistance from a third party is needed in such situations,
• self-sufficiency – it must be determined to what extent the person is able to care for basic daily needs independently, 
• independent coping with requirements and burdens caused by illness or therapy – determining the level of assistance in coping with illness and treatment (taking medication, performing rehabilitation exercises, changing dressings),
• structuring everyday life and social contacts – checking whether the ill person is able to plan the day independently and maintain social contacts.

Points for assessing the level of care

After the above categories have been analysed, points are awarded for each of them, which, when added together, result in the appropriate care grade. Each assessment takes into account the intensity and frequency of the support required in a given aspect of daily life. A higher number of points means that a person requires a broader range of care services and greater support, and as a result may obtain a higher care allowance.

After the assessment has been carried out, the care fund sends notification of the assigned care grade. It should be noted that the assigned category can be appealed or rejected if the assessment is not accepted. To do this, the appropriate form must be submitted to the Pflegekasse together with a justification.

Care grade 1

Care grade 1 is awarded to persons with minor limitations in independence. This applies where an elderly person or an ill person still manages many everyday activities but needs support in organising the day, managing the household, monitoring medication, or functioning safely at home. In practice, this may also include persons with initial symptoms of dementia, Alzheimer’s disease, or other cognitive problems, but the care grade itself does not depend on the diagnosis alone, but on the actual level of independence.

Care grade 2

Care grade 2 means a significant limitation of independence. It is awarded to persons who need regular assistance with daily activities such as washing, dressing, preparing meals, moving around the home, taking medication, or organising the day. It is no longer about the number of minutes of care per day, but about the extent to which a person is unable to function independently without support from relatives, a caregiver, or care services.

Care level 3

Care level 3 is awarded to persons with severe limitations in independence. Such a person usually requires frequent assistance with personal hygiene, dressing, eating, moving around, using the toilet, or coping with the consequences of illness. This group may also include persons with urinary incontinence, orientation problems, advanced dementia, or limited mobility, if their daily functioning requires constant and well-organised support.

Care level 4

Care level 4 means a very severe limitation of independence. It is granted to persons who depend on the assistance of others for most basic activities – both during the day and often at night. This may apply to bedridden persons, persons with serious mobility, neurological or cognitive problems, or after severe illnesses. At this level, care usually includes not only help with hygiene, eating and moving around, but also continuous monitoring of health status and prevention of a deterioration in the person’s condition.

Care level 5

Care level 5 is the highest level and applies to persons with the most severe limitations of independence and particularly high care needs. These are persons who practically cannot function without constant assistance and require intensive support in basic activities of daily living, personal care, mobility, taking medication, or carrying out prescribed medical and care tasks. In practice, this concerns cases in which very extensive, regular and specialised care is needed, often around the clock.

Changes in the care system from 2026

From 1 January 2026, significant changes to care benefits were introduced in Germany, aimed at improving the situation of persons in need of support and their caregivers. The most important changes include:

• Increases in care benefits:
  • Care level 2: €347 per month (increase of €15).
  • Care level 3: €599 per month (increase of €26).
  • Care level 4: €800 per month (increase of €35).
  • Care level 5: €990 per month (increase of €43).
• Increased benefits for day and night care:
  • Care levels 2–5 will see an increase of between €32 and €90 per month.
• Increases for inpatient care:
  • Benefits will rise by between €35 and €99 per month depending on the care level.

Shared budget for substitute care and short-term care in 2026 

Since 1 July 2025, Germany has had a shared annual budget for Verhinderungspflege and Kurzzeitpflege, i.e. substitute care and short-term care. In 2026, this arrangement applies for the entire year and gives persons with Pflegegrad 2–5 up to €3,539 per year to use for both forms of support. This means that the family no longer has to divide the funds rigidly between two separate benefits – the budget can be used flexibly, for example partly for replacement care at home and partly for a short-term stay in a care facility. 

An important change is also the abolition of the previous 6-month care requirement before the first use of Verhinderungspflege, which means that support can be obtained immediately after the relevant care level has been granted. 

From 1 January 2026, a shorter deadline also applies for settling Verhinderungspflege costs. The application for reimbursement, together with documents confirming the expenses, must be submitted no later than the end of the calendar year following the year in which substitute care was provided. For example,costs incurred in 2026 can only be settled until 31 December 2027 – after that, the right to reimbursement expires. The new rule replaces the previously much longer four-year deadline, so receipts and applications should not be put off.