Does health insurance pay for speech therapy?

What basic health insurance pays

Speech therapy is one of the services that specialists provide on a physician’s order at the expense of basic health insurance (Art. 25 para. 2 let. a no. 3 KVG). Unlike physiotherapy, the range of causes is narrow: basic health insurance only pays if a disorder of language, speech, voice, fluency or swallowing is due to one of two conditions (Art. 10 KLV).

Quantities: The insurer pays for at most twelve sessions per physician’s order. The first treatment must take place within eight weeks of the order (Art. 11 para. 1 KLV). Further sessions require a new order (para. 2).

After 60 sessions: If therapy is to continue after treatment equivalent to 60 one-hour sessions within one year, the physician sends the medical adviser a report with a reasoned proposal. The medical adviser proposes whether and to what extent the insurer continues to pay (Art. 11 para. 3 KLV). After that, the physician reports at least once a year on the course of treatment and the indication (para. 4). The reports may only contain information that is necessary to assess the obligation to pay (para. 5).

Not an IV benefit: Invalidity insurance does not cover any costs for speech therapy measures (Art. 14 para. 3 IVG). If a speech disorder is due to a congenital disorder, basic health insurance therefore pays the same benefits as for illness (Art. 27 KVG), provided the requirements of Art. 10 KLV are met.

School and canton: The cantons ensure adequate special needs education for all children and young people with disabilities until the age of 20 is reached (Art. 62 para. 3 Cst.). Speech therapy without a neurological or phoniatric cause is not a benefit of basic health insurance; whether and how the canton or municipality provides it is governed by cantonal law.

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 or retention fee.

What supplementary insurance pays

For speech therapy ordered by a physician with a neurological or phoniatric cause, you do not need supplementary insurance. Supplementary outpatient insurance can step in where basic health insurance stops. Whether and how much it pays is set out by each insurer in its general insurance conditions, for example for:

• sessions without a physician’s order,
• therapies whose cause does not fall under Art. 10 KLV,
• treatment by recognised therapists who may not bill basic health insurance.

Contracts may limit such contributions per session or per year; the figures are in the general insurance conditions. 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. The general insurance conditions and the information from your insurer are decisive.

Conditions

• Physician’s order: Without a prescription, basic health insurance does not pay for speech therapy (Art. 10 KLV). The order is valid for at most twelve sessions.
• Eight-week deadline: The first session must take place within eight weeks of the order (Art. 11 para. 1 KLV).
• Cause under Art. 10 KLV: The disorder must have a neurological or phoniatric cause. The physician records the cause in the order.
• Licensed speech therapist: Speech therapists who are authorised to practise under cantonal law and have a recognised three-year professional training (Art. 50 KVV) may bill, as may licensed speech therapy organisations (Art. 52b KVV).
• Reports to the medical adviser: after 60 one-hour sessions within one year and at least annually after that.
• Deductible and retention fee: Adults pay the deductible and 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 bodies first: In the event of an accident, accident insurance pays; support at school is governed by the canton.

Sample calculation

Example with fictitious people and an assumed price per session. Margrit is 68 and has the standard deductible of CHF 300. After a disease of the nervous system, her physician prescribes speech therapy: two orders of twelve sessions each. A one-hour session costs an assumed CHF 110.00; the actual amount depends on the tariff. Margrit has no other medical bills this year. Deductible and retention fee are the statutory values from Art. 64 KVG and Art. 103 KVV.

The amount paid out is CHF 2,640.00 minus CHF 534.00. For further bills in the same year, Margrit only pays the retention fee until she reaches CHF 700.

Whether a low or a high deductible is cheaper depends on how much you spend on doctors and therapy in a year. You can work out the break-even point in the deductible calculator and compare premiums 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. Clarify the cause: The physician determines whether the disorder has a neurological or phoniatric cause and issues the order.
2. Start within eight weeks: Book the first appointment so that it falls within eight weeks of the order.
3. Check the licence: Ask the practice whether it bills basic health insurance.
4. Keep count of the sessions: After twelve sessions you need a new order, and after 60 hours within one year, the report to the medical adviser.
5. For children, ask the school: If it is about language support without a medical cause, the school or the canton is the right place to ask. 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.
• Not clarifying the cause. Without a neurological or phoniatric cause, the insurer refuses to pay the costs.
• Waiting for the IV. The IV does not pay for speech therapy; applying there only delays billing.
• A 13th session without a new order. One order covers at most twelve sessions.
• Forgetting the annual report. If therapy runs longer, the insurer needs a report at least once a year.

When your insurer pays for occupational therapy is explained on the page Occupational therapy, and what it contributes to fitness on the page Gym membership. You can find all benefits in the overview What does health insurance cover?.