Does health insurance pay for psychotherapy?

What basic health insurance pays

Basic health insurance pays for psychotherapy if it treats a mental or psychosomatic illness and uses methods whose effectiveness is scientifically proven (Art. 2 of the Health Care Benefits Ordinance, KLV). It can take place as individual, couples, family or group therapy. There are two routes:

The second route is called the prescription model. It has applied since 01.07.2022: the authorised psychotherapist bills basic health insurance directly, and the doctor only prescribes. The related coordination services are also covered (Art. 11b para. 1 KLV).

A psychological psychotherapist is authorised if they hold a cantonal licence to practise as a psychotherapist, can show three years of clinical experience, of which at least twelve months in a recognised psychiatric and psychotherapeutic institution, work independently and meet the quality requirements (Art. 50c of the Health Insurance Ordinance, KVV). Organisations of psychological psychotherapy are authorised under Art. 52e KVV.

What supplementary insurance pays

You do not need supplementary insurance for the psychotherapy itself, as long as the conditions of basic health insurance are met. Supplementary insurance may not cover the deductible and retention fee of basic health insurance either (Art. 64 para. 8 of the Federal Health Insurance Act, KVG).

Supplementary outpatient insurance can help where basic health insurance does not pay, for example:

• therapy with psychologists without KVG authorisation or without a doctor’s prescription,
• methods that basic health insurance does not recognise,
• counselling without a diagnosed illness, if the contract provides for it.

Whether and how much a product pays, for example a percentage up to an annual maximum, is set out by each insurer in its general terms and conditions. When you take out the insurance, the insurer may ask health questions; you must answer them truthfully (Art. 4 of the Insurance Contract Act, ICA). Current or past therapy may therefore lead to a reservation or a refusal. We are building a comparison of supplementary products under Supplementary insurance; the article Supplementary insurance after therapy explains what past therapy means for your application. The general terms and conditions and the information from your insurer are what count.

Conditions

• Prescription before the first session: For psychological psychotherapy, you need a doctor’s prescription. Doctors with a postgraduate title in general internal medicine, psychiatry and psychotherapy, child and adolescent psychiatry and psychotherapy or paediatrics, and with the specialisation in psychosomatic and psychosocial medicine, may prescribe it (Art. 11b para. 1 let. a KLV).
• 15 sessions per prescription: One prescription covers at most 15 assessment and therapy sessions. Before they run out, the therapist reports to the prescribing doctor, who issues a second prescription if needed (Art. 11b para. 2 KLV).
• Report after 30 sessions: If the therapy is to continue, the prescribing doctor sends a report with a proposal to the insurer’s medical adviser. If a GP or paediatrician prescribed it, an assessment of the case by a psychiatrist is also required (Art. 11b para. 3 and 3bis KLV). The insurer tells you within 15 working days of receiving the report whether and for how long it will continue to pay (Art. 3b para. 4 KLV). This works like a cost approval for the next phase.
• Data protection: The report may only contain the information needed to assess whether the insurer must pay (Art. 3b para. 2 KLV).
• Authorised practitioner: Ask before you start whether the psychotherapist bills basic health insurance.
• Insurance model: In the GP or HMO model, your choice is restricted (Art. 41 para. 4 KVG). Check the model’s rules to see whether the prescription has to come from the practice you chose.
• Co-payment: Psychotherapy counts towards the deductible; after that, you pay a 10 % retention fee. Within the co-payment, the retention fee is capped at CHF 700 per year for adults and CHF 350 for children, with the deductible on top (Art. 103 para. 2 KVV). Children have no standard deductible (Art. 64 para. 4 KVG). Benefits from the 13th week of pregnancy until eight weeks after the birth are exempt from co-payment (Art. 64 para. 7 let. b KVG).

Sample calculation

Example with fictitious people. Lena is 29. Her GP prescribes psychological psychotherapy and, after 15 sessions, issues a second prescription. Over the year, she has 30 sessions. The price of CHF 150 per session is an assumption; the actual amount depends on the tariff. Lena has a CHF 2,500 deductible and no other healthcare costs during the year.

You notify a lower deductible for the following year by 30 November; the dates are under Deadlines. The article Choosing your deductible explains how to choose your deductible, and the premium calculator shows the premiums in your municipality.

How to proceed

1. Get a prescription: Talk to your GP, a psychiatrist or, for children, the paediatrician. In an acute crisis, any doctor with a postgraduate title may prescribe it.
2. Ask the therapist: Check whether they are authorised under the KVG and when the first appointment is available.
3. Count the sessions: After 15 sessions, a new prescription is needed; after 30, a report to the medical adviser.
4. Check the decision: If the insurer refuses to pay for continuation, you can ask for a written decision and lodge an objection against it (Art. 49 and 52 ATSG). The article Benefit refused explains how.

Common mistakes

• Starting without a prescription. Basic health insurance does not pay for sessions before the doctor’s prescription.
• Forgetting the second prescription. From the 16th session, a new prescription is needed.
• Confusing coaching with psychotherapy. Counselling without an illness is not a compulsory benefit.
• Believing the therapy is free. The deductible and retention fee apply here too.
• Wanting to take out supplementary insurance in the middle of therapy. The insurer asks about ongoing treatment and may refuse you.

You will find other benefits, from massage to vaccinations, in the overview What does health insurance cover?, and key figures for the insurers in the health insurer profiles.