Does health insurance pay for acupuncture?

What basic health insurance pays

Whether basic health insurance pays for your acupuncture does not depend on the method, but on who places the needles. Acupuncture is part of complementary medicine. Of this, basic health insurance only covers services provided by physicians, and only if the physician can prove specific further training.

Art. 4b let. a of the Health Care Benefits Ordinance (KLV) sets this out precisely: insurance covers acupuncture provided the physician has completed further training under the proficiency programme “Acupuncture – Chinese Pharmacotherapy – TCM (ASA)” of the Swiss Institute for Postgraduate and Continuing Medical Education (SIWF). According to the FOPH, the physician also needs a specialist title. Under the same conditions, TCM drug therapy is also covered (Art. 4b let. c KLV).

Like every compulsory benefit, acupuncture must be effective, appropriate and cost-effective (Art. 32 para. 1 of the Federal Health Insurance Act, KVG). The criteria that apply to complementary medicine disciplines are set out in Art. 35a KVV: tradition of use and research, scientific evidence and medical experience, and specific further training. The KLV does not prescribe a fixed number of sessions.

The rule has a history. On 17.05.2009, the people and the cantons adopted Art. 118a of the Federal Constitution: the Confederation and the cantons take complementary medicine into account within the scope of their powers. The article does not create a right to reimbursement for every method. After a provisional phase from 2012, acupuncture by physicians has been a permanent compulsory benefit since 2017, according to the FOPH.

What supplementary insurance pays

If a TCM therapist without a medical degree places the needles, only voluntary supplementary insurance for complementary medicine pays, often part of a supplementary outpatient insurance. It is a contract under private law governed by the Insurance Contract Act (ICA). The law does not prescribe any benefits there; the insurer sets out itself in its general terms and conditions:

• what share of the invoice it pays, for example a percentage or an amount per session,
• how high the limit per calendar year is,
• which methods it recognises, and whether acupuncture is one of them,
• which recognition the therapist needs, often an entry with ASCA or EMR for exactly this method.

Supplementary insurance may not cover the deductible and retention fee of basic health insurance (Art. 64 para. 8 KVG). For acupuncture by a physician with a certificate of proficiency, you therefore always pay the co-payment yourself. When you take out a policy, the insurer may ask health questions (Art. 4 ICA) and exclude existing conditions. We are building a comparison of the benefits of supplementary products under Supplementary insurance. What always counts are the general terms and conditions and the information from your insurer.

Conditions

• ASA certificate of proficiency: For basic health insurance, the physician must hold the certificate of proficiency “Acupuncture – Chinese Pharmacotherapy – TCM (ASA)”. Ask the practice about it before the first session. Without the certificate, the insurer does not pay for acupuncture, even if a physician performs it.
• No prescription needed: The physician is a service provider in her own right under Art. 35 para. 2 KVG and bills under the outpatient medical tariff. You do not need a referral for basic health insurance.
• Rules of your model: If you are insured with a GP, HMO or telemedicine model, the agreed route applies: first to the GP practice, the HMO or the telephone service. If you do not follow it, the insurer may reduce benefits under its model conditions. More on this under Rules of the cost-saving models.
• Deductible and retention fee: The costs count towards the deductible first, then you pay a 10 % retention fee, up to a maximum of CHF 700 a year for adults and CHF 350 for children (Art. 64 para. 2 KVG, Art. 103 KVV). Children have no standard deductible.
• Supplementary insurance: For acupuncture by a therapist, the general terms and conditions apply: recognised method, recognised therapist, percentage and annual limit. Your insurer’s list of recognised therapists is what counts, not the practice’s advertising.
• Other insurance first: If the treatment follows an accident and you are insured through your employer under the UVG, the accident insurance pays. It decides according to its own rules whether it covers acupuncture.

Sample calculation

Example with fictitious people and an assumed price per session. Petra is 35 and has the standard deductible of CHF 300. She has not had any other medical costs this year. She attends ten acupuncture sessions with a physician who holds the ASA certificate of proficiency. We assume CHF 110 per session, CHF 1,100 in total; this is a calculation value, not a tariff. Deductible and retention fee are the statutory values from Art. 64 KVG and Art. 103 KVV.

The calculation shows the key point: with a low deductible, acupuncture by a physician is usually cheaper for you; with a high deductible, you often pay for shorter courses of treatment entirely yourself. Which deductible suits your expected costs, you can work out in the deductible calculator; the premium calculator shows the premiums of all insurers for your municipality.

How to proceed

1. Ask about the certificate of proficiency: Ask the practice before the first appointment whether the physician holds the ASA certificate of proficiency.
2. Check your model rules: Find out whether your insurance model requires you to go through the GP practice, HMO or telephone service first.
3. For therapists, read the general terms and conditions: Check the percentage, limit, recognised methods and registers. If in doubt, ask your insurer in writing whether it recognises the therapist.
4. Submit invoices: Submit physicians’ invoices to basic health insurance, even below the deductible, so that they are counted. Therapists’ invoices go to supplementary insurance.

Common mistakes

• Thinking all acupuncture is a compulsory benefit. Basic health insurance only pays for acupuncture by a physician with the ASA certificate of proficiency.
• Not checking the certificate of proficiency. A physician without the ASA certificate cannot bill acupuncture to basic health insurance either.
• Forgetting the deductible. With a CHF 2,500 deductible, you usually pay for a course of ten sessions yourself.
• Hoping supplementary insurance will fill the gap. It may not cover the deductible and retention fee (Art. 64 para. 8 KVG).
• Overlooking the annual limit. Supplementary insurers often only pay up to a certain amount per year; further sessions are at your expense.

The other methods of complementary medicine and their rules are explained in Does health insurance pay for complementary medicine?. You can find other benefits in the overview What does health insurance cover?, and profiles and key figures of the insurers in the health insurer profiles.