Your Way to Medical Rehabilitation
Persons who are insured under the Social Security Act, are entitled to the necessary measures for the protection, conservation, improvement, and restoration of their health and productivity as well as being protected against economic damages resulting from sickness and a loss of earning capacity (§ 4 SGB I).
Rehabilitation is an opportunity to actively participate in life again. Medical rehabilitation benefits are therefore designated under the SGB IX as benefits for the participation. With the 2007-health reform coming into effect, rehabilitation has become a compulsory performance of health insurance companies (§ 20 Abs. 2 SGB V), meaning that your rights as a patient / insured person have been strengthened considerably. The traditional term "cure" is no longer used in the new social legislation.
What carrier is actually the cost bearer for the treatment, will depend on the main objectives of rehabilitation and is subject to respective insurance law. In most cases, the statutory health insurance (GKV) or statutory pension are (GRV) the responsible payers. In addition, private health insurance (PHI), do assume cost depending on the contractually agreed scope of services.
Preparing for Rehab
Medical rehabilitation requires your active participation. In your application you will have to answer questions and make personal choices. Questions will be what disease you are suffering from, why you want to apply for rehabilitation, what expectations you connect with the rehabilitation, where it will take place and who will bear the costs?
It is important that you talk about your request for medical rehabilitation with your general practitioner, a specialist, or if you are in the hospital, the attending physician or the hospital’s social services. They will consult with you regarding the kind of rehabilitation necessary for you and they will assist you when completing the application.
Your Right to Select the Clinic of your Choice
Prior to planning a rehabilitation program, you should inform yourself about which rehabilitation clinic or hospital treats your condition and what your own expectations are in terms of location, services, and facilities. Important is that the clinic has been certified by an independent regulatory body and accordingly conforms to high, regularly monitored quality standards. The Breisgau Klinik for example is certified according to DIN EN ISO 9001:2008 and the Directives 5.0 of the German Society for Medical Rehabilitation (DEGEMED).
In your application you should state which clinic you prefer for your treatment, meaning which clinic you find more suitable to your needs. According to § 9 SGB IX you have the right to choose a clinic or hospital. The treatment center, clinic or hospital must be certified and offer medical services conducive to your health. A rehabilitation health insurance carrier (e.g. the statutory health insurance) must grant your request to select a treatment center of your choice without your having to pay the difference between the standard rate and the actual charges.
Actively exercise your right to be treated at a clinic or hospital of your choice!
Application Process
Each medical rehabilitation must be applied for by you personally prior to your arrival. For this purpose, a favorable medical opinion from your attending physician is helpful. Persons insured by a statutory health insurance may submit their application directly, i.e. without consulting a practitioner, to the health insurance or pension insurance. Since April 1, 2007, the insurance company must recommend multiple evaluators, if a medical evaluation from a physician is not available.
The application forms may be obtained from the respective insurance provider, whereby the health insurance companies also supply application forms for the German Pension Fund and fill in part of it. After receipt of an application, the cost carriers will clarify the responsibility for payment.
If the initially addressed cost carrier is not responsible for payment, it will submit the application to the next cost carrier. If a medical rehabilitation is required directly after hospitalization, the cost carriers follow special application procedures to have the patient admitted as quickly as possible to an appropriate rehabilitation clinic.
The different methods of medical rehabilitation measures as described below can be undergone both on an in- and outpatient bases at the Breisgau Klinik in costs sponsorship with the German Retirement Insurance (DRV) Baden Württemberg, the Agricultural Health Insurance, all statutory and private health insurances, the Knappschaft (Miners’ insurance), the Employment Agency, the social services, and in the context of exercising the right to select a clinic also in cooperation with other carriers of all other DRVs (e.g. DRV Rheinland Pfalz or DRV Association) and the Maritime Insurance Fund.
Follow-up Curative Treatment (AHB) or Follow-up Rehabilitation (AR)
For many cases, a follow-up treatment after an acute disease or surgical intervention in a hospital or clinic is necessary and required by the treating physicians (Follow-up curative treatment - AHB or follow-up rehabilitation measures – AR). For example, patients who have undergone a hip or knee replacement need rehabilitation treatment and/or follow-up therapies. A simplified application process ensures a fast transfer from the hospital to a rehabilitation clinic. The attending physician at the treating hospital can take all the necessary steps. The Social Services Department will also assist you in the application process and organize registration and admission at the Rehab Clinic, if the decision for rehabilitation was made after the patient has left the hospital.
Follow-up Curative Treatment (AGM)
In contrast to the follow-up curative treatment (AHB), the German pension retirement (state employees) system speaks about continuing health care measures (AGM) if the patient is not a member of any public health insurance or in case a rehabilitation treatment is not possible for medical or other reasons. For insurance purpose, at an AGM each case is reviewed individually to establish the need for the rehabilitation or continuing treatment. Once the need is established, the insurance carrier will approve the rehab. However, a direct transfer from the discharging hospital to the Rehab Clinic is not possible. A direct transfer from the hospital to a continuing health care facility (AGM) is also not possible. After an application process by the German pension retirement system, the patient will be referred to the appropriate treatment facility.
Additionally, a distinction is made according to the primary rehab measures. These are
- Inpatient or outpatient medical treatment (HV, registration and admission without previous acute hospital care)
- Statutory and trade association Next inpatient treatment (BGSW) after occupational accidents at the workplace and on the way to and from the work place
- Extended outpatient physiotherapy (EaP) of statutory and trade associations after occupational accidents at the workplace and on the way to and from the workplace.
"Accelarated Follow-up Rehab"
The so-called accelerated follow-up rehab is available to patients of the German Pension Insurances (DRV). Here rehabilitation is approved within 14 days after a hospital stay. This applies to insured persons whose earning capacity is substantially threatened or impaired by a medical diagnosis and/or review.
Process
- Use AHB request form (8.7501) and mail it together with the AHB diagnostic reports (8.7502)
- Medical services and health services of the hospitals complete the application and submit it to the rehab facility
- Applications with the so-called “red stamp” accelerated rehabilitation process"
- Submit application to the AHB address the German Pension Association (DRV) (FAX +49 30 / 865 279 75)
- Send original documents by postal mail to the German Pension Association (DRV)
The decision granting the rehabilitation measures will be issued by the German Pension Association (DRV) shortly after filing the application.
Private Krankenversicherung (PKV)
• Whether or not a private health insurance will cover the costs for a rehabilitation or follow-up treatment depends on the patient/insurance contract. Please check your policy for coverage prior to registering at the Rehab Clinic.
Generally, the cost of a follow-up treatment will be covered by the private health insurance since it is formally treated as a hospital stay. The Breisgau Klinik is authorized to treat PHI as a so-called "mixed health care facility".
Decision of your health insurance and objection
According to the socio-medical review and insurance assessment of your application, you will receive a notification letter from the insurance provider. In case of rejection, you have the opportunity to object in writing within one month. Often, medical rehabilitation is approved after you have filed an objection - so do not hesitate to exercise your right to object to the rejection. You have the same rights in the event that you do not agree with the proposed facility. Just ask for an immediate change of registration in the clinic of your choice since your wish for a clinic of your choice must be taken into consideration.
More information under ...
The social services association VdK Deutschland offers in-depth information at
"Wie bekomme ich eine Reha"
The work group Health also provides useful information at
arbeitskreis-gesundheit.de/fuer-patienten/reha-recht