Does health insurance pay for rehabilitation?

What basic health insurance pays

Medical rehabilitation is a compulsory benefit of basic health insurance: it covers “medical rehabilitation measures carried out or ordered by a doctor” (Art. 25 para. 2 let. d KVG). Like every benefit, rehab must be effective, appropriate and cost-effective (Art. 32 para. 1 KVG). This is exactly where most disputes arise: the health insurer checks whether inpatient rehab is necessary or whether outpatient therapy is enough.

Inpatient rehab: only in a listed clinic

Under the KVG, a rehab clinic counts as a hospital: institutions that provide medical rehabilitation measures on an inpatient basis need a place on a canton’s Hospital List (Art. 39 para. 1 KVG). Billing is done with performance-related flat rates (Art. 49 para. 1 KVG). The health insurer and your canton of residence share them; the canton sets its share every year, at least 55 % (Art. 49a para. 2ter KVG).

You are free to choose among the listed clinics of your canton of residence and of the canton where the clinic is located. If the clinic is outside your canton, the health insurer and the canton pay at most the tariff that applies to this treatment in a listed hospital in your canton of residence (Art. 41 para. 1bis KVG). You or a supplementary hospital insurance pay the difference.

Outpatient rehab

With outpatient rehab, you live at home and go to your therapy sessions. For physiotherapy, the rule is: at most 9 sessions per doctor’s prescription, the first within 5 weeks; further sessions require a new prescription. If therapy is to continue after 36 sessions, the doctor reports to the health insurer’s medical adviser, who decides whether it continues (Art. 5 para. 2–4 KLV). Details are on the page Does health insurance pay for physiotherapy?.

What you pay yourself

All rehab services are subject to the deductible and the 10 % retention fee, for adults up to a maximum of CHF 700 a year (Art. 64 para. 2 KVG, Art. 103 KVV). In the clinic, there is also the hospital contribution of CHF 15 per day; you do not pay for the day of discharge. Children, young adults in education and women who are exempt from the co-payment because of maternity do not pay a hospital contribution (Art. 104 KVV).

Rehab is not spa treatment: for a balneotherapy cure, basic health insurance pays only CHF 10 per day, and nothing for a convalescent stay. The difference is explained on the page Does health insurance pay for spa treatment?. After an accident, accident insurance pays for the medical treatment first (Art. 10 UVG); the health insurer pays only if no accident insurance covers it (Art. 1a para. 2 let. b KVG).

What supplementary insurance pays

Basic health insurance pays for rehab in the general ward of a listed clinic. Anything beyond that is a matter for voluntary supplementary insurance under the Insurance Contract Act (ICA). Each health insurer sets out in its general terms and conditions:

• whether it covers a room in the semi-private or private ward of the rehab clinic,
• whether it covers the tariff difference of a clinic in another canton,
• whether it pays for clinics that are not on a Hospital List and which clinics it recognises,
• which benefits it provides for convalescent stays after rehab,
• whether it requires prior cost approval.

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 supplementary products under Supplementary insurance. What always counts are the general terms and conditions and the information from your health insurer.

Conditions

• Doctor’s order: Rehab must be carried out or ordered by a doctor (Art. 25 para. 2 let. d KVG). Clarify who registers you with the rehab clinic: the acute hospital or your doctor.
• Effective, appropriate, cost-effective: The health insurer checks whether the chosen form is necessary, for example whether inpatient rehab is indicated or outpatient rehab is enough (Art. 32 para. 1 KVG).
• Medical adviser: The medical adviser checks the conditions for coverage on behalf of the health insurer and is independent in their judgement; neither the health insurer nor the clinic can give them instructions (Art. 57 para. 4 and 5 KVG).
• Cost approval: Whether a cost approval must be in place before admission is governed by the agreements between the health insurer and the clinic. Ask before admission whether it has been granted; the same applies to supplementary insurance.
• Listed clinic: For inpatient care, basic health insurance pays only in a clinic on a cantonal Hospital List, and in another canton at most at the tariff of your canton of residence (Art. 39 para. 1 and Art. 41 para. 1bis KVG).
• Accident insurance first: If the rehab is the result of an accident and you are insured under the UVG, accident insurance pays.
• Deductible, retention fee and hospital contribution: They apply as for every benefit, per calendar year; the date of treatment is what counts (Art. 103 para. 3 KVV).

Sample calculation

Example with fictitious people and an assumed amount on the clinic’s bill. Peter, 67, receives a new hip joint in March. With the operation, he has already used up his deductible of CHF 300 and the annual maximum retention fee of CHF 700 for this year. He then spends 21 days in a rehab clinic on the Hospital List of his canton of residence. The clinic’s bill is assumed, as is a cantonal share of exactly 55 %; the hospital contribution and co-payment follow from Art. 64 KVG and Art. 103 and 104 KVV.

How a high or low deductible affects a year with an operation and rehab is shown by the deductible calculator. You can lower your deductible for the next year until 30 November; all dates are listed under Deadlines.

How to proceed

Before admission

1. Clarify the form: Ask your doctor whether outpatient or inpatient rehab is indicated and why.
2. Check the clinic: Ask whether the clinic is on the Hospital List of your canton of residence. If it is outside your canton, clarify the tariff difference.
3. Wait for the cost approval: Get confirmation that the health insurer has granted the cost approval, and the same for supplementary insurance.

If your health insurer refuses to pay for rehab

1. Ask for reasons: Have the refusal explained in writing. If you disagree, ask for a written decision; the health insurer must issue one (Art. 49 and 51 para. 2 ATSG).
2. Submit a medical report: Ask your doctor to explain to the medical adviser why rehab is necessary and why outpatient care is not enough.
3. File an objection: You can file an objection to the decision with the health insurer within 30 days. The procedure is free of charge (Art. 52 ATSG).
4. Get advice: The Office of the health insurance ombudsperson advises and mediates free of charge.
5. Appeal: You can file an appeal against the response to the objection with the Cantonal Insurance Court within 30 days (Art. 56 and 60 ATSG).

More on this route is in the article Benefit rejected: your rights, objection and ombudsperson.

Common mistakes

• Confusing rehab and spa treatment. Basic health insurance does not pay for a convalescent stay, not even after an operation.
• Choosing a clinic that is not on a Hospital List. Then basic health insurance does not pay for the stay.
• Accepting a verbal refusal. You can only file an objection against a written decision.
• Overlooking the turn of the year. The deductible and retention fee start again each calendar year.
• Informing your health insurer first after an accident. If you are insured against accidents through your employer, report the accident there.

After rehab, care often continues at home; what basic health insurance pays for care at home is explained on the page Does health insurance pay for Spitex?. Key figures and supplementary offers of the health insurers are in the health insurer profiles, premiums in the premium calculator, and all benefits in the overview What does health insurance cover?.