Did rehab work for you

Online health insurance guide

prevention

Insured persons receive comprehensive pension benefits. The aim is to remedy a deterioration in health that would likely lead to an illness in the foreseeable future, to counteract the endangerment of a child's health development and to avoid the need for care. Depending on the individual case, medical preventive care includes either outpatient treatment and care at the place of residence, outpatient treatment and care in a recognized rehabilitation clinic, or treatment and care in an inpatient care facility.

rehabilitation

The goal: To get along as well as possible in everyday life - the patient's participation, which is threatened or impaired for health reasons, is to be restored, improved or prevented from worsening through rehabilitation medical care. The measures help restore performance.

Even with an illness, prevention is now part of the treatment concept. In addition to early and regular medical treatment, a targeted diet or, for example, individually tailored exercise therapy and corresponding relaxation exercises can also have a positive effect on the course of the disease in sick people. In this way, possible consequences of illness, for example a stroke, are often mitigated. Relapses, deterioration in overall condition and secondary diseases are less common.

Who is responsible for rehabilitation services and prevention?

Outpatient and inpatient care benefits are usually the responsibility of the statutory health insurance, while rehabilitation benefits are also the responsibility of the pension insurance or accident insurance. What counts as preventive care or rehabilitation for a certain clinical picture and which insurance is then the cost bearer for which measures - insured persons do not initially need to know these complex regulations. If you want to take advantage of rehabilitation and preventive care, you should first talk to your doctor. He or she will then check whether a rehabilitation service is medically necessary. The responsible social insurance agency decides on the approval of the rehabilitation or preventive measure.

Direct follow-up rehabilitation is often necessary after an operation or after a hospital stay due to a serious illness - for example, after a heart attack, hip surgery or tumor disease. In order to ensure the seamless transition, the application for this should already be made in the hospital. Patients should therefore speak to the treating doctor at the clinic at an early stage - the social services can also help here as a contact person.

As part of each assessment to determine the need for care, the medical service must also determine whether and to what extent services for medical rehabilitation are suitable, necessary and reasonable. The findings on medical rehabilitation must be made by the medical service or the experts commissioned by the long-term care insurance fund on the basis of a nationwide, structured procedure and documented in a separate prevention and rehabilitation recommendation.

The prevention and rehabilitation recommendation will be automatically sent to the insured person - if they do not object to the sending - with the expert opinion to determine the need for care. In its decision on the need for long-term care, the long-term care insurance fund must comment on the rehabilitation recommendation and also inform the applicant that an application process for medical rehabilitation benefits in accordance with the provisions of Book Ninth is sent to the competent rehabilitation provider with a notification of the need for rehabilitation Social Security Code (SGBIX) is triggered if the applicant consents to this procedure.

If there is a rehabilitation recommendation, the insured person and other persons and institutions (e.g. relatives and relatives, family doctor or inpatient and outpatient care facilities) can be informed about the expert findings of the medical service. People in need of care and those at risk of care can thus receive better support from people or institutions they trust when submitting an application and deciding whether to carry out a rehabilitation measure.

What is the difference between outpatient and inpatient preventive and rehabilitation services?

The preventive and rehabilitation measures are used as flexibly as possible today in order to do justice to the patient's life situation. Two variants are possible:

Inpatient rehabilitation

Here, patients are not only treated in a facility, they also live there - care around the clock.

Outpatient and mobile rehabilitation

In the case of outpatient rehab, a local rehab center or a rehab clinic with health insurance approval is visited daily. There, patients receive targeted, complex measures from doctors or therapists, which include medical, physiotherapeutic, psychotherapeutic and other services. The patients only come to the facilities for treatment. If this is also not possible for them, “rehabilitation comes into the house” - that is, certain rehabilitation and preventive services are also offered in the familiar surroundings of the patients by mobile rehabilitation teams.

What is the goal of geriatric rehabilitation?

Older people should live in their familiar surroundings for as long as possible after an accident or illness and should be given the opportunity to actively participate in life. This is what geriatric (geriatric medicine) rehabilitation is geared towards. It can be inpatient, partial inpatient or outpatient. Mobile rehabilitation teams are also used. Those who are already in need of care can, for example, receive rehabilitation benefits in inpatient care facilities.

What are parents' entitlements?

Preventive medical care and rehabilitation measures for mothers and fathers - the so-called mother-child and father-child measures - are compulsory health insurance benefits. That means: If they are medically necessary, they have to be paid for by the health insurance company. Parents can obtain information from their treating physicians, the health insurance companies and the maternal convalescence organization.

How often and for how long are rehabilitation and preventive benefits reimbursed?

Inpatient preventive and rehabilitation services usually last three weeks, outpatient rehabilitation services a maximum of 20 treatment days. The standard duration of inpatient preventive and rehabilitation measures for children under the age of 14 is four to six weeks. If there is a justified medical need, an extension of the preventive or rehabilitation benefit can be requested. Parents should talk to their doctor and their health insurance provider about this. The standard duration of geriatric rehabilitation was set in the Intensive Care and Rehabilitation Strengthening Act (IPReG), which came into force on October 29, 2020, at 20 treatment days (outpatient) or three weeks (inpatient).

Can you choose your own rehabilitation facility?

Patients can inform their health insurer of their wishes regarding a specific rehabilitation facility. If this is suitable from a medical point of view and takes into account the wishes of the personal life situation, age, family situation or religious and ideological needs, the health insurance company must comply with these wishes. When the health insurance company decides on the facility, principles of economy and economy must of course also be taken into account.

When the Health Care Strengthening Act came into force on July 23, 2015, the insured's right to wish and choose in the field of medical rehabilitation, for example after an operation or a long hospital stay, was strengthened. You can now also choose certified rehab facilities, regardless of whether they have signed a supply contract with your health insurance company. The IPReG stipulates that the additional costs that the insured must bear if they choose a rehabilitation facility other than the one assigned by the health insurance company is halved.

What co-payments do the insured have to make?

All patients over 18 years of age have to make co-payments. The following rules apply:

  • Additional payment of ten euros per day for inpatient care and rehabilitation

  • The additional payment is limited to 28 days for follow-up rehabilitation. Hospital co-payments that have already been made are taken into account.

  • The personal co-payment limit is two percent of gross income or one percent in the case of a serious chronic illness (regulation for chroniclers).

18 days hospital stay + 22 days follow-up rehabilitation = 40 days
Additional payment: only 28 days x 10 EUROS = 280 euros

In the case of outpatient preventive services in health resorts, the health insurance company pays the costs for medical treatment, including the prescribed medication. Remedies, including the so-called spa-specific remedies and health promotion measures, are also paid for. The health insurance company can provide a financial contribution to the other costs incurred in connection with outpatient medical care services. If insured persons are older than 18 years, however, they have to make co-payments, for example for remedies or medicines.

In principle, the general co-payment regulations apply. A complete exemption from co-payments is not possible. As soon as insured persons have reached their limit - two percent of their gross income or one percent if insured persons are seriously chronically ill (so-called chronicler regulation), they are exempt from all further co-payments for the rest of the calendar year.

You can visit a specialist of your choice, provided that he or she is authorized to provide medical care.


March 26, 2021