Definition and Fundamentals of Health Assistance
Health assistance represents a central benefit of social welfare in German social law and is regulated in the Twelfth Book of the Social Code (SGB XII). It is part of the assistance in special life situations (§§ 47 et seq. SGB XII) and serves to provide people with low incomes the necessary health-related services outside of statutory or private health insurance. Health assistance helps to ensure basic medical, therapeutic, and nursing care for those who are excluded from regular health insurance.
Legal Basis of Health Assistance
Legal Framework in SGB XII
The legal basis for health assistance is in particular the Third Chapter (§§ 47-52 SGB XII). According to this, persons who are neither statutory nor privately insured and cannot cover their necessary living expenses from their own resources may claim health assistance from the social welfare provider.
Scope of Application and Requirements
Health assistance is primarily considered when there is no health insurance coverage within the meaning of §§ 5-10 SGB V (statutory health insurance) or within the meaning of the Insurance Contract Act (VVG) and no possibility of family insurance exists. Furthermore, eligibility presumes that neediness according to § 19 SGB XII is present, meaning that income and assets do not exceed certain exempt amounts.
Eligible Persons
Entitled persons include in particular those residing permanently in Germany who, due to lack of alternative health insurance, depend on health assistance. Special provisions apply to foreign nationals, especially asylum seekers and persons with tolerated status, whose medical care is primarily governed by the Asylum Seekers’ Benefits Act (AsylbLG).
Scope of Health Assistance Benefits
Principle of Appropriateness and Necessity
The benefits include all medically necessary measures for the treatment and prevention of diseases. The scope is generally based on the catalogue of benefits of the statutory health insurance (§ 48 SGB XII in conjunction with SGB V). Covered are, among others:
- Medical and dental treatment
- Provision of pharmaceuticals, bandages, and remedies
- Provision of dental prostheses, hearing aids, and orthopedic aids
- Early detection and disease prevention measures
- Inpatient and outpatient hospital treatment
- Pregnancy and maternity assistance
- Home nursing care
- Psychotherapy and medical rehabilitation (to a limited extent)
Limitations and Special Features
Health assistance is subordinate to prior claims against health insurance providers and third parties. If there are maintenance claims or claims for benefits from higher-priority social benefit providers, these must be asserted before making use of health assistance.
The benefits must be ‘economical, sufficient, necessary, and appropriate.’ Restrictions apply, for example, to optional and additional services in hospitals (chief physician treatment, single rooms, etc.).
Procedure and Implementation
Application and Administrative Procedure
Health assistance must be applied for at the locally competent social welfare provider, usually the social welfare office. Within the administrative procedure (§§ 17 et seq. SGB I, §§ 60 et seq. SGB I), all necessary proof of need and lack of health insurance coverage must be provided.
Reimbursement and Direct Billing
Benefits under health assistance are provided either in kind, through direct billing by the service providers with the social welfare agency, or in exceptional cases as monetary benefits (reimbursement of already paid treatment costs). The social welfare agency may conclude framework agreements with service providers in accordance with § 264 SGB V. In practice, affected persons are often issued a so-called treatment card analogous to health insurance.
Special Provisions and Delineations
Distinction from Health Insurance Benefits
Persons with existing insurance in statutory or private health insurance are excluded from receiving health assistance benefits, unless the costs for medical services are demonstrably not or not fully covered. In such cases, supplementary assistance in the form of an allowance may be considered, whereby the subordinate nature of social welfare must always be observed.
Assistance for People without Papers (Undocumented Individuals)
A special group of persons are those without residence permits or papers. In principle, these individuals are also entitled to health assistance. According to § 87 SGB XII, social welfare agencies are required not to report to immigration authorities, provided this is necessary solely for the enforcement of social welfare claims.
Relationship to Other Social Benefits
Health assistance is always subordinate to other social benefits, in particular to benefits under the Asylum Seekers’ Benefits Act, SGB II (basic security for job seekers), or higher-priority private insurance benefits.
Financing and Cost Bearing
The financing of health assistance is provided through the general tax budget of municipalities and federal states. The costs are borne by the social welfare agencies, which must provide for the necessary funds in their budgets. The expenses for health assistance are transparent and subject to budgetary control.
Legal Protection and Appeals Procedures
If a negative decision is made on an application for health assistance, it is possible to file an appeal in accordance with § 85 SGG. After an unsuccessful appeal procedure, legal proceedings may be brought before the Social Court. In urgent cases, especially in medical emergencies, preliminary legal protection can be applied for.
Development and Reforms
Health assistance was most recently developed further with the Act for the Coordination of Social Security Systems as well as various measures to strengthen social health protection. The goal is a continuous alignment with the scope of benefits under statutory health insurance and the closing of gaps in care.
Literature and Sources
- Social Code Book Twelve (SGB XII) – Social Welfare
- Statutes and administrative regulations at federal and state level
- Social court rulings on the interpretation of § 48 SGB XII and related provisions
Conclusion: Health assistance in social welfare law is a central component in safeguarding healthcare for people without health insurance coverage or with special needs. It is clearly legally regulated, designed to be subordinate, and closely linked to societal developments in public health care.
Frequently Asked Questions
Who is entitled to health assistance under SGB XII?
Persons entitled to health assistance under the provisions of the Twelfth Book of the Social Code (SGB XII) are, in principle, those who cannot cover their necessary living expenses and, in particular, the necessary costs of healthcare from their own resources, especially income and assets, and do not have a (sufficient) claim to benefits under the Fifth Book of the Social Code (SGB V) or to alternative health insurance benefits. Eligible persons primarily include those who are neither statutorily nor privately insured or whose health insurance provides only limited benefits. These include, for example, homeless people, people without a fixed residence, foreigners without entitlement to benefits under SGB II or SGB III, as well as certain groups of persons with special residence status. Income and asset testing is carried out according to §§ 85 et seq. SGB XII, with certain exemptions to be observed. The entitlement covers necessary medical and dental treatment, provision of medications, remedies and aids, and other medically necessary measures, if no other coverage exists.
What benefits are provided under the health assistance program?
Under health assistance according to SGB XII, benefits are provided that correspond in scope to those of the statutory health insurance (§§ 47 et seq. SGB XII in conjunction with SGB V). These include outpatient and inpatient medical treatment, dental care, provision of pharmaceuticals, bandages, remedies, and aids, home nursing care, and measures for early detection and prevention of diseases. Rehabilitation services and measures to ensure medical care, such as patient transport, are also included. Excluded are benefits not considered medically necessary or those expressly excluded by statutory health insurance. Benefits are granted according to the principle of benefits in kind, meaning costs are usually settled directly with service providers. Additionally, there is a claim to advice and support in connection with health assistance services.
What role does health insurance play in health assistance?
Primary coverage through health insurance is of crucial importance in the context of health assistance. As long as a person entitled to benefits is covered by statutory or private health insurance and this insurance provides adequate cover, there is no entitlement to health assistance under SGB XII. Only if neither statutory nor private health insurance exists—or the existing insurance provides only inadequate protection—can an entitlement to health assistance be considered. The social welfare office is also obligated to review and initiate, where applicable, the inclusion of those not insured into the statutory health insurance scheme as provided under § 264 SGB V. Health assistance is always provided as a secondary measure and is not intended to replace alternative health insurance, but only to supplement or bridge it.
Are there co-payments or personal contributions required for health assistance?
The principle of personal contribution applies in health assistance, similar to the regulations of statutory health insurance. According to § 62 SGB V, beneficiaries are generally required to make co-payments, for instance for medications, aids, or inpatient stays. However, SGB XII provides for special hardship regulations, as those in need should not be unduly burdened by co-payments. Exemption from co-payments is possible if the annual burden limit of 2% of annual income (or 1% for the chronically ill) is exceeded. The office assesses individually whether and to what extent co-payments are reasonable and, if necessary, assumes the corresponding costs.
How is an application for health assistance submitted and what documentation is required?
Health assistance is generally provided only upon application. The application must be submitted to the responsible social welfare office (social welfare provider). Extensive documentation is required: proof of income and assets, documentation of any existing or previous health insurance, proof of identity, and, where applicable, medical certificates confirming the necessity of certain treatments. Documents regarding residence status must also be provided by foreign applicants. The social welfare office then examines eligibility, the scope of medically required services, and whether primary coverage through health insurance is possible or necessary. If the decision is positive, benefits are usually granted without delay, particularly in acute medical emergencies.
What should be considered in acute emergencies?
In acute medical emergencies, such as life-threatening illnesses or injuries, the social welfare office is required to provide immediate assistance even if a formal application has not yet been submitted. Doctors and hospitals are authorized and obliged to initiate urgently needed measures immediately; the application can then be submitted retrospectively. This results from the duty of care of social welfare agencies and the constitutionally guaranteed right to a dignified minimum existence under Article 1 in conjunction with Article 20 of the Basic Law. In such situations, the costs incurred will retroactively be borne by the social welfare agency, provided the entitlement requirements can subsequently be established.
Is health assistance limited to certain periods or services?
Health assistance is provided only for those periods and services for which need and demand exist. It is not granted as a lump sum or indefinitely, but is tailored to the individual’s needs. A renewed assessment of entitlement is conducted regularly, at least annually or whenever there is a change in circumstances, such as taking out health insurance or an increase in income. Services are always assessed for necessity and appropriateness, and costs for unnecessary or medically unrecognized measures are excluded. Assistance ends as soon as the eligibility requirements cease to apply, such as upon obtaining health insurance or cessation of need.
