Apply for preventive medical benefits for insured persons of the statutory health insurance
In the case of 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 remedies in the case of outpatient care. You pay for accommodation and meals as an insured person.
Outpatient medical services are medical and therapeutic treatments, such as spas or physiotherapy, which are carried out by therapy centres in state-approved health resorts. You can choose the health resort and the therapy centre together with your doctor. You can arrange your own accommodation and meals.
Inpatient pension benefits
If an outpatient preventive care service in a state-approved health resort is not sufficient, for example because you are physically severely impaired or need intensive medical care, your health insurance company must grant you an inpatient preventive service upon application. In addition to treatment, this also includes accommodation and meals in the spa clinic.
Medical necessity
Your health insurance company can only grant you outpatient or inpatient preventive care if you have previously exhausted all therapy offers at your place of residence. In the application, your doctor must justify the necessity of the preventive benefit to your health insurance company.
A cure may be considered medically necessary if
- it can prevent an imminent illness or avoid its aggravation, or
- the need for long-term care is avoided or
- a threat to the health development of a child can be counteracted.
Duration
The duration of outpatient preventive care should be provided for a maximum of 3 weeks. An extension can only be considered if this is urgently necessary for medical reasons in order to achieve the precautionary goal.
Inpatient preventive care should be provided for a maximum of 3 weeks - unless an extension of the service is urgently required for medical reasons.
In individual cases, spa stays abroad are also possible, please contact your health insurance company for more information.
Process flow
For a pension benefit, proceed as follows:
- In a consultation, your doctor will prescribe a preventive medical service.
- For an outpatient preventive care service: Your doctor fills out the application form (model 25) together with you and justifies the necessity of the measure.
- For an inpatient preventive service: Your doctor will fill out the application form from your health insurance company together with you and justify the necessity of the measure.
- You send the completed application to your statutory health insurance company. You can submit the application by post and – with many health insurance companies – also online or hand it in at the office.
- The health insurance company will check whether there is an entitlement to a preventive benefit and inform you of the result.
- In the case of outpatient preventive services: Together with your doctor, you will select a suitable state-approved health resort from a medical point of view.
- In the case of inpatient preventive services: You are welcome to tell your health insurance company your wishes for a specific preventive care facility. Your health insurance company will check whether these wishes can be met.
Requirements
Your doctor will prescribe the cure and explain the medical necessity to your health insurance company.
Which documents are required?
In individual cases, medical records may be required. You can find out what these are from your doctor or health insurance company.
What are the fees?
Under certain conditions, your statutory health insurance will cover the costs of spa medical treatment and proportionately the costs of spa remedies in the case of outpatient care. You pay for accommodation and meals. For this purpose, a subsidy from the health insurance company is possible.
In the case of inpatient care, the health insurance company covers the costs of treatment, accommodation and meals. You pay the usual deductible.
What deadlines do I have to pay attention to?
In order for your health insurance company to approve the application, your last outpatient cure must usually be at least 3 years ago.
As a rule, your last inpatient cure must have been at least 4 years ago.
In case of urgent medical necessity, shorter intervals are also possible in both cases.
Processing duration
For outpatient preventive care services, the processing time is usually 5 to 18 working days.
For inpatient pension benefits, the processing time is usually 5 to 20 working days.
For a quick processing and decision, your health insurance company must have the necessary information and, if necessary, the necessary documents complete and meaningful.
The health insurance company decides on applications in a timely manner, whereby the statutory processing deadline is observed in order to protect patients' rights.
Please note that the stated processing time is an average value of all health insurance companies. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and can be extended accordingly. The same applies if documents or records are sent by post to you or your health insurance company.
If necessary, the medical service must be involved. This requires an additional 5 weeks to process your request.
Applications / forms
- Forms: yes
- Online procedure possible: Many statutory health insurance companies offer an online procedure.
- Written form required: yes
- Personal appearance required: no
Appeal
- Contradiction
- 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.
