💳 Cost coverage for psychotherapy
In brief
Outpatient psychotherapy is a standard benefit of statutory health insurance (GKV). The process is structured by law into several steps: consultation hour, acute treatment if needed, preliminary sessions and – only after that – the actual guideline-based therapy with an application to the health insurance fund. A laborious expert review procedure as in the past is now only necessary in a few cases.
Step by step
- Attend the consultation hourAt least one appointment in the psychotherapy consultation hour is a prerequisite before acute treatment, preliminary sessions or therapy can begin.
- Complete preliminary sessionsAdults attend between two and four preliminary sessions; they clarify the diagnosis, treatment need and the personal fit with the therapist.
- Apply for cost coverageThe practice recommends applying to the health insurance fund for cost coverage no earlier than from the second preliminary session; for short-term therapy an informal notification is usually enough, for long-term therapy an anonymised report to an expert reviewer.
- Wait for the health insurance fund's decisionThe health insurance fund must decide within three weeks, or within five weeks if the expert review procedure is involved – if it does not respond in time, the application is deemed approved.
- Begin treatment and extend if neededShort-term and long-term therapy have different hour quotas depending on the therapy method; if the approved quota is not enough, an extension can be applied for.
Deadlines
- Without the prescribed consultation hour and, where applicable, preliminary sessions, the fund generally does not cover guideline-based therapy.
- Under the Psychotherapy Guideline, short-term therapy comprises two quotas of 12 therapy units each (24 in total); the quotas for long-term therapy differ by method (behavioural therapy, psychodynamic or analytic psychotherapy) and are given here only as a framework – the exact, method-specific maximum limits are set out in detail in the G-BA's Psychotherapy Guideline.
- Only psychotherapists with a statutory-insurance practice seat (accreditation) bill the health insurance fund directly; without a practice seat a separate cost reimbursement procedure is necessary, which is subject to conditions.
- An approved quota does not lapse immediately when you change therapist, but must be applied for again or transferred – clarify this early with the new practice.
In depth · legal basis, figures and practice – for advisers and professionals
Process under the Psychotherapy Guideline
Since the 2017 reform, outpatient psychotherapy is structured as: psychotherapy consultation hour (at least one appointment), acute treatment if needed, preliminary sessions (2 to 4 for adults) and finally guideline-based therapy (short-term or long-term therapy). An application to the health insurance fund is required for guideline-based therapy.
Hour quotas
Short-term therapy is divided into two sections of 12 therapy units each (KZT 1 and KZT 2, together 24 units), for which no expert review procedure is needed. Long-term therapy has different standard quotas and exception limits depending on the method; short-term therapy hours already used are credited towards a subsequent long-term therapy. For the exact, method-specific figures, the current Psychotherapy Guideline of the G-BA is authoritative.
Expert review procedure
Since April 2017 the expert review procedure has been limited to long-term therapy and is anonymised: The practice submits a report without a name, and an independent expert reviewer assesses necessity on behalf of the health insurance fund.
Deemed approval
If the health insurance fund does not decide within the statutory deadline (§ 13 para. 3a SGB V) and also does not communicate any sufficient reason for a delay, the requested benefit is deemed approved.
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