Basic insurance benefits: services paid by health insurance
Anyone who lives or works in Switzerland requires compulsory health insurance. Here you can read which services are covered.
16.08.2023
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1. What is covered by basic insurance?
The basic insurance covers certain medical services, taking into account out-of-pocket expenses. It is also known as compulsory health insurance.
What basic insurance pays is regulated by law and is recorded in the benefits catalogue.
What are out-of-pocket expenses?
Out-of-pocket expenses refer to the money you have to contribute to your own medical expenses.
They include:
Deductible (fixed annual amount)
Coinsurance
Contribution to hospital costs
As an insured person, you initially pay the entire cost of the basic insurance medical services you receive yourself. This applies until you reach the franchise level you have selected.
Once the franchise has been reached, a deductible is due for additional medical services: you must pay 10% of the additional costs yourself. Basic insurance covers the remaining 90%.
This applies up to a maximum of 700 francs per year for adults and 350 francs per year for children. After this, you do not have to pay any further coinsurance.
If you stay in hospital overnight due to illness, as an adult you have to pay an additional contribution to hospital costs of 15 francs per night. This excludes minors and persons under 25 years of age who are still in education or training.
Are you looking for suitable basic insurance?
Compare different health insurance companies and franchise levels with Comparis. This gives you an overview of the costs and benefits of various offers.
2. KVG benefits: what are the legal requirements?
The insured benefits are defined in the Health Insurance Act (German abbreviation: KVG) and are the same for all health insurance companies. Other provisions are enshrined in the Health Insurance Act (German abbreviation: KVV) and the Health Insurance Benefits Ordinance (German: KLV) (Pages available in German, French, Italian).
Good to know
The KVG provides the legal framework for insured benefits. The two ordinances are subordinate to the KVG and clarify its implementation.
3. An overview of the most important health insurance benefits
These are the most important services that your basic insurance must pay, taking into account franchise and deductible.
Doctor’s fees
As a rule, medical treatment is covered by basic insurance. If services are not covered, the doctor must inform you about this.
Here you can find out more about the choice of doctor available to you.
Glasses/contact lenses:
Basic insurance pays 180 francs annually for glasses or contact lenses for children and adolescents up to 18 years of age. A prescription from an ophthalmologist is required.
For adults, basic insurance only covers the costs of glasses and lenses if this is medically necessary. This applies, for example, after eye surgery, when the eye is clouded or when vision problems caused by diabetes arrive.
Vaccinations
Basic insurance pays for various vaccinations in accordance with the guidelines and recommendations of the Swiss Vaccination Plan. Travel vaccinations are not covered — for example against yellow fever or rabies.
Complementary Medicine/Alternative Medicine
Basic insurance covers complementary medical treatments such as acupuncture, anthroposophic medicine, traditional Chinese medicine, homeopathy and phytotherapy (herbal medicine).
Treatments must be carried out by doctors trained in conventional medicine with appropriate training.
Medication
Basic insurance covers medicine that is prescribed by a physician and is included in the list of reimbursable pharmaceutical specialities.
If medication is prescribed that is not covered by basic insurance, the patient must be informed. Find out more here about medication not covered by basic insurance.
Maternity
Insurance covers preventive check-ups during pregnancy and after birth. Birth preparation courses, breastfeeding advice and midwifery services are also partly covered. Also, services from obligatory basic insurance do not require out-of-pocket expenses to be paid.
Non-medical therapies such as physiotherapy, occupational therapy or nutritional advice
The Health Insurance Benefits Ordinance (German abbreviation: KLV) details whether or not a non-medical therapy is reimbursed by basic insurance. In general, treatment must be carried out by approved therapists. Only a limited number of sessions may be reimbursed.
Psychotherapy
Basic insurance covers up to 40 therapy sessions with a psychiatrist.
With a doctor’s prescription it also pays costs for psychotherapy by a psychologist with further training and a cantonal professional practice permit.
Transportation and rescue costs
Taking into account coinsurance and deductible, basic insurance pays the costs of life-saving rescue transports as well as half of the costs per medically necessary transportation.
However, there is a maximum amount:
500 francs for patient transport
5,000 francs for rescue transport
Hospital treatment
Treatment in a general ward of a hospital is covered – provided that the hospital is included in the Hospital List of the canton of residence.
Hospital treatment that cannot be carried out in the canton of residence or in a registered hospital or contracted hospital for medical reasons is usually also paid for.
Is inpatient treatment carried out without a good need in a hospital that is not on the hospital list in the canton of residence? The patient must then bear the additional costs.
Spitex (in-home nursing services)
Doctors may prescribe up to 60 Spitex hours every three months, However, this requires approval from the health insurance company. One condition is that the selected Spitex organization or nursing specialist is qualified and certified.
Precautions
Insurance covers certain preventive measures such as vaccinations, selected examinations and screening or early detection tests. A definitive list of preventive measures is provided in the Health Insurance Benefits Ordinance (available in German, French, Italian).
Dentistry
Dental treatment is not covered unless it is required in the context of a “serious, unavoidable” disease of the mouth or jaw or a “serious general medical condition”. Here you can read more about dental and orthodontic treatment.
Good to know
Mandatory health insurance only reimburses costs in full when the deductible and coinsurance limits have been reached.
Good to know
Mandatory health insurance only reimburses costs in full when the deductible and coinsurance limits have been reached.
4. Basic insurance benefits catalogue in detail
An overview of important health insurance benefits
These general medical services are covered by basic insurance:
Hospital stay in a general ward of a recognised hospital in canton of residence
The canton of residence and the health insurance company also jointly cover:
Services for medically necessary reasons that are not offered in the canton of residence (e.g. complex procedures such as organ transplants)
Medical emergencies outside the canton of residence
Anyone seeking treatment in a hospital outside the canton of residence without medical need will pay any additional costs themselves. Anyone who has supplementary hospital insurance “general ward throughout Switzerland” is exempt from the additional costs.
Please note that insurance policyholders must contribute 15 francs per day to the costs of staying in hospital.
Tip: for more privacy in a 1-bed or 2-bed room, a right to choose your doctor freely or for general ward cover throughout Switzerland, you can apply for the relevant hospital insurance.
Outpatient hospital treatment and operations
This includes outpatient operations in day clinics for eye treatment and psychiatric day clinics. In these cases, patients stay in the clinic for a few hours after treatment, but not overnight.
Examinations, treatment and nursing
These recognized measures are covered:
Treatments by doctors and chiropractors: in principle, there is a free choice of doctor and chiropractor for outpatient treatment. Insured persons with a Telmed, family doctor or HMO model are excluded. You must first call (Telmed model), go to the family doctor (family doctor model) or go to the group doctor’s surgery (HMO model). There are also models that specify the pharmacy as the first point of contact in the event of health problems or restrict the purchase of medication to certain pharmacies only.
Physiotherapy (with a doctor’s prescription): costs minus out-of-pocket expenses are covered as long as the treatment is performed by a licensed therapist. The health insurance company covers nine appointments per doctor’s prescription. The first treatment must be carried out within five weeks of receiving the doctor’s prescription. For the reimbursement of further sessions, a new medical prescription is required. If the treatment has not been completed after 36 sessions and is to continue to be covered by the health insurance company, the doctor performing the treatment must send a report to the trusted medical advisor of the health insurance company.
Psychotherapy (on medical prescription): costs for psychotherapy minus out-of-pocket expenses are covered as long as the treatment is carried out by a certified therapist. The health insurance company covers 15 appointments per doctor’s prescription. For the reimbursement of further sessions, a new medical prescription is required. If the treatment has not been completed after 30 sessions and is to continue to be covered by the health insurance company, the doctor performing the treatment must send a report to the health insurance company.
Medical psychotherapy: insurance covers the costs of psychotherapeutic services provided by recognized psychiatrists. Initially, 40 therapy sessions are covered. If more than 40 sessions are required, the doctor performing the treatment must submit a reasoned recommendation to the health insurance company’s medical advisor to continue treatment.
Occupational therapy (with a doctor’s prescription): costs minus out-of-pocket expenses are covered as long as the treatment is performed by a licensed therapist. A maximum of nine sessions per doctor’s prescription are covered. The first treatment must be carried out within eight weeks of receiving the doctor’s prescription. For reimbursement of further sessions, a new medical prescription is required. If the treatment has not been completed after 36 sessions and is to continue to be covered by the health insurance company, the doctor performing the treatment must send a report to the trusted medical advisor of the health insurance company.
Outpatient care or in a nursing home: costs are covered only when prescribed by a doctor — and only if the care is provided by nursing professionals, nursing homes or nursing organizations. You can find more information about this in the Benefits Ordinance (German abbreviation KLV Art. 7) (page available in German, French, Italian).
Dietary advice (with a doctor’s prescription): up to six sessions are covered on a doctor’s prescription. Should further consultations be necessary, the doctor can renew the prescription. After 12 sessions, the doctor performing the treatment must contact the medical advisor of the insurance company and provide a recommendation for continuing treatment. Basic insurance only covers dietary advice for certain illnesses and allergies.
Diabetes advice (with a doctor’s prescription): up to ten sessions are covered on a doctor’s prescription. If more sessions are necessary, the doctor can renew the prescription. The amount reimbursed by the insurer varies according to the existing tariffs for your place of residence or work.
Speech therapy (with a doctor’s prescription): up to 12 sessions are covered on each doctor’s prescription. They must be carried out within three months. For reimbursement of further sessions, a new medical prescription is required. After 60 one-hour sessions in a single year the doctor performing the treatment must contact the medical advisor of the insurance company and provide a recommendation for continuing treatment.
Medical treatment abroad: only emergency treatment is covered. Basic health insurance will only pay up to twice the amount the same treatment would cost in Switzerland. Within Europe, basic insurance is sufficient. For certain overseas areas – especially the USA, Canada, Australia and Japan – it is highly recommended to get additional insurance cover.
Usually, basic health insurance will not cover transportation costs back to Switzerland (repatriation). Important: anyone who uses medical services in the EU or EFTA countries does not benefit from a deductible that has already been used up in Switzerland. This is because the cost contribution of the respective country applies. It is advisable to take out adequate supplemental insurance or separate holiday and travel insurance.
Ambulance and rescue transport
Emergency transportation to the closest hospital abroad and in Switzerland is only reimbursed at 50% (no more than 5,000 francs per year). Ambulance transport is also covered at 50%, but only to 500 francs per year. Transport involving hospital transfers for medical reasons are covered by basic insurance.
Spa therapies
Contribution of up to 10 francs per day towards the cost of spa therapies for up to 21 days per calendar year if ordered by a doctor. Basic insurance covers the costs of doctors, medicines and approved therapies, minus out-of-pocket expenses.
Nursing services
Contribution towards treatment costs in a recognised nursing home. Mandatory basic insurance results in different benefits from canton to canton for care benefits at home (Spitex) or in a nursing home. In principle, the doctor can prescribe up to 60 Spitex hours per quarter, but this requires approval from the health insurance company. The scope of the required benefits influences the amount the patient must pay out of pocket for care in a nursing home. You have to pay for your accommodation and meals yourself.
Medical rehabilitation measures
Basic insurance generally covers the costs of medical rehabilitation measures carried out or ordered by a doctor.
Alternative medicine
Acupuncture, anthroposophic medicine, homeopathy, phytotherapy and traditional Chinese medicine (TCM) are covered under certain conditions. Services will be covered if performed by doctors having obtained a qualification in the listed therapies.
Covered according to the list of analyses, the list of medicinal products and the list of specialities (analysis page available in German, French, Italian). The list of analyses and medicines can be found in the Health Insurance Benefits Ordinance (Art. 28, Appendix 3 and Art. 29, Appendix 4) (page available in German, French, Italian). Order address for the lists: EDMZ, 3003 Bern.
The means and objects subject to health insurance for examinations or treatment are listed in the Health Insurance Benefits Ordinance (Art. 20, Appendix 2) and on the list of means and objects (German abbreviation: MiGeL) (page available in German, French, Italian). Order address for the lists: EDMZ, 3003 Bern or from the BAG (page available in German, French, Italian).
In the case of birth disorders that are not covered by disability insurance, benefits are provided under compulsory basic insurance. A list of birth defects can be found in the Health Insurance Benefits Ordinance (KLV) (page available in German, French, Italian).
Check-ups carried out by doctors or midwives or ordered by a doctor during and after pregnancy.
Mandatory basic health insurance covers the cost of seven routine examinations (two of which may be ultrasound scans between the 11th and 14th as well as between the 20th and 23rd week of pregnancy). In the event of a high-risk pregnancy, further examinations are also covered.
After birth, a follow-up check is available between 6 and 10 weeks, which is also covered by basic insurance.
Non-invasive prenatal test (NIPT):
Only to test for trisomy 21, 18 or 13 in single-onset pregnancies. From the 12th week of pregnancy.
Childbirth
Childbirth at home, in the general ward of a hospital in the canton of residence or in a semi-inpatient facility. Including obstetrics and birth preparation by doctors or midwives and a maximum of three breastfeeding consultations.
Prenatal care
The insurance covers a contribution of 150 francs for birth preparation in courses that the midwife offers individually or in groups.
A consultation with the midwife is also possible with regard to the birth, planning and organization of the postnatal period at home, and preparation for breastfeeding.
Deductible and coinsurance in case of pregnancy
No deductible or coinsurance is charged on maternity services. Additionally, women do not pay out-of-pocket expenses from the 13th week of pregnancy until eight weeks after the birth, even in case of illness or accident.
Chargeable pregnancy related services
Women who want to freely choose their gynaecologist for the birth at home or in the hospital may require supplementary hospital insurance (for example, private or semi-private). The insurance must be taken out in good time.
Legal abortion
For a legal abortion (see article 120 of the Swiss Criminal Code), services are provided under compulsory basic insurance.
Basic health insurance reimburses treatment of severe and unavoidable diseases of the mastication system and dental treatment required due to a critical general medical condition (list) and the resulting consequences.
Accidents causing damage to teeth are also covered if no other insurance covers it.
The costs for dental fillings, removal of wisdom teeth, replacing amalgams or corrective dental work are not covered.
Good to know: braces for straightening children’s teeth can be insured by buying the appropriate supplemental cover. However, it must be taken out early enough.
Basic health insurance covers the cost of certain examinations for early detection of diseases as well as the cost of 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.
Prevention, screening and early detection services:
Up to eight 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 first two examinations yearly, after that one examination every 3 years).
Colonoscopy if there is a history of colon cancer in the family.
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 vaccination: diphtheria and tetanus in adults (every 10 years).
Tetanus booster shot following injury
Haemophilus influenzae vaccination for children up to 5 years of age
Influenza vaccinations for people over 65 years of age or with a serious illness.
Pneumococcal vaccination for babies and children between the ages of 2 months and 5 years and according to the 2016 vaccine schedule.
Hepatitis B vaccination generally for all age groups. For infants of positive mothers and persons at higher risk of contracting the disease. The main focus is on vaccination programmes for 11 to 15-year-olds.
Corona vaccination, if recommended.
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 rickets prevention during the first year of life.
Sonographic hip screening according to Graf’s method for newborns (up to the age of 6 weeks).
Mandatory basic health insurance contributes to the cost of optical aids for children. For adults, part of the cost is covered only in the presence of certain medical conditions or following eye surgery.
In order to receive further benefits for vision aids, supplementary insurance for glasses is necessary.
This article was first published on 20.09.2022
