Preliminary note: contribution to costs
Policyholders contribute to the cost of benefits claimed by paying an annual deductible rate and a retention of 10 percent, as a rule, of all costs exceeding this amount to a max. of CHF 700 per year (CHF 350 per year for children). An exception from the deductible rate and retention are benefits for maternity.
Example of contributions
Benefits provided by basic health insurers are determined by law and therefore identical for all health insurance companies.
Overview of benefits
Overview of service coverage in alphabetical order
Complete text versions can be found under federal laws on health insurance, in the regulations for health care and regulations for nursing care.
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 (e.g.complex operations such as organ transplants, etc.) or if he must undergo emergency treatment outside his canton of residence, resulting costs will be covered.
Single persons must contribute CHF 10 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 at the patient's home, or out-patient health care in hospitals and nursing homes by:
- Physicians,
- Chiropractors... (without a physician's referral)
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. 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 referral), as long at the treatment is performed by a licensed therapist. At most 9 sessions within a 3 month period from the date of a doctor's referral. 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 physician's referral), as long as the treatment is performed by a licensed therapist. At most 9 sessions within a 3 month period from the date of a doctor's referral. Coverage for further sesssions 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, in a nursing home or outpatient nursing care.
- Nutritionist consultations (with a physician's referral): The insurer must cover up to 6 consultations. Should further consultations be necessary, the doctor must repeat his referral. After 12 consultations, this doctor must consult one of the insurance company's 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.
- Consultations for diabetics (with a physician's referral): The insurer must cover costs for up to 10 consultations upon a doctor's orders. Should further consultations be necessary, the doctor must renew his referral. Up to 20 consultations per year are covered by the insurer. 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.
- Logopaedic treatment (with a physician's referral): The insurer must provide coverage for up to 12 sessions within a time period of 3 months. Coverage for additional sessions will be provided after the doctor renews his referral. For over 60 1-hour sessions within a year, this doctor must consult one of the insurance company's 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 clarification and therapy sessions are covered. In order to receive coverage for the costs of the next 30 sessions, the treating doctor/psychiatrist has to notify the 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/psychiatrist must make a well-founded suggestion to the 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 supplementary health insurance for psychotherapists without a medical degree, unless they treat you in a doctor's practice under medical supervision (delegated psychotherapy).
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 and only 50% of emergency transportation costs to the next hospital abroad, up to CHF 500 per year.
Tip: If necessary, buy supplementary health insurance or separate holiday and travel insurance.
1.5 Transportation and rescue missions: Basic health insurance pays 50% of the costs for medicinally necessary rescue missions totalling up to CHF 5,000 per year. For transportation in non-life threatening situations, also only 50% of costs and up to 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: The insurer must contribute CHF 10 per day to costs of stays in a health resort or spa if ordered by a doctor for up to 21 days per calendar year. Costs for medical examinations, medication and recognised forms of therapy are fully covered by basic health insurance.
1.7 Nursing care: The insurer must contribute to treatment costs in an recognised nursing home. Since fees for nursing care at home (Spitex) and in nursing homes vary from canton to canton, so will coverage. Doctors are generally able to order up to 60 hours of home care (Spitex) per quarter, this though must be granted by the insurer. The amount of service provided in a nursing home influences how much the patient must contribute to the total costs of his care. However, he must fully cover all costs for room & board himself.
1.8 Medical rehabilitation treatment performed or ordered by a physician
1.9 Alternative medicine: Since 1.7.2005 basic health insurance does not cover any form of alternative medicine with the exception of acupuncture.
2. Analysis and medication
Covered according to the analysis, medication and
speciality lists. The first two lists can be found in the regulations for health care (art. 28, app. 3 and art. 29, app. 4). Orders may be placed at: EDMZ, 3003 Bern.
3. Accessories
Accessories necessary to perform treatment covered by mandatory basic health insurance are listed in the regulations for health care (art. 20, app. 2). Place orders at: EDMZ, 3003 Bern,
(PDF).
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 can be found in the regulations for health insurance.
5. Additional benefits for maternity
- Examinations performed by doctors or midwives or examinations ordered by doctors are covered by basic health insurance during and after pregnancy. Insurers must cover costs for 7 routine examinations (2 of which may be uterus scans, between the 10th and 12th as well as between the 20th a nd 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, is covered, as well as:
- Up to three breastfeeding consultations
Important: Costs arising due to maternity are not liable to either the deductible rate or 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 will only cover treatment costs for serious and inevitable masticatory illnesses and those connected to serious general illness (list) and their resulting consequences. Basic health insurance will also cover costs for dental treatment after accidents, but only if no other insurer will cover those claims. Costs for dental fillings, removal of wisdom teeth, amalgam replacement and the straightening of teeth are not covered by basic health insurance.
Tip: Braces for straightening childrens' teeth can be covered by buying the appropriate supplementary health insurance. However, it must be purchased early enough!
8. Medical prevention
Basic health insurance must cover costs for certain examinations in order to detect early stages of disease as well as costs for preventative measures for policyholders who are at a higher risk for certain diseases. These examinations must be performed by a doctor. They are:
- up to 8 pre-school examinations
- Screening for phenylketonuria, galactosemia, lack of biotinidase, adrenogenital syndrome, hypothyreosis and protective vitamin K
- HIV tests for infants of HIV-positive women
- HIV tests for persons at higher risk of contracting the HIV virus
- Gynaecological examinations (the second examination after one year, after that one examination every 3 years)
- Colon examination if family members have had colon cancer
- Diverse protective and preventative injections, e.g against diptheria, tetanus, pertussis, poliomyelitis, measles, mumps und rubella for children and young persons up to 16 years of age
- booster shots: diptheria and tetanus for adults(every 10 years)
- Tetanus booster shots after injuries
- Haemophilus-influenzae shots for children up to 5 years of age
- Flu jabs for individuals either older than 65 or suffering from a serious disease
- Hepatitis B shots generally for all age groups, for infants of positive mothers and individuals at higher risk of contracting the disease. Special attention is given to a series of injections for 11- to 15-year olds
- Skin examinations if a family member has had a melanoma
- Mammograms 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
Compulsory basic health insurance must contribute to spectacle lenses and contact lenses:
- CHF 180 per year for children and young persons up to the age of 18.
- CHF 180 every 5 years from the age of 18. For the first prescription for spectacle lenses and contact lenses a medical prescription is required, after that, an optician may test eyesight.
This coverage is liable to the deductible rate and retention. Basic health insurance may provide additional coverage for very poor eyesight or certain eye diseases.
