Preliminary note: contribution to costs
Policyholders contribute to the cost of medical benefits claimed by paying a predetermined annual amount, the deductible rate, themselves. As a rule, policyholders have to pay for 10% of the costs exceeding the deductible rate (retention) up to a maximum of CHF 700 per year (CHF 350 per year for children). Benefits for maternity are not subject to deductible rate and retention.
Example of contributions
Basic insurance benefits are determined by law and therefore identical with all health insurance companies.
Overview of benefits
Overview of service coverage in alphabetical order
Complete text versions can be found in the Federal Act on Health Insurance (KVG), in the Health Insurance Ordinance (KVV) and in the Health Insurance Benefits Ordinance (KLV) (texts not available in English).
1. General benefits
1.1 Hospital stay in a general ward of a recognised hospital in canton of residence
Exception: Should the policyholder be compelled for medical reasons to undergo treatment not performed in his canton of residence (complex operations such as organ transplants, etc.) or if he must undergo emergency treatment outside his canton of residence, resulting costs will also be covered by the canton of residence.
Policyholders must contribute CHF 15 per day to the costs of staying in hospital.
Tip: For more privacy in a 1 or 2-bed room, a right to choose your physician freely or for general ward coverage nationwide, you can apply for corresponding supplementary health insurance.
1.2 Semi-inpatient arrangements: These may be e.g. semi-inpatient eye clinics or psychiatric day clinics. This means that patients stay in the clinic for a few hours after actual treatment, but not overnight.
1.3 Examinations, treatment and nursing care performed on an outpatient basis, at the patient's home, in hospitals or nursing homes by:
- Physicians
- Chiropractors ... (without a doctor's prescription)
Patients are generally allowed to consult the physician and/or chiropractor of their choice for out-patient treatment, unless they are insured according to the Telmed, GP or HMO model. However, coverage provided by the insurer varies according to valid tariffs for your place of residence or work. If you undergo treatment outside these areas, you will have to brace yourself for uncovered costs.
... and persons providing services prescribed by a physician in the following areas of health care:
- Physiotherapy (with a doctor's prescription), as long as the treatment is performed by a licensed therapist. At most 9 sessions within a 3 month period from the date of the doctor's prescription. Coverage of costs for further sessions is provided only upon doctor's orders. Coverage provided by the insurer varies according to valid tariffs for your place of residence or work. If you undergo treatment outside these areas, you will have to brace yourself for uncovered costs.
- Ergotherapy (with a doctor's prescription), as long as the treatment is performed by a licensed therapist. At most 9 sessions within a 3 month period from the date of the doctor's prescription. Coverage of further sessions is provided only upon doctor's orders. Coverage provided by the insurer varies according to valid tariffs for your place of residence or work. If you undergo treatment outside these areas, you will have to brace yourself for uncovered costs.
- Nursing care: at home, on an outpatient basis or in a nursing home.
- Nutrition counselling (with a doctor's prescription): The insurance will cover up to 6 consultations with a doctor's prescription. Should further consultations be necessary, the doctor can renew the prescription. After 12 consultations, the treating doctor must consult one of the insurance company's fiduciary physicians and suggest how his patient's treatment should continue. Coverage provided by the insurer varies according to valid tariffs for your place of residence or work. If you seek medical consultation outside these areas, you will have to brace yourself for uncovered costs.
- Diabetes counselling (with a doctor's prescription): The insurance will cover up to 10 consultations with a doctor's prescription. Should further consultations be necessary, the doctor can renew the prescription. Up to 20 consultations per year are reimbursed. Coverage provided by the insurer varies according to valid tariffs for your place of residence or work. If you seek medical consultation outside these areas, you will have to brace yourself for uncovered costs.
- Logopaedic treatment (with a doctor's prescription): The insurer will cover up to 12 consultations within a period of 3 months. Coverage of further sessions is provided only upon doctor's orders. After 60 one-hour consultations within a period of one year, the treating doctor must consult one of the insurance company's fiduciary physicians and suggest how his patient's treatment should continue. Coverage provided by the insurer varies according to valid tariffs for your place of residence or work. If you undergo treatment outside these areas, you will have to brace yourself for uncovered costs.
- Psychiatric therapy: At most, 10 work-up and therapy sessions are covered. In order to receive coverage for the costs of the next 30 sessions, the treating doctor has to notify the fiduciary physician about the started treatment after 6 sessions (latest after 9 sessions). If more than 40 sessions are needed for a psychiatric therapy, the treating doctor must make a well-founded suggestion to the fiduciary physician of the health insurance company about how the therapy should continue. Psychiatric therapy for self-awareness, self-realisation or character maturity is not covered by health insurance. Coverage provided by the insurer varies according to valid tariffs for your place of residence or work. If you undergo treatment outside these areas, you will have to brace yourself for uncovered costs.
Tip: You will need outpatient supplementary health insurance if treated by psychotherapists without a medical degree, unless they treat you in a doctor's practice under medical supervision (psychotherapy delegated by a physician).
1.4 Coverage abroad: Only emergency treatment is covered abroad. Basic health insurance will only pay up to twice the amount the same treatment would cost in Switzerland. This is sufficient for travel within Europe, but in certain overseas areas it is highly recommended to buy additional insurance, especially for travel in the USA, Canada, Australia and Japan. Usually, basic health insurance will not cover transportation costs back to Switzerland (repatriation) and only 50% of emergency transportation costs to the next hospital abroad are paid (no more than CHF 500 per year).
Tip: If necessary, buy adequate supplementary health insurance or separate holiday and travel insurance.
1.5 Transport and rescue missions: Basic health insurance pays 50% of the costs for medically necessary rescue missions, max. CHF 5,000 per year. For transportation in non-life threatening situations, also 50% of costs, but no more than CHF 500 per year will be paid. However, transportation costs due to hospital transfers are fully covered by basic health insurance.
1.6 Health resorts and spas: Contribution up to CHF 10 per day to costs of stays in a health resort or spa for up to 21 days per calendar year if ordered by a doctor. Costs for medical examinations, medication and recognised forms of therapy are covered by basic health insurance less contribution to costs.
1.7 Nursing services: Contribution to treatment costs in a recognised nursing home. Coverage of fees for nursing care at home (Spitex) and in nursing homes by basic health insurance varies from canton to canton. Doctors may generally order up to 60 hours of home care (Spitex) per trimester, but this must be approved by the insurer. The amount of coverage necessary influences how much the patient must contribute to the total costs of his care in a nursing home. However, he must fully cover all costs for room and board himself.
1.8 Medical rehabilitation treatment performed or ordered by a physician
1.9 Alternative medicine: From 2012 to 2017, five healing methods (anthroposophic medicine, homoeopathy, neural therapy, phytotherapy and traditional Chinese medicine) will be allowed under certain conditions. Services will be covered if performed by doctors having obtained a qualification in the listed therapies.
2. Analysis and medication
Covered according to the analysis, medication and specialities lists. The analysis and medication list can be found in the Health Insurance Benefits Ordinance (Krankenpflege-Leistungsverordnung, KLV, art. 28, app. 3 and art. 29, app. 4). Orders may be placed at: EDMZ, 3003 Bern.
3. Medical aids and devices
Medical aids and devices necessary to perform examinations or treatment covered by mandatory basic health insurance are listed in the Health Insurance Benefits Ordinance (Krankenpflege-Leistungsverordnung, KLV, art. 20, app. 2). Orders may be placed at: EDMZ, 3003 Bern.
4. Birth defects
Costs which arise due to birth defects not covered by disability insurance are covered by basic health insurance. A list of birth defects (in German) can be found in the Health Insurance Benefits Ordinance (KLV).
5. Additional benefits for maternity
- Examinations performed by doctors or midwives and examinations ordered by doctors during and after pregnancy. Mandatory basic health insurance covers costs for 7 routine examinations (2 of which may be ultrasound scans, between the 10th and 12th as well as between the 20th and 23rd week of pregnancy, more in case of a high-risk pregnancy) and a post-natal examination (6 to 10 weeks after giving birth).
- Childbirth either at home, in a general hospital ward in the canton of residence or in a semi-inpatient situation, including preparation and aid provided by doctors or midwives.
- Up to three breastfeeding consultations
Important: Costs arising due to maternity are neither subject to the deductible rate nor to retention.
Tip: Women who wish to be able to choose their gynaecologist freely for giving birth either at the hospital or at home will need private or semi-private supplementary health insurance, which must be purchased early enough.
6. Legal abortion
Legal abortion (art. 120 StGB) is covered for by mandatory basic health insurance.
7. Coverage for dental treatment
Basic health insurance only reimburses treatment for severe and unavoidable diseases of the mastication system and dental treatment required due to a critical general medical condition (list; in German) and the resulting consequences. It will also cover costs for dental treatment after accidents, but only if this claim is not covered by any other insurance. Costs for dental fillings, removal of wisdom teeth, amalgam replacement and corrective dentistry are not covered by basic health insurance.
Tip: Braces for straightening children's teeth can be covered by buying the appropriate supplementary health insurance. However, it must be purchased early enough.
8. Medical prevention
Basic health insurance covers costs for certain examinations for early detection of disease as well as costs for preventative measures for policyholders who are at a higher risk for certain diseases. These examinations or preventive measures must be performed or prescribed by a doctor. They are:
- Up to 8 examinations of state of health and normal development for children at pre-school age
- Screening for phenylketonuria, galactosaemia, biotinidase deficiency, adrenogenital syndrome, hypothyreosis and vitamin K prophylaxis
- HIV tests for infants of HIV-positive women
- HIV tests for persons at higher risk of contracting HIV
- Gynaecological examinations (the second examination after one year, after that one examination every 3 years)
- Colon examination if family members have had colon cancer
- Various protective and preventative vaccinations, e.g against diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps and rubella for children and adolescents up to 16 years of age
- Booster shots: diphtheria and tetanus for adults (every 10 years)
- Tetanus booster shots after injuries
- Haemophilus influenzae shots for children up to 5 years of age
- Flu vaccination for individuals older than 65 or suffering from a severe disease
- Hepatitis B vaccination generally for all age groups, for infants of positive mothers and individuals at higher risk of contracting the disease. The main focus is on vaccination programmes for 11 to 15-year-olds
- Skin examinations if a family member has had melanoma
- Mammogram if a family member has had breast cancer
- Preventative mammograms for women over 50 (every 2 years; yearly for women whose mother, daughter or sister has had breast cancer)
- Additional vitamin D for rachitis prevention during the first year of life
- Sonographic hip screening according to Graf for newborns (up to 6 weeks of age)
9. Spectacle lenses and contact lenses
Mandatory basic health insurance reimburses optical aids for children. For adults, part of the costs is covered only in the presence of certain medical conditions or following eye surgery.
Many types of outpatient supplementary health insurance cover costs for optical aids.
