The Health and Social System in Germany – An Overview for Study and Practice

PART 1 – The structured system: terms and basic idea

Why knowing who is responsible is part of professional guidance

Benefits for health, long-term care, participation and subsistence do not come from a single source. They are provided by numerous bodies, each with its own laws, its own procedures and its own contact persons. In social policy, this coexistence is called a structured system (gegliedertes System): depending on the cause and the aim of a need, a different provider organisation (Träger) is responsible. For people in difficult life situations this is often confusing, and this is exactly where professional support comes in. Anyone who knows who is responsible can shorten pathways, avoid duplicate applications and prevent concerns from being left lying between the bodies.

In Module 1 you were introduced to the insurance principle, the welfare principle and the provision principle as organising concepts, and in Module 2 to the five branches of insurance and their risks. This module adds a further layer: it asks neither about the principle nor about the risk, but about the body that acts. This is the question that clients, patients and family members ask most often, and for managers it is at the same time an organisational question: how do we make sure that this knowledge is available in the team and can be reliably accessed?

The term benefit provider (§ 12 SGB I)

The General Part of the Social Code defines who is responsible for social benefits: these are the corporations, institutions and authorities named in §§ 18 to 29 SGB I, which are referred to as benefit providers (Leistungsträger). According to § 12 SGB I, how their responsibilities are to be distinguished from one another follows from the specific parts of the Social Code. This leads to a sober but important insight: there is no single provision that governs ‘the’ responsibility. Anyone who wants to know whether a health insurance fund (Krankenkasse), a pension insurance provider or a social assistance provider is responsible has to look at the relevant book of the Social Code that governs the need.

The benefit provider must be distinguished from the service provider (Leistungserbringer). The benefit provider decides on the entitlement and approves the benefit; the service provider, such as a hospital, a care service or a counselling centre, actually delivers the benefit. For you as a manager of a social organisation, this means: your organisation is, as a rule, a service provider. The decision on responsibility and entitlement is made by the benefit provider, not by your team. Your team can, however, provide good orientation, accompany the path there and prepare applications so that they are clear and complete.

Figure 1 shows the five building blocks of this module as a mind map: the term benefit provider, the rehabilitation providers, submitting an application, clarifying responsibility and the rule of thumb for distinguishing between SGB II and SGB XII, which we look at explicitly together with its limits.

Three guiding questions for every clarification of responsibility

So that you do not have to start from scratch every time in practice, a simple structure helps. First: what is the need – treatment, long-term care, participation, protection in the event of unemployment, or subsistence? Second: what is the cause – an illness, an accident at work, a disability, a lack of income? Third: what is the personal situation – for example the question of the ability to work, age or existing insurance relationships? These three guiding questions run through the following parts and reappear in the decision tree in Figure 4.

PART 2 – Who covers what? Benefit providers and rehabilitation providers at a glance

Need and benefit provider: the responsibility map

Figure 2 assigns typical needs to the bodies that may be considered for them under the Social Code. The needs are on the left, the benefit providers with their code book on the right. The map is deliberately a selection at the level of legal provisions: it does not name any local authorities, because their names and remits differ depending on the federal state (Land) and municipality.

Two reading notes help with the map. The ‘R’ marks bodies that can be rehabilitation providers under § 6(1) SGB IX; they are described in more detail in the following section. And the dashed line is a reminder that, depending on the situation, a need can involve more than one possible provider. In addition, many people are not faced with just a single need: after a serious illness, medical treatment, long-term care, participation and securing subsistence can all play a role at the same time, and enquiries may then have to be made with different bodies at the same time.

The table serves two purposes. It is a memory aid for matching body and code book. It also shows that some bodies appear in two roles: as providers of their ‘own’ benefits and additionally as rehabilitation providers. The health insurance fund, for example, approves sickness benefit and can at the same time decide on benefits for medical rehabilitation.

Rehabilitation providers under § 6 SGB IX and the five benefit groups

Participation law (Teilhaberecht) organises its benefits into five groups. Under § 5 SGB IX these are, first, benefits for medical rehabilitation; second, benefits for participation in working life; third, subsistence-securing and other supplementary benefits; fourth, benefits for participation in education; and fifth, benefits for social participation. Who may provide these benefits is governed by § 6(1) SGB IX: rehabilitation providers can be the statutory health insurance funds, the Federal Employment Agency, the providers of statutory accident insurance, the providers of statutory pension insurance and of old-age security for farmers (Alterssicherung der Landwirte), the providers of social compensation (Soziale Entschädigung) and of soldiers’ compensation (Soldatenentschädigung), the providers of public child and youth welfare services and the providers of integration assistance (Eingliederungshilfe).

What matters is how the providers are assigned to the benefit groups, because not every provider delivers every group. Under § 6(1) SGB IX, the health insurance funds come into consideration for benefit groups 1 and 3, the Federal Employment Agency for groups 2 and 3. The providers of statutory accident insurance are named for groups 1 to 3 and 5, the providers of statutory pension insurance for groups 1 to 3. Child and youth welfare and integration assistance are named for groups 1, 2, 4 and 5; the providers of social compensation and of soldiers’ compensation for all five. Benefits for participation in education (group 4) are therefore provided neither by health insurance funds nor by pension insurance, but among others by the providers of integration assistance and of child and youth welfare; an application under § 16 SGB I can nevertheless be submitted to any benefit provider (Part 3). We look at the complete matrix and its practical significance in more depth in Module 6.

PART 3 – The application on its way: § 16 SGB I and § 14 SGB IX

Submitting an application under § 16 SGB I: every door leads further

The most common worry of people seeking advice is: ‘What if I hand in the application at the wrong office?’ The General Part of the Social Code answers this. Applications for social benefits are to be submitted to the responsible benefit provider, but are also accepted by all other benefit providers and by all municipalities (Gemeinden) (§ 16(1) SGB I). If the body is not responsible, it forwards the application without delay. The legal consequence is central for counselling: the application is deemed to have been submitted at the time it was received by the first body (§ 16(2) SGB I). According to the wording of the law, choosing the wrong addressee therefore does not cost the applicant their application date.

The third subsection is addressed to the benefit providers themselves: they work towards ensuring that clear and appropriate applications are made and that incomplete information is supplemented (§ 16(3) SGB I). This is the legal background to you going through applications together with clients without providing legal advice. At the same time, a practical tip remains: record when and where an application was handed in, ideally with an acknowledgement of receipt or a note, because the date of receipt at the first body is the decisive factor.

Clarifying responsibility under § 14 SGB IX: two and three weeks

For participation benefits, SGB IX provides for a special clarification procedure, because several rehabilitation providers may come into consideration. Within two weeks of receiving the application, the rehabilitation provider determines whether it is responsible for the benefit. If it does not consider itself responsible, it forwards the application without delay to the provider it considers responsible and informs the applicant (§ 14(1) SGB IX). If the application is not forwarded, it determines the rehabilitation need without delay and comprehensively and provides the benefits. If no expert opinion (Gutachten) is required, it decides within three weeks of receiving the application (§ 14(2) SGB IX).

The question of responsibility is thus shifted from the sphere of the people concerned to that of the administration: people do not have to find out for themselves which provider is the right one; instead, the provider that receives the application must clarify within a short period whether it is responsible. What applies further after an application has been forwarded, for example regarding reimbursement of costs between providers, is not the subject of this module and is deliberately not covered here.

Worked example: an application for retraining step by step

Before you practise yourself, we take a fictitious application through both provisions in six steps. Ayşe Rossi, an employee with a chronic back condition, will probably no longer be able to work in her previous occupation and would like to apply for retraining. This is a benefit for participation in working life, i.e. benefit group 2 under § 5 SGB IX. She hands in the application at her health insurance fund because she already knows contact persons there. Figure 3 shows the process.

This is how you think it through step by step: in the first step you ask whether the application has been received and whether the date can be proven. In the second step you know from § 16(1) SGB I that handing it in at this body was not in vain. In the third step you recognise that the special procedure under § 14 SGB IX applies, because participation benefits are involved. The assignment of benefit group 2 to the providers in § 6(1) SGB IX shows that the health insurance fund in the example may consider itself not responsible. In the fourth step this results in Route A with forwarding and informing the applicant; in the fifth step Route B, for the case where the application is not forwarded. In the sixth step you see your own contribution: you do not decide anything, but you make sure that the path remains traceable. How the two provisions relate to each other in detail when calculating deadlines is clarified in the individual case by the benefit provider or through legal advice; this is not a task for the practitioner.

PART 4 – Responsibility in practice: decision tree, rule of thumb and cases

The decision tree ‘Who is responsible?’

Figure 4 translates the guiding questions from Part 1 into a decision tree. You start at the top by clarifying the need and then ask six questions in turn. The first question concerns the cause: if there is an accident at work or an occupational disease, the path leads to accident insurance, whose tasks include prevention, restoration of health and compensation (§ 1 SGB VII). The further questions concern long-term care, rehabilitation and participation, medical treatment and finally subsistence. A ‘yes’ leads to the right to the benefit provider, a ‘no’ leads down to the next question. The tree is an orientation aid for the conversation and no substitute for the benefit provider’s decision.

Note the footnote in the graphic: several needs can exist side by side. Someone who comes to need long-term care after an accident at work may need both accident insurance and the long-term care fund. The tree is then worked through several times, and the practitioner brings the results together in an overview instead of stopping at the first answer.

The rule of thumb ‘able to work → SGB II, not able to work → SGB XII’ and its limits

In counselling, the rule of thumb that people who are able to work (erwerbsfähig) and in need of support belong with the Jobcenter, and those who are not able to work belong with the social assistance provider, has proved useful. As a first signpost this is helpful; legally it is a simplification. SGB II (Social Code Book II) is linked to several requirements at the same time: in addition to the ability to work, among others, neediness, a minimum age of 15 years, not having reached the age limit, and habitual residence in Germany (§ 7(1) sentence 1 SGB II). In addition, members of a joint household for benefit purposes (Bedarfsgemeinschaft) with persons able to work who are themselves not able to work also receive basic income support benefit, provided there is no entitlement to basic income support in old age and in the event of reduced earning capacity (§ 19(1) SGB II).

Basic income support in old age and in the event of reduced earning capacity under SGB XII, by contrast, is linked to reaching the age limit or to permanent full reduction in earning capacity from the age of 18 (§ 41(1) and (3) SGB XII); Module 7 covers the exact requirements. Social assistance is also subsidiary: it is not received by anyone who can help themselves or who receives the benefit from others (§ 2(1) SGB XII; see Module 1). The rule of thumb therefore captures the core correctly, but overlooks the age limit, the joint household and the principle of subsidiarity. What ‘able to work’ means in detail and how it is determined is decided by the responsible bodies; practitioners do not make this classification but prepare the conversation.

Practice cases from hospital and counselling

PART 5 – Critical appraisal: limits, tensions, consequences

The structured system: strength and barrier to access

The structured system can be viewed from at least two perspectives. From a legal and organisational point of view, it enables specialised bodies that map needs precisely within their code book and have expertise in risk, financing and procedures. The division by cause and aim follows a comprehensible logic which you got to know in Modules 1 and 2 as the logic of insurance and of welfare. From the point of view of the people concerned, the same structure can be an obstacle. Anyone who is ill, has little energy or only partly masters the language has to know the map of responsibilities before making a first application. This view is a professional interpretation, not a finding empirically substantiated here; it is regarded as a widespread criticism of the complexity of the system.

The provisions you have learned about in this module are a legal response to this tension. § 16 SGB I and § 14 SGB IX relieve those affected of the risk of choosing the wrong addressee. § 14 SGB I gives people seeking advice a right to advice from the benefit providers, and the participation counselling under § 32 SGB IX offers supplementary counselling independent of benefit providers and service providers, including before specific benefits are applied for. Both remain a topic in Module 8, which deals with duties to advise and the navigator role. It remains open how well these instruments actually work in practice; this course provides no evidence-based statements on this, and you should not claim any in conversations either.

Tensions for practitioners and management

A first tension concerns the practitioner’s role. Knowledge of responsibilities is meant to provide orientation without turning into binding information or legal advice. Phrases such as ‘As a rule, … is responsible for this; the provider determines this itself’ keep the balance. A second tension lies between speed and care. In everyday work, time is often pressing, for example with discharges from hospital; at the same time, applications are only helpful if they are clear and complete. A third tension concerns interfaces: when several providers are involved, coordination work arises that nobody ‘owns’. This is where the management level comes into play.

From this, design tasks can be derived for managers. These include maintaining an overview of responsibilities for the team, supplemented by the local contact points that apply in your area. It has also proved useful to agree on a uniform procedure for documenting the submission of applications, to discuss questions of responsibility openly in case reviews and to introduce new staff specifically to the logic of responsibilities. Because laws change, the overview needs a date and a responsible person who records changes; the example of the New Basic Income Support since 1 July 2026 shows how quickly names and rules can shift. Questions of employment, data protection or procurement law should be clarified with your legal department or staff representation.

Self-reflection – 5 questions

Voluntary · not graded – your answers are not saved and are not evaluated by anyone. Click an answer; the explanation helps you assess your own understanding.