Advising on tooth replacement: compare reimbursement bases and statutory payments

For tooth replacement, the calculation base determines what a percentage is worth to your customer. As a supplementary dental insurance intermediary, you can make this clear: which amount is being considered, what does the German statutory health fund pay, and what remains for the insured person? A useful comparison starts with amounts in euros and where they come from. Only then does the benefit percentage make sense. Your customer can assess which offer matches the financial protection they want.

Put the statutory payment in the right place

For people covered by German statutory health insurance, the tooth replacement subsidy relates to the clinical findings and the corresponding standard treatment. Section 55 of Book V of the Social Code sets the basic subsidy at 60 percent of the amounts established for that standard treatment. With the prescribed evidence of preventive check-ups, 70 or 75 percent can apply. These percentages refer to standard treatment. Choosing a more expensive option does not turn them into an equivalent percentage of its entire invoice. Establish this distinction before explaining supplementary insurance benefits.

The KZBV explains that the findings-based subsidy also remains available for treatment of the same type with extras, or a different type of treatment. Additional costs change the patient’s contribution. Have the dental practice explain the intended treatment rather than infer the statutory payment from the price of a proposal. Your insurance comparison then needs the actual subsidy figure. An assumed check-up bonus or a self-calculated statutory payment is an uncertain basis.

A higher fixed subsidy supported by check-up records can change how the health fund and supplementary insurer divide the payment. Whether the customer’s final contribution also falls depends on the tariff’s calculation rule. First establish the confirmed statutory amount, then how the specific offer treats it. This prevents the same advantage being counted twice. The customer discusses clinical alternatives with their dental practice; you make their insurance financing comparable.

Keep three amounts separate

Work with three distinct figures: the complete invoice, the costs eligible under the tariff, and the health fund’s prior payment. They can differ. The whole invoice is the starting point for the customer’s actual expenditure. Eligible costs follow from the policy wording. The statutory payment is another payment whose treatment you check in the tariff. Only when all three figures are clear can you calculate the remaining expense reliably.

You can use your own worksheet and record the basis for each number. Put the practice’s cost breakdown beside the invoice amount, the health fund’s information beside its payment, and the relevant policy provision beside the calculation base. Mark an unresolved figure with a question mark instead of estimated precision. This is particularly helpful when a customer brings several offers with similar percentages. You compare the same starting situation and see where the offers actually differ.

A benefit summary can help, but its headlines do not answer every calculation question. Check whether a percentage describes the total including the statutory payment, or an additional benefit based on something else. Also establish whether a stated doubling refers to the fixed subsidy. These formulations differ mathematically. Take the calculation method from the actual offer, then translate it into an understandable amount.

Explain an inclusive percentage

Barmenia Mehr Zahn 90, dated 1 January 2026, provides a specific insurer example. Section B.1 describes 90 percent for tooth replacement including prior benefits from statutory health insurance or another payer. The statutory payment already forms part of that total. It is not added on top of the full percentage. This illustrates one policy rule; assess other offers using their own documents.

Explicitly fictional calculation assumptions: a tooth replacement invoice is €3,000; all costs are assumed eligible for this model; the confirmed statutory payment is €600. No other limits are assumed to apply at this calculation stage. These figures are neither treatment prices nor a benefit commitment for a real case.

At a total rate of 90 percent, the model first produces a combined target amount of €2,700. This already includes the statutory €600. The supplementary payment therefore calculates to €2,100, leaving €300 for the customer. Adding €2,700 in supplementary benefits and a further €600 from the health fund would count the same share twice. Explain that both payers together reach the assumed total percentage, provided the other requirements are met.

Now change only the assumed statutory payment to €750 and keep the other model figures unchanged. The combined target remains €2,700. The calculated supplementary payment falls to €1,950; the customer still pays €300. This second calculation makes the offset visible. The higher statutory payment has not disappeared: it changes the split between payers. Whether a real offer works this way depends on its complete wording, including any bonus provisions.

Compare a subsidy-based formula on the same facts

To compare formulas, place a second, explicitly invented rule alongside it: the supplementary payment equals twice the confirmed fixed subsidy, capped at the invoice balance after the statutory payment. This is not a claimed market offer. Its sole purpose is to show how different bases work with the same invoice.

With €3,000 in total costs and a €600 statutory payment, this model rule produces €1,200 in supplementary benefits. Together, €1,800 would be funded and €1,200 paid by the customer. The factor two refers to the fixed subsidy, not the entire invoice. If the assumed statutory payment rises to €750, the model supplementary payment becomes €1,500 and the customer’s balance €750. A higher subsidy therefore has a different effect from the inclusive percentage calculated earlier.

This gives you a precise comparison question: which amount does the benefit multiplier apply to, and what happens when the statutory payment changes? Let the customer see the amounts side by side. A large number in a tariff name does not answer this any more than the word doubling. At the same premium, different formulas may suit different protection priorities. The decision needs an explained mechanism and a comparison scenario relevant to the customer.

When the eligible cost base is smaller

A total percentage applies only to costs recognised under the particular policy. The Barmenia example explicitly addresses fee limits and reasonable material and laboratory costs in its benefits section. An invoice for €3,000 therefore does not establish that every euro belongs to the same calculation base. Check specific differences against the relevant provision and ask the insurer to clarify unresolved items. General assumptions about arbitrary laboratory prices offer little help.

Another fictional calculation shows the effect: the total invoice remains €3,000, but only €2,600 is confirmed as the insured cost base. The model retains an inclusive rate of 90 percent, with the entire €600 statutory payment offset against it. The combined target becomes €2,340 and the additional payment €1,740. The customer pays €660 of the complete invoice. This change results from the smaller cost base even though the percentage remains unchanged.

Show both parts of this balance: under these assumptions, €400 was never included in the insured cost base, while another €260 is the remaining share of that base. Together they make €660. This explains more than saying that ten percent remains. It helps the customer ask a focused question: which item creates the difference, and what policy provision determines its treatment?

Missing statutory payments also need careful classification. It matters whether an item attracts no entitlement at all or an available benefit was simply not claimed. The insurer example describes a specific deduction for the latter situation. Establish why payment is missing and read the corresponding provision. A zero in the statutory payment column does not automatically increase the supplementary benefit. The explanation should identify the precise facts it addresses.

If the customer mentions a maximum amount, establish whose payment it limits. A cap on the supplementary payment is mathematically different from a cap on the combined reimbursement. Mark where the limit enters your calculation. Only then can you check whether a statutory payment is deducted before or after the cap is applied. If the wording is unclear, ask the insurer for the full calculation using the same inputs. One final sum does not explain the mechanism.

Finally, consider different invoice amounts. If the fixed subsidy remains unchanged as assumed total costs rise, its share of the invoice under a subsidy-based model changes. A percentage of eligible costs behaves differently. You need no forecast of the customer’s future dental health: two clearly labelled scenarios can demonstrate the relationship. The customer can decide which financial uncertainty they want to reduce and what remaining amount they could fund themselves.

Connect the calculation to the actual offer

Before using a model for a specific decision, check the actual policy’s other limits. These may include initial benefit caps, special maximum payments and the requirements for the insured event. Another applicable provision can restrict a mathematically possible payment. Record the formula separately from conditions still needing investigation. This keeps established facts distinct from figures valid only under stated assumptions.

Individual benefit assessment is especially important when tooth replacement is already envisaged. The insurer document recommends submitting a treatment and cost plan before treatment to clarify benefits. Explain which body assesses the individual claim and which documents it actually needs. A mathematically correct illustration does not replace that assessment. Nor should a later invoice date lead you to assume that an earlier treatment need automatically falls within cover.

If the practice changes the proposed treatment, update the calculation too. A different total can come with a different cost breakdown; the insurer’s existing confirmation must match. Do not silently apply the old cost base to a new option. Compare dated versions and describe the decisive change. The customer can then see whether they are deciding about additional treatment costs, a different reimbursement base, or both.

For the final choice, invite the customer to describe the protection they want in their own words. Do they want a clear share of broader eligible expenses or a differently calculated supplement to their statutory subsidy? What remaining amount can they afford themselves? Bring together the current premium, the verified calculation and specific unresolved limits. A decision is stronger when the customer can explain why the chosen calculation method suits their priority.

Find new conversations about tooth replacement cover

Register your business on webRichtung’s supplementary dental insurance page. Enquiries include benefit priorities, self-reported treatment stage, timing and contact details in Germany; diagnoses and cost plans are not supplied. Your welcome email takes you to webRichtung Customer, where you choose area, delivery option and monthly limit. You see the current price before placing a binding order. You then work through the individual benefit decision personally.

Sources

Section 55, Book V of the German Social Code, read in full on 18 October 2026: findings-based subsidy and standard treatment. KZBV: fixed subsidy and patient contribution, read in full on 18 October 2026: treatment types and subsidy base. Barmenia Mehr Zahn 90, dated 1 January 2026, all four pages read on 18 October 2026: B.1 and D.2. A specific insurer example, not a market standard; the tariff applies together with its general conditions.