Definition and legal classification of medical assistance
Die Medical assistance is a central concept in German social law, encompassing the granting of assistance services in case of illness or impending illness. Medical assistance is particularly relevant in the context of the Social Code Books (SGB) as well as the Asylum Seekers Benefits Act (AsylbLG). It includes services for the treatment and cure of illnesses, prevention, and the improvement or alleviation of health complaints when costs are not otherwise covered, such as by statutory or private health insurance.
Statutory foundations of medical assistance
Medical assistance under the Social Code (SGB)
Medical assistance according to SGB XII – Social Assistance
Medical assistance, within the framework of social assistance, is regulated in the Twelfth Book of the Social Code (SGB XII). It constitutes a benefit of health assistance in accordance with §§ 47 et seq. SGB XII. Eligible are individuals who are neither covered by statutory nor private health insurance and who meet the needs-based requirements for social assistance.
According to § 48 SGB XII, medical assistance includes:
- Preventive health assistance
- Assistance in case of illness
- Assistance with family planning
- Assistance during pregnancy and maternity
The scope and type of benefits are generally modelled on the benefits of statutory health insurance, but are provided as benefits in kind or, in certain cases, as reimbursement or cash benefits.
Distinction from other social benefits
Medical assistance under SGB XII must be distinguished from benefits provided by statutory health insurance. It is only granted when there is no compulsory insurance and voluntary insurance has not come about and is also not reasonable. It also differs from benefits under the third chapter of SGB V and similar regulations, which normally presume membership in statutory health insurance.
Medical assistance under the Asylum Seekers Benefits Act (AsylbLG)
For beneficiaries under the Asylum Seekers Benefits Act, medical assistance is regulated in §§ 4 and 6 AsylbLG. In principle, the scope of benefits is limited to the treatment of acute illnesses and pain as well as necessary medical and dental treatments. In individual cases, additional benefits may be granted at the discretion of the authorities if they are essential to safeguarding health.
Other statutory regulations
Medical assistance can also be relevant in other legal provisions, for example in the context of the Victims Compensation Act (OEG) or other specific social systems, where health services are provided in the absence of other insurance coverage.
Eligibility requirements for medical assistance
Neediness and lack of alternative coverage
The central condition for entitlement is the absence of alternative coverage in the event of illness, particularly having no health insurance under SGB V, no private insurance, and no coverage by third parties.
Additionally, neediness as defined in § 19 SGB XII must be established. This means that the applicant has neither income nor assets above the legally stipulated thresholds.
Application and granting of benefits
The granting of medical assistance generally requires an application to the competent social authority. In an emergency, assistance can also be provided immediately to avert acute health dangers. The decision on the scope of benefits and their concrete structure is the responsibility of the respective social welfare agency or district administrative authority.
Scope of medical assistance benefits
Content and scope of benefits
Medical assistance extends particularly to:
- Medical and dental treatment
- Provision of medicines, bandages, and therapeutic products
- Hospital treatment
- Measures for early detection and prevention of diseases (preventive measures)
- Assistance with rehabilitation
Where medically necessary, benefits may also be granted for prevention and compensation of disabilities.
Restrictions and special features
The scope of benefits may be restricted or expanded compared to statutory health insurance; as a rule, however, the scope of statutory health insurance benefits is used as a reference. Specific regulations apply, for example, to asylum seekers, where restrictions may apply for migration or asylum law reasons.
Financing and reimbursement of costs
Benefits in kind and cash benefits
Medical assistance is predominantly granted as a benefit in kind, meaning that social assistance providers enter into contracts with doctors, hospitals, and pharmacies. In exceptional cases, the costs may be covered or reimbursed if immediate assistance is required and benefits in kind cannot be provided at all or in a timely manner.
Contribution by the beneficiary
As a rule, beneficiaries of medical assistance are not required to make co-payments as in statutory health insurance, provided their income and assets are below the relevant thresholds. Co-payments may be stipulated in individual cases, for instance when exclusively receiving dental prostheses.
Legal protection and administrative proceedings
Objection and legal action
In the event of negative decisions regarding medical assistance, both administrative objection proceedings and social court actions are available pursuant to the provisions of the Social Court Act (SGG). In urgent cases, preliminary legal protection can also be applied for to ensure the necessary medical care.
Data protection and confidentiality
In the context of medical assistance, requirements for data protection and the preservation of medical confidentiality must be observed. Data processing takes place exclusively within the framework of the statutory regulations, especially under the social data protection provisions of SGB X.
Importance and current challenges
Societal relevance
Medical assistance provides a minimum standard of medical care for socially or economically disadvantaged individuals in Germany. It is an indispensable part of the welfare state principle and contributes to the protection of human dignity.
Challenges and reform debates
Increasing societal diversity and migration, rising costs in the health sector, and access to standard benefits present new challenges for the administration of medical assistance. In particular, the provision of care for uninsured persons and beneficiaries under the AsylbLG is a subject of ongoing discussion regarding adequacy and the design of the benefit catalogue.
Literature and web links
Further information can be found in relevant commentaries on the SGB, the AsylbLG, and in specialist literature in the field of social law. Legal texts are available via the portal of laws on the Internet of the Federal Ministry of Justice available.
Frequently asked questions
How is entitlement to medical assistance determined under social law?
Entitlement to medical assistance in social law is generally governed by the provisions of the Twelfth Book of the Social Code (SGB XII) and the Asylum Seekers Benefits Act (AsylbLG). What is decisive is always an individual needs assessment that takes into account personal living circumstances, and especially income and assets (§§ 19 ff., 41 ff., 47 SGB XII; § 1ff. AsylbLG). Persons who meet the requirements and do not have a primary statutory or private health insurance may apply for medical assistance. In the administrative process, the competent authority (e.g., social welfare office) checks whether there is a social welfare need for illness-related benefits and grants appropriate benefits as benefits in kind (via medical certificates) or as cash benefits if all requirements are met. In addition, the type and scope of benefits are determined as needed pursuant to § 48 SGB XII, while medical necessity, cost-effectiveness, and appropriateness must be observed. Changes in personal circumstances will also lead to a review, as medical assistance always remains subsidiary to other social benefits.
What benefits does medical assistance under SGB XII include?
Medical assistance under SGB XII is essentially based on the catalogue of benefits provided by statutory health insurance (§ 48 SGB XII in conjunction with §§ 27 et seq. SGB V), although it is not completely identical. Eligible persons receive, among other things, medical and dental treatment, the provision of medicines, bandages, therapeutic and assistive devices, hospital treatment, preventive check-ups, vaccinations, and measures for early disease detection. Rehabilitation benefits may be covered to a limited extent if they serve to prevent, eliminate, or alleviate a disease. Additionally, medical assistance includes benefits for the prevention, early detection, and treatment of illnesses, including necessary follow-up treatment. As a rule, costs for comfort services or medically unnecessary procedures are not covered. Benefits may be granted as in-kind services or cash payments, with medical necessity always being checked individually; exceptions require specific justification.
In what cases is medical assistance excluded?
Exclusion from medical assistance under SGB XII applies in particular if primary benefit systems apply (principle of subsidiarity, § 2 SGB XII). This is the case, for example, if the person concerned is a member of statutory or private health insurance, or can receive support under another social benefit provider (e.g., under SGB V, SGB VII, or SGB XI). Furthermore, for individuals serving a prison sentence, entitlement to benefits is excluded; in these instances, the prison system is responsible for their care (§ 5 AsylbLG, § 46 SGB XII). No entitlement exists for treatments and services that are not approved or not medically necessary. Where the illness is deliberately caused, exclusion of benefits or a reduction in claims may apply under certain circumstances.
How is the cost of medicines and therapeutic products covered by medical assistance?
The coverage of costs for medicines, bandages, therapeutic and assistive devices in the context of social assistance is subject to the requirement of cost-effectiveness (§ 70 SGB XII in conjunction with § 12 SGB V). As a rule, only products that are medically necessary, appropriate, and cost-effective and that fall within the framework provided by statutory health insurance are covered. This generally excludes over-the-counter medicines for adults, unless an exception is made in individual cases. Prescriptions must be issued by a licensed physician; for specific therapeutic and assistive devices, prior approval by the social welfare office may be required. Supporting documents such as medical prescriptions and specialist certificates must be attached to the application; otherwise, reimbursement will not be provided.
Can foreign nationals also receive medical assistance?
Foreign nationals may, in principle, receive medical assistance under SGB XII or the Asylum Seekers Benefits Act, provided they are lawfully resident in Germany and do not have other health insurance coverage. Entitlement depends on residence status: for asylum seekers and those with a toleration status, the AsylbLG applies, which provides a more limited scope of benefits (§ 4 and § 6 AsylbLG). Here, only acute illnesses and pain as well as pregnancy and birth are covered. Special conditions apply to other groups of foreigners, such as EU citizens, regarding the legal prerequisites for residence and possible grounds for exclusion, e.g., if there is no right of residence or inability to work. Particularly, duration and purpose of stay are examined to prevent abuse of social benefits.
What effect does joining statutory health insurance have on medical assistance?
If an eligible person joins statutory health insurance or is enrolled under a compulsory insurance arrangement, entitlement to medical assistance under SGB XII ends (§ 2 SGB XII). Medical assistance benefits are subsidiary and therefore are only granted as long as coverage through other systems (such as statutory health insurance, private health insurance, or civil service benefits) does not exist or is not possible. When eligibility ceases, the social welfare authority must discontinue benefits and, if necessary, reclaim amounts already paid in accordance with the transfer rules under § 93 SGB XII. Dual claiming is legally excluded; medical assistance benefits terminate with the commencement of statutory health insurance membership.
Is there a co-payment obligation for medical assistance benefits?
For recipients of medical assistance under SGB XII, there is generally no obligation to make co-payments for medicines, therapeutic and assistive devices, hospital stays and other medical services, as imposed on those insured under statutory health insurance, as long as doing so would jeopardize their ongoing necessary subsistence (§ 61 SGB XII). The financial burden limits set out in § 62 SGB V usually do not apply; instead, social welfare providers may, on request, waive or cover co-payments if this would otherwise be unreasonable hardship. In practice, the financial resources and reasonableness for the beneficiary are assessed on a case-by-case basis, so that the financially weak are not exposed to disproportionate burdens. What is decisive is a decision at reasonable discretion by the competent authority.
