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Applying for medical preventive services for insured persons of the statutory health insurance


For preventive medical services, the principle applies: outpatient before inpatient.

Outpatient preventive care services

Upon application and under certain conditions, your statutory health insurance will cover the costs of medical services and spa medication for outpatient preventive care. Accommodation and meals are paid by you as the insured person.

Outpatient preventive medical services are medical and therapeutic treatments, for example, therapeutic baths or physiotherapy, which are carried out by therapy centers in state-recognized health resorts. You can choose the health resort and the therapy center together with your doctor. You organize your own accommodation and meals.

Inpatient preventive services

If an outpatient preventive treatment at a state-recognized health resort is not sufficient because, for example, you are physically severely impaired or require intensive medical care, your health insurance company must grant you an inpatient preventive treatment upon application. In addition to treatment, this also includes room and board in the spa clinic.

Medical necessity

Your health insurance company can only approve an outpatient or inpatient preventive care benefit if you have previously exhausted all therapy offers at your place of residence. Your doctor must justify the necessity of the preventive treatment to your health insurance company in the application.

A cure can be considered medically necessary if

  • it can prevent an impending illness or avoid its aggravation, or
  • prevent the need for nursing care, or
  • a risk to the health development of a child can be counteracted.

Duration

The duration of outpatient preventive services should be provided for a maximum of 3 weeks. An extension can only be considered if this is urgently required for medical reasons in order to achieve the preventive care goal.

Inpatient preventive services should be provided for a maximum of 3 weeks - unless an extension of the service is urgently required for medical reasons.

In individual cases, stays at a health resort abroad are also possible; please contact your health insurance company for more information.

Process flow

For a preventive service, proceed as follows:

  • In a consultation, your doctor will prescribe a preventive medical service for you.
  • For outpatient preventive care: Your doctor fills out the application form (model 25) together with you and justifies the necessity of the measure.
  • For inpatient preventive care: Your doctor fills out the application form of your health insurance together with you and justifies the necessity of the measure.
  • You send the completed application to your statutory health insurance fund. You can submit the application by mail and - for many health insurance companies - also online or hand it in at the office.
  • The health insurance fund will check whether there is an entitlement to preventive care benefits and inform you of the result.
  • For outpatient preventive care benefits: Together with your doctor, you will select a suitable state-recognized spa from a medical point of view.
  • For inpatient preventive care benefits: You are welcome to inform your health insurance company of your wishes regarding a specific preventive care facility. Your health insurance fund will check whether these wishes can be met.

Requirements

Your doctor prescribes the cure and justifies the medical necessity to your health insurance company.

Which documents are required?

In individual cases, medical documents may be required. You can find out what these are from your doctor or your health insurance provider.

What are the fees?

Under certain conditions, your statutory health insurance will cover the costs of spa medical treatment and a proportion of the costs of spa medication in the case of outpatient preventive care. Accommodation and meals are paid by you. A subsidy from the health insurance fund is possible for this.
In the case of inpatient preventive care, the health insurance company covers the costs of treatment, accommodation and meals. You pay the usual co-payment.


What deadlines do I have to pay attention to?

In order for your health insurance company to approve the application, your last outpatient spa treatment must generally have taken place at least 3 years ago.

As a rule, your last inpatient spa treatment must have taken place at least 4 years ago.

In case of urgent medical necessity, shorter intervals are also possible in both cases.

Processing duration

For outpatient preventive services, the processing time is usually 5 to 18 business days.

For inpatient preventive care benefits, the processing time is usually 5 to 20 working days.

For rapid processing and decision-making, your health insurance fund must be provided with the necessary information and any required documents in a complete and meaningful manner.
The health insurance company will make a decision on applications promptly, while adhering to the statutory processing time limit in order to protect patients' rights.
Please note that the processing time indicated is an average value for all health insurance funds. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and may be longer accordingly. The same applies if documents or records are sent to you or your health insurer by mail.


If necessary, the Medical Service must be involved. This will take up to an additional 5 weeks to process your request.

Appeal

  • Objection
  • Action before the social court

Technically approved by

Federal Ministry of Health

Professionally released on

02.12.2021

Author

The text was automatically translated based on the German content.

Source: Serviceportal Niedersachsen (Portalverbund des Bundes und der Länder)