Rehabilitation

What is rehabilitation?

Rehabilitation, or rehab for short, covers all medical measures that help you become as independent as possible again after an illness, an operation or an accident. They include physiotherapy, occupational therapy, speech therapy, training, nursing care and medical supervision, often coordinated in a joint programme. Typical reasons are a new hip or knee joint, a heart procedure, a neurological illness or a long stay in hospital.

The Federal Health Insurance Act (KVG) speaks of “measures of medical rehabilitation”. Basic health insurance covers them if a doctor carries them out or prescribes them. This makes rehabilitation a compulsory benefit like an operation or a medicine, provided it is effective, appropriate and cost-effective.

It is important to distinguish it from three similar terms:

• Spa treatment: a spa treatment is for recuperation. Basic health insurance only pays a small contribution towards medically prescribed balneotherapy.
• Acute and transitional care: nursing care after a hospital stay, for at most two weeks, without an intensive therapy programme.
• Vocational rehabilitation: measures for returning to work are a matter for invalidity insurance, not for the health insurer.

How it works

Outpatient rehabilitation

With outpatient rehabilitation, you live at home and go to therapy sessions. The most common is physiotherapy. The health insurer pays for at most 9 sessions per medical prescription, and the first session must take place within 5 weeks. Further series require a new prescription. After 36 sessions, the doctor must report to the health insurer’s medical adviser, who decides whether treatment continues. Similar rules apply to occupational therapy, where the first session must take place within 8 weeks.

Inpatient rehabilitation

With inpatient rehabilitation, you stay in a clinic for a few weeks. For health insurance purposes, a rehabilitation clinic counts as a hospital. It must therefore meet the same requirements as an acute hospital and be on a canton’s Hospital List. The costs are billed using flat rates. The health insurer and the canton of residence share the flat rate; the canton bears at least 55 %.

You can choose among the clinics on the list of your canton of residence or of the canton where the clinic is located. If you go to a clinic in another canton without a medical reason, the health insurer and the canton pay at most the tariff that applies in a clinic in your canton of residence. You or a supplementary insurance bear any difference. Before a planned admission, it is worth clarifying with your health insurer whether it will cover the costs. This confirmation is called cost approval.

What you pay yourself

The deductible and a 10 % retention fee apply to all rehabilitation benefits, up to the annual maximum of CHF 700. For inpatient stays, the hospital contribution of CHF 15 per day is added. You do not pay for the day of discharge. Children, young adults in education and women during pregnancy and maternity do not pay the hospital contribution if they are exempt from the co-payment.

Legal basis

Art. 25 para. 2 let. d KVG includes “measures of medical rehabilitation carried out or prescribed by a doctor” in the benefits of basic health insurance. Art. 39 para. 1 KVG defines institutions used for the inpatient provision of such measures as hospitals; they need a place on a cantonal Hospital List. Art. 49 para. 1 KVG prescribes flat rates for inpatient treatment, and Art. 49a para. 2ter KVG a cantonal share of at least 55 %. The free choice among listed hospitals and the limit to the tariff of the canton of residence are set out in Art. 41 para. 1bis KVG.

The details are set out in the ordinances. Art. 104 of the Health Insurance Ordinance (KVV) sets the hospital contribution of CHF 15 per day and the exceptions. Art. 5 of the Health Care Benefits Ordinance (KLV) governs physiotherapy, with 9 sessions per prescription and the report to the medical adviser after 36 sessions. Art. 25 KLV limits the contribution towards balneotherapy to CHF 10 per day for at most 21 days per calendar year.

Example: three weeks of rehabilitation after a hip operation

Peter is 67 years old and, after a hip operation, goes to a rehabilitation clinic on the Hospital List of his canton for 21 days. He has the standard deductible of CHF 300 and has had no costs so far this year. The calculation uses the statutory values; the clinic’s flat rate is not given because it differs from clinic to clinic and from one tariff agreement to another.

Item	Amount
Hospital contribution: 20 days × CHF 15 (day of discharge not counted)	CHF 300
Deductible	CHF 300
Retention fee 10 %, at most	CHF 700
Own share at most (excluding days in the acute hospital)	CHF 1,300

If Peter had chosen a deductible of CHF 2,500, his own share including the hospital contribution would have risen to up to CHF 3,500. You can see in the premium calculator how the deductible and the premium balance each other out in a year with an operation.

What this means for you

Plan rehabilitation early. If an operation is foreseeable, talk to your doctor about follow-up treatment before the procedure. Ask whether outpatient rehabilitation is enough or whether an inpatient stay is necessary, and which clinics are on your canton’s Hospital List.

Check your insurance before admission:

1. Is the clinic on a Hospital List? Only then does basic health insurance pay.
2. Is it outside your canton? Then a tariff difference may arise. Supplementary hospital insurance can cover it; the conditions are set out in your contract.
3. Is your deductible right? If an operation is planned for next year, the low deductible often pays off. The change must reach your health insurer by 30 November; all dates are listed under Deadlines.

Compulsory benefits are the same with all health insurers. There are differences in premium, service and supplementary products; you can find key figures on the insurers under Health insurers.

Common mistakes

• Confusing rehabilitation with a spa treatment. Basic health insurance does not pay for a recuperation stay, even if it takes place at a spa facility with therapy on offer.
• Choosing a clinic without a place on the list. Basic health insurance then does not pay for the stay.
• Forgetting the hospital contribution. The CHF 15 per day also applies in the rehabilitation clinic and does not count towards the maximum retention fee.
• Letting the physiotherapy prescription expire. If therapy does not start within 5 weeks, you need a new prescription.
• Informing your health insurer first after an accident. If you are insured against accidents through your employer, report the accident there.

We explain how we prepare examples and figures under How we calculate.