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

PART 1 – Introduction: long-term care insurance, the need for long-term care and the principle of partial cover

A phone call from practice: a daughter reports that her father now has ‘Pflegegrad 2’ (care grade 2) and asks what this means for the family. Behind this single question lie several layers, which this module unpacks one after another: a legal concept of the need for long-term care, a standardised assessment procedure, a range of benefits linked to the care grade, and a boundary at which long-term care insurance ends and other forms of support begin. For managers, there is a further layer: they must ensure that the team reliably explains, refers and documents – without straying into individual legal advice.

Long-term care insurance within the social insurance system

In Module 2 you got to know long-term care insurance as one of the five branches of social insurance, and in Module 1 the insurance principle and the solidarity principle. Both are assumed here. What is new is the special feature of this branch: benefits from long-term care insurance under SGB XI are not linked to a diagnosis but to the care grade that has been determined (sections 14 and 15 SGB XI). Unlike statutory health insurance (Module 4), in which benefits are generally provided as benefits in kind and services (section 2(2) sentence 1 of Social Code Book V, SGB V), long-term care insurance also includes a cash benefit, the care allowance (Pflegegeld), with which people in need of care can organise their care at home themselves.

The second difference concerns the scope: long-term care insurance is designed as a partial-benefit system. It provides benefits within a legally defined framework and does not automatically cover the actual need for care in full (cf. section 61 of Social Code Book XII, SGB XII). The image of ‘Teilkasko’ (partial cover, as in car insurance) is often used as a memory aid. Importantly, this is a teaching image, not a legal term. It is only meant to illustrate that a remainder may be left over after the long-term care insurance has paid. How this remainder is dealt with is the subject of Part 5.

What does ‘in need of long-term care’ mean? The concept under section 14 SGB XI

The key concept is set out in section 14(1) SGB XI. According to this, people in need of long-term care are persons who have health-related impairments of their independence or abilities and therefore require help from others. The need for help must be long-term, expected to last at least six months, and must reach at least the severity laid down in section 15 SGB XI.

From a professional perspective, four building blocks can be identified. First, the health-related cause: not every need for support is a need for long-term care in the legal sense. Second, the yardstick of independence and abilities: the question is what a person can do themselves and where they depend on others – not which diagnosis they have. Two people with the same illness may therefore be classified differently. Third, help from others as a consequence of these impairments. Fourth, a time and substantive threshold: expected to last at least six months and reaching at least the severity under section 15. This structure is a professional interpretation; only the wording of the law is binding.

The six areas of the need for long-term care

What counts as an impairment is defined in section 14(2) SGB XI through six areas. They form the compass for the entire procedure:

• mobility – for example moving around the home or changing body position;
• cognitive and communicative abilities – for example orientation, understanding and making oneself understood;
• behaviour and psychological problems – for example distressing restlessness or anxiety that requires help;
• self-care – for example personal hygiene, eating and drinking, and dressing;
• coping with and independently managing demands and stresses caused by illness or therapy – for example medication, doctor’s appointments, aids;
• organising everyday life and social contacts – for example daily structure and participation in social life.

The examples after the dashes are explanations for practice, not the wording of the law. Figure 1 shows as a mind map how the concept, care grades, benefits, limits and current developments fit together into an overall picture. It serves as a map for the following parts.

PART 2 – Legal fundamentals: assessment, care grades and the application process

The assessment instrument under section 15 SGB XI

Under section 15 SGB XI, the care grade is determined using an assessment instrument grounded in nursing science (Begutachtungsinstrument). This instrument is made up of six weighted modules. ‘Weighted’ means that the areas do not contribute equally to the overall result; for self-care, the provision gives a weighting of 40 per cent as an example. For counselling practice it is sufficient to know the principle: the ratings in the modules produce a total score, and this determines the care grade. If you need the other weightings, you can look them up in the law – in conversations with relatives this is rarely the decisive question.

What matters is a change of perspective compared with the everyday understanding: the care grade does not measure how ‘ill’ someone is, nor how much time a carer spends. It reflects the extent to which independence and abilities are impaired in the six areas. The fact that this results in a single number is a deliberate simplification – with advantages and side effects that Part 5 returns to.

From total points to care grade

Under section 15(3) SGB XI, the total points determine the care grade. Table 1 sets out the bands and, in the last column, adds the care allowance under section 37(1) SGB XI, which Part 3 discusses in detail.

Always read the thresholds as lower limits: ‘from 47.5’ includes the value 47.5, ‘under 70’ excludes 70. A person with exactly 47.5 total points therefore already belongs to care grade 3, while a person just below this still belongs to care grade 2. Anyone who does not reach the lower limit of 12.5 total points does not, under this system, meet the minimum severity of section 14(1) SGB XI. This reading is important for conversations with relatives because it helps avoid misunderstandings about ‘rounding’ or ‘goodwill’ – the assignment follows fixed bands.

From application to care grade: the procedure

Figure 2 shows the process in six steps. It begins with the application for long-term care insurance benefits. As described in Module 3, under section 16 SGB I applications are accepted not only by the responsible benefit agency but also by all other benefit agencies and by all municipalities, and are forwarded without delay; the date of application is the date of receipt by the first office. This gives a simple rule for practice: an application should not be left lying around just because responsibility is still unclear.

In the second step, the situation is assessed. As a rule, this is done by the Medizinischer Dienst (MD, the medical assessment service of the health and long-term care insurance funds); using the assessment instrument from section 15 SGB XI, it records how independent the applicant is in the six areas. In the third step, the partial ratings produce the total points, and in the fourth step these are assigned to one of the five care grades. In the fifth step, the Pflegekasse communicates the result in writing, and in the sixth step the benefits and counselling services follow. Anyone who disagrees with the result will find information on the deadline and form of an objection (Widerspruch) in the decision notice. The deadlines that apply in the procedure are determined by law and by the decision notice; they are deliberately not listed here because they are decisive in the individual case and must be checked there.

PART 3 – Benefits and counselling: care allowance, counselling visit and care counselling

Care allowance under section 37(1) SGB XI

The care allowance is the cash benefit of long-term care insurance for people who are cared for at home and organise their care themselves – often through relatives. Since 1 January 2025, the monthly amounts under section 37(1) SGB XI have been 347 euros in care grade 2, 599 euros in care grade 3, 800 euros in care grade 4 and 990 euros in care grade 5. Table 1 has assigned them to the respective care grade. No care allowance is listed in this table of amounts for care grade 1; the people concerned can find out from the Pflegekasse which benefits apply there.

In addition to the care allowance, SGB XI provides for further benefits, such as services from home care services (ambulante Pflegedienste) and residential care benefits. Their amounts are not the topic here; for counselling it is more important to convey the logic: the benefits are linked to the care grade, they are limited, and the Pflegekasse is the body that provides binding information on their type and scope in the individual case.

Counselling visits for care allowance recipients (section 37(3) SGB XI)

Those who receive care allowance are not left on their own: under section 37(3) sentence 1 SGB XI, care allowance recipients in care grades 2 to 5 must request a counselling session in their own home once every six months; in care grades 4 and 5, counselling every three months is possible. From a professional point of view, this visit offers an opportunity to discuss the care situation, clarify questions and point out ways of obtaining relief. This classification is an interpretation; the wording of the law specifies the frequency, not the content of the conversation.

Care counselling under section 7a SGB XI: the care plan as a bridge

Care counselling (Pflegeberatung) must be distinguished from counselling visits. Under section 7a(1) SGB XI, anyone who receives benefits under SGB XI is entitled to individual counselling and assistance from care counsellors in selecting and making use of social benefits and support services. Their tasks include systematically recording and analysing the need for help, taking the assessment into account; drawing up an individual care plan (Versorgungsplan); working towards its implementation and approval by the benefit agencies; monitoring and adjusting the plan; and providing information on relief services for carers.

Anyone who has studied case management will recognise the logic: record needs, draw up a plan, support implementation, adjust the plan. Module 8 takes this up again as part of the navigator role. The following comparison helps you keep the two forms of counselling clearly apart in conversation.

Worked example: from score to care allowance

Before you practise yourself, here is a complete demonstration of how a score is translated into information on benefits. Figure 3 goes through the five steps using the example of David Zimmermann (fictitious). His assessment report shows 52 total points. The task is: determine the care grade, read off the care allowance and identify follow-up questions for the conversation.

Note what the example does not do: it does not calculate an entitlement in the individual case, but places a value in the statutory bands and reads off the amount stated in the law. The binding decision is made by the Pflegekasse. The sequence of steps – record the value, find the band, look at the limits, read off the benefit, clarify follow-up questions – can also be transferred to other situations and provides the pattern for the following exercise.

PART 4 – Care in reality: figures for planning, conversations and casework

How many people are in need of long-term care – and where are they cared for?

For planning and counselling, it is worth looking at official statistics. According to the care statistics (Pflegestatistik) of the Federal Statistical Office (Statistisches Bundesamt, Destatis), just under 5.7 million people were in need of long-term care within the meaning of SGB XI in December 2023 (Destatis, 2024). Compared with December 2021, this represents an increase of 730,000 people, or 15 per cent. 61 per cent of people in need of care were women, and 78 per cent were aged 65 and over. The care statistics are published every two years; December 2023 is the current status on which this module is based.

On the type of care, the statistics state: 86 per cent, or 4.9 million people in need of care, were cared for at home, of whom 3.1 million received care allowance only, mostly cared for by relatives, and 1.1 million were cared for together with or by home care services. 14 per cent, or 800,000, lived full-time in nursing homes (Destatis, 2024). Figure 4 shows the three groups as bars.

Text summary of the values: In December 2023, 3.1 million people in need of care were cared for at home with care allowance only, 1.1 million at home together with or by home care services, and 0.8 million in full-time residential care. The three groups shown do not add up to the total number of people in need of care; other types of care are not shown here. The bars are therefore an extract, not a complete picture.

Finding and interpretation: The finding is that the large majority of people in need of care live at home and that care allowance is the most frequently documented type of care there. An interpretation – and therefore not part of the finding – is the conclusion that care in Germany depends heavily on the availability and resilience of relatives. For managers, this has a plausible consequence: counselling and relief do not belong only at the end of the chain of care, but in the work with families. The figures alone do not show why the types of care are distributed in this way; further data and analyses would be needed for that.

Consequences for management and teamwork

Parts 1 to 3 give rise to tasks for managers. First: build communication skills. Staff should be able to explain without hesitation what a care grade is, that it is derived from total points and that the benefits are linked to it. Second: mark boundaries. Information and orientation are tasks for practitioners; binding information on entitlement and amount in the individual case is given by the benefit agency. Third: clarify interfaces. Who in the organisation – nursing service management, social services, counselling – handles which conversations, when is a referral made to care counselling (section 7a SGB XI), and how is it documented? Fourth: keep information up to date. Reform projects sometimes change responsibilities and benefits faster than information material is updated. An agreed schedule in which the team discusses new legal positions is therefore useful; employment law issues, for example on responsibilities and the allocation of tasks, should be clarified with your legal department or staff representative body (Mitarbeitervertretung).

Conversations with relatives: explaining the care grade clearly

A care grade sounds like a judgement of the person, but it is an administrative result with consequences. In conversations with relatives, a simple four-step structure has proved useful, which you can use without additional aids: What has been determined? (care grade and, if known, total points), What follows from it? (benefits such as the care allowance, entitlement to counselling), What remains open? (personal contributions, needs not covered, questions for the Pflegekasse) and What is the next step? (appointment, application, referral). Speak in short sentences, explain technical terms such as ‘total points’ or ‘need for long-term care’ once in everyday language, and ask the other person to repeat what they have heard in their own words. If your organisation provides for this, summarise the most important points in writing and file the content of the conversation in line with your organisation’s procedures.

PART 5 – Critical evaluation: limits, areas of tension and current developments

Partial-benefit system: why long-term care insurance does not pay for everything

Anyone who understands the need for long-term care solely as an insured event overlooks the basic principle of this branch: long-term care insurance grants benefits within a legally defined framework. It therefore does not automatically cover all costs; in everyday counselling, there is often a remainder that the people concerned must pay from their own income and assets – particularly visible in residential care. How high this remainder is in the individual case is deliberately not discussed here; it depends on factors that the care setting and the benefit agency can specify.

Assistance with care under section 61 SGB XII and the subsidiarity of social assistance

Supplementary protection is provided for in SGB XII. Under section 61 sentence 1 SGB XII, people in need of care within the meaning of section 61a SGB XII are entitled to assistance with care insofar as they and their spouses or civil partners who do not live apart from them cannot reasonably be expected to raise the necessary funds from income and assets in accordance with the provisions of Chapter Eleven of SGB XII. The interaction follows the principle of subsidiarity of social assistance (Nachrang der Sozialhilfe), which you know from Module 1: under section 2(1) SGB XII, social assistance is not granted to anyone who can help themselves or who receives the necessary benefit from others, for example from providers of other social benefits. Long-term care insurance is therefore the primary form of protection, and assistance with care fills a gap insofar as income and assets do not have to be used. You can read more about securing a basic livelihood in general in Module 7.

Figure 5 places the two systems side by side. The cards are a memory aid for counselling conversations: they make it clear that these are two different logics – an insurance logic with a care grade on the one side, and a welfare logic with a check of financial need (Bedürftigkeitsprüfung) on the other.

Areas of tension and open questions

Standardisation and the individual case. The points system creates comparability and transparency: the same characteristics lead to the same results, and the thresholds are visible to everyone. At the same time, every threshold creates borderline cases, because a difference of a few points can lead to a different care grade and therefore to different benefits. Both perspectives are legitimate; practitioners can help the people concerned to put the result into context without either glossing over the procedure or criticising it wholesale.

Snapshot and course over time. An assessment describes the situation at a particular point in time. Care needs can change. Changes are a reason to take a fresh look at the situation and to clarify with the Pflegekasse how to proceed. The procedures that apply are governed by law; in conversation it is sufficient to point out that the people concerned can obtain advice on this.

Home care and relatives. The statistics show that a large proportion of people in need of care are cared for at home, mostly with care allowance (Destatis, 2024). The obvious interpretation is that the system relies on the willingness and resilience of relatives. This raises questions for practice and policy: How can relief be made accessible? How can counselling visits and care counselling be designed so that they really reach people? There are no simple answers to these questions, and the data used here do not answer them.

A structured system and access. The Pflegekasse, the social assistance agency and, where applicable, rehabilitation agencies are separate bodies with their own procedures. This is difficult for the people concerned to keep track of, as you know from Module 3. Module 6 shows how rehabilitation and participation are organised with their own agencies, and Module 8 shows the role of care counselling as a signpost.

Current (as at October 2026): extension of powers and the Long-Term Care Reorganisation Act

Figure 6 places the developments on a timeline. Solid circles represent what already exists, dashed circles represent drafts and plans. The timeline is not to scale; its main purpose is to make clear what applies today and what is only planned. You already know about the planned contribution surcharges from Module 2, where they were also explicitly identified as a draft.

Evaluation. The arguments on such a project can be set out side by side objectively. In favour of an adapted assessment is the wish for more accurately targeted classifications; in favour of protecting existing entitlements is reliability for people who already have a care grade. Critical questions concern, among other things, what ‘more accurately targeted’ means in concrete terms, how higher benefits are to be financed and what a contribution surcharge means for contributors, as well as how a community-based budget instead of the previous relief amount would affect access and handling. Whether and in what form the project becomes law is open; content may change in the further legislative process. For your counselling, therefore: inform people about current law, explicitly label draft content as a draft and refrain from making forecasts about amounts or thresholds.

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.