Does health insurance pay for occupational therapy?

What basic health insurance pays

Occupational therapy is one of the services that health professionals provide on a physician’s order at the expense of basic health insurance (Art. 25 para. 2 let. a no. 3 of the Federal Health Insurance Act, KVG). Exactly when the insurer pays is governed by Art. 6 of the Health Care Benefits Ordinance (KLV). The ordinance names three cases; basic health insurance does not cover other purposes.

Number of sessions: The insurer pays for at most nine sessions per medical prescription. The first treatment must take place within eight weeks of the prescription (Art. 6 para. 2 KLV). Further sessions require a new prescription (para. 3). The time window is longer than for physiotherapy, where it is five weeks.

After 36 sessions: If occupational therapy is to continue, the treating physician sends the insurer’s medical adviser a report with a reasoned proposal. The medical adviser reviews it and proposes whether, to what extent and for how long until the next report the insurer continues to pay (Art. 6 para. 4 KLV).

Tariff: The occupational therapist bills according to the agreed or officially set tariff. For services covered by basic health insurance, she may not charge you more (tariff protection, Art. 44 KVG).

Children with congenital disorders: If a child has a recognised congenital disorder, they are entitled to medical measures from invalidity insurance (IV) until the age of 20 is reached (Art. 13 IVG). These include services by health professionals on a physician’s order, which means occupational therapy (Art. 14 para. 1 let. a no. 3 IVG). The health insurer only pays where the IV is not responsible (Art. 27 KVG). If occupational therapy continues after the 20th birthday, the rule with the report to the medical adviser applies to the continuation (Art. 6 para. 5 KLV).

Accident: After an accident, accident insurance pays for outpatient treatment by a medical auxiliary on a physician’s order (Art. 10 para. 1 let. a UVG), without the health insurer’s deductible and retention fee.

What supplementary insurance pays

You do not need supplementary insurance for occupational therapy ordered by a physician: it is covered by basic health insurance. A supplementary outpatient insurance can step in where basic health insurance stops. Whether and how much it pays is set by each insurer in its general terms and conditions, for example for:

• sessions without a medical prescription or for purposes not named in Art. 6 KLV,
• therapies with recognised therapists who may not bill basic health insurance,
• aids and appliances that are not on the Aids and Appliances List or whose price is above the maximum reimbursement amount.

Supplementary insurance may not cover the deductible and retention fee of basic health insurance (Art. 64 para. 8 KVG). 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

• Medical prescription: Without a prescription, basic health insurance does not pay for occupational therapy (Art. 6 para. 1 KLV). The prescription covers at most nine sessions.
• Eight-week deadline: The first session must take place within eight weeks of the prescription. If it is later, you need a new prescription.
• Licensed therapist: Occupational therapists with a cantonal licence and two years of practical experience who meet the quality requirements may bill (Art. 48 KVV), as may licensed occupational therapy organisations (Art. 52a KVV). If in doubt, ask the practice or your insurer before the first session.
• One of the three purposes: The therapy must serve a purpose from Art. 6 para. 1 KLV. Support without a link to an illness is not included.
• Review after 36 sessions: Until the medical adviser has decided, it is open whether the insurer will pay for further sessions.
• Deductible and retention fee: Occupational therapy counts towards the deductible; after that you pay a 10 % retention fee up to CHF 700 a year. Children pay no deductible, and their retention fee is capped at CHF 350 (Art. 64 para. 2 and 4 KVG, Art. 103 KVV). More on co-payment in the glossary.
• Other insurance first: In the event of an accident, accident insurance pays; for congenital disorders up to age 20, the IV pays.

Sample calculation

Example with fictitious people and an assumed price per session. Erwin is 62 and has the standard deductible of CHF 300. After shoulder surgery, his physician prescribes occupational therapy so that he can dress himself and run his household again: two prescriptions of nine sessions each. A session costs an assumed CHF 95.00; the actual amount depends on the tariff and the duration. Erwin has no other medical bills this year. Deductible and retention fee are the statutory values from Art. 64 KVG and Art. 103 KVV.

For further bills in the same year, Erwin only pays the retention fee until he reaches CHF 700; CHF 141 of this has already been reached.

Whether a low or a high deductible is cheaper depends on your expected costs. You can work out the break-even point in the deductible calculator and compare the premiums of all insurers in the premium calculator. A lower deductible for the next year must reach your insurer by 30 November; the dates are listed under Deadlines.

How to proceed

1. Get a prescription: Have your physician prescribe occupational therapy before you book the first appointment.
2. Start within eight weeks: Plan the first session so that it takes place within eight weeks of the prescription.
3. Check the licence: Ask the practice whether it may bill basic health insurance.
4. Keep count of the sessions: After nine sessions you need a new prescription, after 36 sessions the report to the medical adviser. Raise this with your physician in good time.
5. Clarify who is responsible: If a congenital disorder is involved, register your child with the IV; after an accident, as an employee you report the case to your employer. The health insurer profiles show how insurers organise billing and contact.

Common mistakes

• Starting without a prescription. Basic health insurance does not pay for sessions before the physician’s order.
• Letting the eight weeks pass. If therapy starts later, the prescription is no longer valid.
• Simply carrying on after the ninth session. Without a new prescription, the insurer does not pay for the tenth session.
• Bypassing the IV. For congenital disorders up to age 20, the IV is responsible; through the health insurer you pay the retention fee and, as an adult, the deductible.
• Confusing aids and appliances with therapy. Splints or everyday aids are not part of occupational therapy; basic health insurance only reimburses them if they are on the Aids and Appliances List.

When your insurer pays for walking aids is explained on the page Aids and rollators, and the rules for speech and swallowing therapy on the page Speech therapy. You can find related therapies under Physiotherapy and in the overview What does health insurance cover?.