Persons who have health-related impairments of independence or abilities and therefore require help from others may be entitled to assistance with care in accordance with Book XII of the German Social Code (SGB XII) if the benefits provided by the long-term care insurance fund and their income and assets are insufficient.

The reason for the need for assistance may be physical, cognitive or mental impairments or health-related burdens or requirements that cannot be compensated for and managed independently. The Medical Service of the Health Insurance (MDK) determines whether and to what extent there is a need for care. The MDK is commissioned by the responsible long-term care insurance fund when an application is made for long-term care insurance benefits. The standard for the assessment is the degree of independence of the person. The focus is on the question of how independently the person can manage his or her everyday life. To this end, his or her abilities in various areas of life are assessed: Mobility, cognitive and communicative abilities, behavior and psychological problems, self-care, dealing with illness-related demands and stresses, organizing everyday life and social contacts.

The MDK uses a point system to determine how independent a person still is. The more points the person receives, the higher the care level and the greater the need for care and support. The social welfare agency is also bound by the MDK's findings. If a person does not have long-term care insurance and therefore does not have a report from the MDK and no classification in a care degree by the long-term care insurance fund, the social welfare agency must determine the necessary care needs and calls in the health department with a request for an opinion on the scope of the necessary care services. If possible, the wish to be cared for at home should be given priority over inpatient care according to social welfare law (§ 13 SGB XII).

In the case of care at home, people in need of care are entitled to basic care and domestic help as a benefit in kind for nursing care provided by outpatient services and social welfare stations (home care assistance). Alternatively, it is possible to receive a care allowance if people in need of care can use it to provide basic care and domestic services themselves. A combination of cash and non-cash benefits is possible.

The range of benefits provided by long-term care insurance also includes services when the caregiver is unavailable (home care), day or night care (partial inpatient care), and short-term care (temporary inpatient care).

People in need of care are entitled to care in fully inpatient care facilities if home care or day care is not possible or cannot be considered due to the special nature of the individual case.

In addition, care aids and technical aids, subsidies for measures to improve the individual living environment and care courses for relatives and voluntary caregivers can be granted.

Caregiving relatives or caregiving neighbors and friends may receive social security benefits for the caregiver in the form of contributions to the responsible pension insurance institution, if applicable.

Long-term care insurance benefits are covered by long-term care insurance only up to certain maximum limits, depending on the type of benefit.

In the case of full inpatient care, the costs of room and board are not covered, as these must also be borne in the home environment.

If it is not possible for those in need of care to cover the uncovered residual costs, social assistance benefits (SGB XII) may be considered.

However, social assistance as state aid only comes into play if the income and assets of the person in need of care - and, if applicable, of the spouse or partner - are insufficient. Dependents are only included if their total annual income exceeds 100,000 euros (§16 SGB IV, Common Regulations for Social Insurance).

• Those insured for long-term care first contact the responsible long-term care insurance fund to clarify which benefits they are entitled to and how much they are entitled to. Only if these benefits are not sufficient or if no benefits are due at all can assistance for care be applied for from the relevant social welfare agency.
• In the case of persons who are not insured under the statutory long-term care insurance scheme, the social welfare agency will arrange for the health authority to determine the need for long-term care and the necessary assistance.
• If the requirements are met and the income and financial circumstances do not prevent the granting of assistance for care, a notice of approval is issued.

Information on how to apply can be obtained from the relevant social welfare office in your district or independent city.

• In principle, only those in need of care in care grades 2 to 5 receive the benefits of care assistance. Those in need of care in care level 1 are (only) entitled to care aids and measures to improve the living environment due to the low degree of their impairments. In addition, a relief amount of currently a maximum of 125 euros per month is granted.
• There is no entitlement to care assistance below care level 1.
• However, care assistance is only granted to the extent that the person's own resources are insufficient, the person in need of care is unable to cover the costs of care himself or herself from his or her income and assets, and does not receive it from others, in particular from the care insurance fund. This may be the case if the person in need of care is not insured under the long-term care insurance scheme or does not yet fulfill the pre-insurance periods, or if the benefits provided by the long-term care insurance scheme are insufficient.

The evidence required is the same as that required for the decision to grant assistance under SGB XII (including assistance with living costs). You must provide proof of all your income.

In addition, in the case of applicants with long-term care insurance, the medical report of the MDK as well as the decision of the long-term care insurance fund on the classification into a long-term care degree and the benefits from the long-term care insurance must be submitted.

For those not insured for long-term care, a medical report should be enclosed; the assessment will be arranged by the authority responsible for granting assistance for long-term care.

There are no fees to pay.

Deadlines may have to be observed. Please contact the responsible office.

A decision on the application will be made as quickly as possible. The processing time depends, among other things, on the completeness of the information and the submission of the evidence required for processing the application.

An objection may be lodged against the decisions of the competent social welfare agency within one month of notification.

Once the appeal procedure has been concluded with an appeal decision, an action may be brought before the Social Court within one month of notification.

The text was automatically translated based on the German content.

TMASGFF

04.10.2021