Basic insurance benefits: What does the health insurer pay?

As a rule, medical treatments are covered by the basic insurance (Art. 25 KVG). If services are not covered, the doctor must inform you of this.

Depending on the insurance model your choice of doctor is limited. Then, for example, treatment by specialists must be prescribed by your first point of contact.

Here you can find further information on choosing a doctor.

For children and adolescents up to 18 years of age, the health insurer pays an annual amount for visual aids. For adults, the basic insurance covers the costs for glasses and lenses only if medically necessary.

Basic insurance pays for certain complementary medical treatments (Art. 4b KLV). They must be performed by conventionally trained doctors with appropriate further training be performed.

Basic insurance covers medicines. Prerequisite: They are prescribed by a doctor and listed in the so-called specialty list listed (Art. 52 KVG, Art. 4a KLV). With a cost approval there are exceptions in cases of medical necessity.

If the doctor prescribes a drug outside the list of specialities, he or she must inform the patient about this (Art. 2 para. 3 BAG Directive). In our article you will learn more about non-compulsory medicines.

The insurance covers preventive examinations during pregnancy and after the birth (Art. 13 KLV). The following are also covered:

• Antenatal classes (Art. 14 KLV)

• Breastfeeding advice (Art. 15 KLV)

• certain midwifery services (Art. 16 KLV)

The health insurer also pays for care and hospital stay of the child, as long as mother and child are together in the hospital (Art. 29 para. 2 KVG).

In addition, the following applies: medical services in connection with pregnancy are exempt from cost sharing.

Non-medical treatments must be prescribed by a doctor. They must also be carried out by licensed therapists. The number of sessions covered is limited:

• Physiotherapy (Art. 5 KLV): nine sessions per prescription. After 36 sessions, prior approval of the costs is required.

• Occupational therapy (Art. 6 KLV): nine sessions per prescription. After 36 sessions, prior approval of the costs is required.

• Nutritional advice (Art. 9b KLV): six sessions per prescription. After twelve sessions, prior approval of the costs is required.

• Diabetes counselling (Art. 9c KLV): ten sessions, then prior approval of the costs is required.

• Psychotherapy (Art. 11b KLV): 15 sessions per order. After 30 sessions, a detailed psychiatric assessment and a new order for 15 sessions or another 15 sessions is required.

Some therapies are only covered by basic insurance under certain conditions.

Basic insurance covers up to 40 therapy sessions for a medical psychotherapy (Art. 3 KLV). After the 40 sessions, a medical examiner decides whether and for how long the health insurer will continue to pay for the therapy (Art. 3b KLV).

On medical order it also pays costs for psychological psychotherapy (Art. 11b KLV). A doctor’s order is always valid for 15 sessions (Art. 11b para. 2 KLV). After 30 sessions, a medical examiner decides whether and for how long the health insurer will continue to pay for the therapy (Art. 11b para. 3 KLV).

Basic insurance pays the costs for life-saving rescue transports (Art. 27 KLV) as well as half of the costs for medically necessary transport (Art. 26 KLV).

However, a maximum amount:

• 500 francs for patient transport

• 5’000 francs for rescue transports

Inpatient services in the general ward of a hospital are covered. But: The hospital must be on the hospital list of the canton of residence. Hospitals outside the canton of residence may also be on the list (Art. 41 para. 1 KVG).

If hospital treatment for medical reasons cannot be carried out in a listed hospital, treatment in another hospital is usually paid for. However, you often need a confirmation of costs from your health insurer and the canton of residence (Art. 41 para. 3 KVG).

Are you without medical necessity in a hospital outside the hospital list of your canton of residence? Then the health insurer pays at most as much as for a listed hospital in your canton (Art. 41 para. 1 KVG). You must pay the additional costs. Exceptions apply to hospitals that have a contract with your health insurer.

In order for the basic insurance to cover Spitex contributions, the care must be ordered by a doctor (Art. 8 KLV). The order is time-limited:

• Maximum nine months for long-term care services. However, the orders can be repeated.

• Maximum two weeks for acute and transitional care after a hospital stay.

Nursing professionals determine the need for care services (Art. 8a KLV). If this exceeds 60 hours per quarter, the health insurer can have the need checked by a medical examiner (Art. 8c KLV).

Good to know: the Health Insurance Ordinance also determines who is allowed to carry out the care (Art. 7 para. 1). These include:

• Nursing professionals

• Nursing organisations and help at home

• Nursing homes

The insurance covers certain preventive measures (Chapter 3 KLV). These include:

• Vaccinations according to the Swiss vaccination plan (Art. 12a KLV)

• Measures to prevent diseases (Art.12b KLV)

• Examinations of the general state of health in children (Art. 12c KLV)

• Measures for the early detection of diseases in at‑risk groups (Art. 12d KLV) and in the general population (Art. 12e KLV)

Compulsory basic insurance pays benefits for diagnosis and treatment of diseases and their consequences (Art. 25 para. 1 KVG). In this list you can see which general medical and doctors’ services are covered by the basic insurance.

Stay in the general ward of a recognised hospital in the canton of residence

The following applies: the hospital must be on the hospital list of your canton. Hospitals outside the canton may also be on the hospital list (Art. 41 para. 1 KVG).

The canton of residence and the health insurer also jointly cover (Art. 41 para. 3 KVG):

• Services for medically compelling reasons, which are not offered in the canton of residence. These include, for example, complex interventions such as organ transplants. In this case, you need a permit from the canton of residence.

• Emergency required services outside the canton of residence.

If you are treated in a hospital outside your canton of residence without medical necessity, you will pay any additional costs yourself (Art. 41 para. 1 KVG) – unless you have a supplementary hospital insurance «general ward throughout Switzerland».

Important: insured persons contribute 15 francs hospital contribution per day to the costs of hospitalisation (Art. 104 KVV). The hospital contribution is independent of the deductible and coinsurance.

Outpatient hospital treatments and operations

The health insurer pays for outpatient operations, for example in day eye clinics and psychiatric day clinics. Outpatient means: patients are still in the clinic for a few hours after treatment, but remain not overnight.

Good to know: in Switzerland, the following regulation applies to some services: «outpatient before inpatient». It only pays for an inpatient procedure if the outpatient procedure is not appropriate or economical due to special circumstances (Art. 3c para. 1 KLV). The list of services that are generally reimbursed on an outpatient basis can be found in Appendix 1a of the KLV.

Examinations, treatments and care measures

Here you will find a list of recognised measures. Most treatments are only covered if prescribed by a doctor.

• Treatments by doctors and chiropractors: in principle, there is a free choice of doctor and chiropractor for outpatient treatment (Art. 41 para. 1 KVG). Exceptions are insured persons with an alternative insurance model. You must first contact your chosen first point of contact and will be referred if necessary (Art. 41 para. 4 KVG). There are also models that limit the purchase of medicines to certain pharmacies.

• Medical psychotherapy (Art. 2 to Art. 3b KLV): The insurance covers the costs of psychotherapeutic services provided by recognised psychiatrists. Initially, a maximum of 40 clarification and therapy sessions. If more than 40 sessions are required, the attending physician must submit a substantiated proposal to the medical officer of the health insurer for the continuation of the therapy.

• Psychological psychotherapy (Art. 11b KLV): Reimbursement of psychotherapy, provided the treatment takes place with a licensed therapist. The health insurer covers per prescription 15 sessions. A new medical prescription is required to cover the costs of further sessions. If the treatment is not yet complete after 30 sessions and is to continue to be covered by the health insurer, the attending physician must send a report to the health insurer.

• Neuropsychology (Art. 11a KVG): the basic insurance pays up to six sessions per medical order. A maximum of two orders per person are possible per year.

• Physiotherapy (Art. 5 KLV): coverage of costs, provided that the treatment takes place with an approved therapist. The health insurer covers nine sessions per prescription. The first treatment must be carried out within five weeks of the doctor’s prescription. A new medical prescription is required to cover the costs of further sessions. If the treatment has not yet been completed after 36 sessions and is to continue to be covered by the health insurer, the treating doctor must send a report to the medical officer of the health insurer.

• Occupational therapy (Art. 6 KLV): coverage of costs, provided that the treatment takes place with an approved therapist. A maximum of nine sessions per prescription are covered. The first treatment must be carried out within eight weeks of the doctor’s prescription. A new medical prescription is required for further sessions to be covered. If the treatment has not yet been completed after 36 sessions and is to continue to be covered by the health insurer, the treating doctor must send a report to the medical officer of the health insurer.

• Nutritional advice (Art. 9b KLV): the health insurer pays up to six sessions by medical prescription or on a doctor’s instructions. If further sessions are necessary, the medical prescription can be repeated. From twelve sessions, the attending physician must report to a medical officer of the health insurer and submit a proposal for the continuation of treatment. Basic insurance only pays for nutritional counselling in the case of certain illnesses and allergies.

• Diabetes counselling (Art. 9c KLV): up to ten sessions on medical prescription. If further sessions are necessary, the medical prescription can be repeated. The reimbursement by the health insurer is based on the applicable tariffs at the place of residence or work. The consultation must be carried out by a nurse or an approved diabetes counselling centre.

• Speech therapy (Art. 10andArt. 11 KLV): reimbursement is provided for up to twelve sessions per medical prescription, if the speech disorder can be attributed to certain conditions and causes. The first treatment must be carried out within eight weeks of the doctor’s prescription. A new medical prescription is required for the assumption of further sessions. From 60 one-hour sessions within a year, the attending physician must report to a medical officer of the health insurer and submit a proposal for the continuation of treatment.

• Podiatry (Art. 11c KLV): the health insurer only covers costs for people with diabetes mellitus. Depending on the medical background, it reimburses annually four to six sessions. A new prescription is required after the end of a calendar year.

• Medical treatments abroad (Art. 36 KVV): Benefits are only paid for emergency treatments. Abroad, the compulsory basic insurance pays a maximum of twice the amount that the same treatment would cost in Switzerland. Basic insurance is sufficient within Europe. In certain overseas territories, additional insurance cover is required, as treatment costs are very high there. This is particularly true in the USA, Canada, Australia and Japan.

Important: in the EU and EFTA countries, the cost sharing of the respective country applies. You pay neither deductible nor coinsurance. In addition, you are entitled to reimbursement for the same services as the insured persons in the country – the Swiss service catalogue does not apply.

Tip: if necessary, take out additional travel insurance with your health insurer or separate travel insurance.

Patient and rescue transports

For patient transport the basic insurance pays 50% – but a maximum of 500 francs per year (Art. 26 KLV). Transports in connection with hospital transfers for medical reasons are also covered by the basic insurance (Art. 33 para. g KVV).

In the case of rescue transports to the nearest hospital in Switzerland and abroad, the basic insurance also pays 50% of the costs. In this case, the limit is a maximum of 5,000 francs per year (Art. 27 KLV).

The basic insurance usually covers not the return transport (repatriation) from abroad to Switzerland.

Spa treatments

Contribution to the costs of medically prescribed spa treatments for a maximum of 21 days per calendar year. You receive 10 francs per day (Art. 25 KLV). The costs for doctors, medicines and recognised therapies are covered by the basic insurance minus cost sharing.

Medical rehabilitation measures

The basic insurance generally covers the costs of medically performed or prescribed medical rehabilitation measures (Art. 25 para. d KVG).

Alternative medicine

The basic insurance pays complementary medical treatments (Art. 4b KLV). These include:

• Acupuncture

• Anthroposophic medicine

• Traditional Chinese medicine

• Homeopathy

• Phytotherapy (herbal medicine)

Requirement: treatments must be carried out by doctors trained in conventional medicine with appropriate further training.

In order for the basic insurance to cover Spitex contributions, the care must be ordered by a doctor (Art. 8 KLV). The order is limited in time:

• Maximum nine months for long-term care services. However, the orders can be repeated.

• Maximum two weeks for acute and transitional care after a hospital stay.

Nursing professionals determine the need for care services (Art. 8a KLV). If this exceeds 60 hours per quarter, the health insurer can have the need checked by a medical examiner (Art. 8c KLV).

Good to know: the Health Insurance Ordinance also determines who is allowed to provide care (Art. 7 para. 1). These include:

• Nursing professionals

• Nursing and home help organisations

• Nursing homes

The care services covered by basic insurance are set out in the KLV (Art. 7). This includes:

• Measures for clarification, advice and coordination. These may be carried out by nursing professionals even without medical instruction. Prerequisite: The needs assessment certifies the necessity of the services.

• Measures for examination and treatment. These services are only paid for by the basic insurance on the basis of a doctor’s order based on the needs assessment.

• Measures of basic care. These may be carried out by nurses even without medical instruction. Prerequisite: The needs assessment certifies the necessity of the services.

The services can be provided on an outpatient basis or in a nursing home. You must pay for services outside the service catalogue yourself, for example, domestic services. This also applies to accommodation and meals in the nursing home.

Good to know: the amount of the costs for care services covered by the basic insurance is set by law (Art. 7a KLV).

Covered according to analyses, medicines and specialities list. The analyses and the medicines list can be found in Annexes 3 and 4 of the Nursing Services Ordinance.

Medication

The basic insurance generally covers medication costs. Prerequisite: they are prescribed by a doctor and listed in the so-called specialities list (listed (Art. 52 KVG, Art. 4a KLV).

In the case of medical necessity the health insurer also covers costs for medicines outside the list of specialities (Art. 71a KVV, Art. 71b KVV, Art. 71c KVV). However, you need a cost approval from the health insurer (Art. 71d KVV).

If the doctor prescribes a medicine outside the list of specialities, he or she must inform the patient about it (Art. 2 para. 3 BAG Directive). In our article you will learn more about non-compulsory medicines.

The insurance pays means and objects, which serve the treatment or examination of a disease (Art. 20 KLV). Prerequisite: they must be prescribed and on the List of means and objects. The list also defines the cases in which the basic insurance pays for which means and objects.

Until the 20th birthday, some birth defects are covered by the disability insurance. Which ones are covered is defined in the Ordinance of the EDI on birth defects defined.

In the case of other birth defects as well as people over 20 years of age, the basic health insurance pays for the treatment. You will receive the same benefits as people without birth defects. A list of birth defects according to KVG can be found in the Health Care Benefits Ordinance (Art. 19a).

Basic health insurance pays for check-ups during and after pregnancy (Art. 29 KVG). They must be carried out by doctors or midwives or ordered by a doctor. It also covers the costs of:

• Childbirth at home, in a hospital or a birthing centre

• Obstetrics by doctors or midwives

• Breastfeeding advice

• Care and stay of the newborn, as long as it is in the hospital with the mother

Health insurance also covers the costs for special maternity benefits (Chapter 4 KLV). In a normal pregnancy, this includes seven routine examinations and two ultrasound examinations:

• one between the 11th and 14th week of pregnancy

• one between the 20th and 23rd week of pregnancy

Good to know: in the case of a high-risk pregnancy further examinations are also covered.

Six to ten weeks after birth a follow-up check of the mother is scheduled, which is also covered by the basic insurance. The check-up also includes a consultation.

First-trimester test

Basic insurance covers a test to clarify the risk of trisomy 21, 18 and 13. Several factors are tested in the mother and the foetus.

Non-invasive prenatal test (NIPT)

Only for examination for a trisomy 21, 18 or 13 from the 12th week of pregnancy. The health insurer only covers the costs if the risk for one of the chromosomal disorders is 1 in 1’000 or higher. The risk is determined beforehand during an ultrasound.

Amniocentesis, chorionic biopsy, cordocentesis

The health insurer pays for the examinations if one of the following conditions is met:

• Positive result in a NIPT test: the risk of trisomy 21, 18 or 13 is 1 in 380 or higher.

• High risk of a genetic disease: due to an ultrasound finding, family history or for any other reason, the risk of a genetic disease is 1 in 380 or higher.

• Risk to the foetus: this may be due to a pregnancy complication, a disease of the mother, a non-genetic disease or a developmental disorder of the foetus.

Check-up after a miscarriage

After a miscarriage between the 13th and 23rd week of pregnancy the basic insurance covers the costs of a check-up.

After a miscarriage or a medically indicated abortion, the midwife can make up to ten home visits perform (Art. 16 para. 1a KLV).

Birth preparation

The insurance covers a contribution of 150 francs for childbirth preparation (Art. 14 KLV). One type of preparation is courses conducted by the midwife. Birth preparation can take place individually or in groups.

It is also possible to have a consultation with the midwife with regard to the birth, the planning and organisation of the postnatal period at home and preparation for breastfeeding.

Breastfeeding advice

The health insurer pays for up to three breastfeeding consultations (Art. 15 KLV). They must be carried out by:

• Midwives

• midwives’ organisation

• Nurses with special training in breastfeeding counselling

Postpartum care

Basic insurance pays for home visits by the midwife in the 56 days after birth (Art. 16 para. 1c KLV). How many visits the health insurer covers depends on the situation:

• 16 home visits for premature births, multiple births, first-time births and after a caesarean section

• 10 home visits in all other cases

For further home visits or visits after the 56 days, a medical prescription is necessary.

Good to know: in the first ten days after birth, the midwife can make up to five further visits on the same day.

Deductible and coinsurance in case of pregnancy

On the maternity benefits you do not have to pay a deductible or coinsurance. In addition, women from the 13th week of pregnancy until eight weeks after birth, even in the event of illness or accident no coinsurance (Art. 64 para. 7 KVG).

Penalty-free termination of pregnancy

In the first twelve weeks of pregnancy, you can terminate the pregnancy without penalty (Art. 119 StGB). In the event of a risk of serious physical harm or serious mental distress, termination without penalty is also possible thereafter.

If the pregnancy is terminated without penalty, the basic insurance covers the costs for the same benefits as in the event of illness (Art. 30 KVG).

The compulsory basic insurance reimburses dental treatment costs only in the case of severe, unavoidable disease of the masticatory system (Art. 31 KVG). It also covers dental treatment costs in connection with a serious general illness and its consequences. The cases in which the health insurer pays are defined in the KLV (Chap. 5).

Dental damage is also covered by accidents, if no other insurance covers it.

The compulsory basic insurance covers the costs for medical prevention (Art. 12 KLV). This includes certain examinations for the early detection of diseases as well as precautionary measures for the benefit of persons at increased risk of disease (Art. 26 KVG).

The examinations or precautionary measures must be carried out or ordered by a doctor.

Vaccinations

Vaccinations include «basic vaccinations» and «supplementary vaccinations». Basic vaccinations have the goal of achieving both individual protection and the protection of public health. Supplementary vaccinations serve mainly to provide individual protection. Both types of vaccinations are covered by the health insurer for defined vaccinations.

The health insurer pays for the following vaccinations (Art. 12a KLV) according to Swiss vaccination plan:

• Preventive and protective vaccinations:

  • Diphtheria

  • Tetanus

  • Pertussis

  • Poliomyelitis

  • Measles

  • Mumps

  • Rubella

  • Rotaviruses

• Haemophilus influenzae: in children up to 5 years of age.

• Influenza (Flu): annual vaccination in people with an increased risk of complications, in pregnant women and in people aged 65 and over.

• Hepatitis B: primary vaccination for people up to 16 years of age. Also for people with an increased risk of complications as well as an increased risk of exposure and transmission.

• Pneumococci: primary vaccination for children up to 12 months. As a supplementary vaccination in people aged 65 years and over. In addition, for people at increased risk up to 6 years of age and from 65 years of age.

• Meningococci: primary vaccination for children. Vaccination for people at increased risk of disease as well as after contact with the disease. The costs are only covered for vaccines that are approved for the corresponding age group.

• Tuberculosis: for newborns and infants up to twelve months with an increased risk of infection.

• Tick-borne encephalitis (TBE): for people aged three years and over who stay in a risk area for at least a certain period of time. In individual cases, children can receive the vaccination from the age of one year. Booster vaccinations every ten years. Good to know: with the exception of the canton of Ticino, the whole of Switzerland is considered a TBE risk area.

• Varicella: the costs are only covered for vaccines that are approved for the corresponding age group.

• Human papillomaviruses: between the 11th and 27th birthday. You do not have to pay a deductible for this vaccination, but a flat-rate fee.

• Hepatitis A: for people with an increased risk of exposure or complications. Vaccination after contact with the disease within seven days.

• Rabies: vaccination after contact with an animal with or suspected of having rabies.

• Covid-19 (Coronavirus): annually in people over 65 years of age, in pregnant women and people from six months of age with a weak immune system. The costs are only covered for vaccines that are approved for the corresponding age group.

• Herpes zoster: only with a specific vaccine.

• Mpox: for persons with an increased risk of exposure according to the «Analysis framework and recommendations for vaccination against monkeypox» of the FOPH. The insurance pays 100 francs per vaccination dose. The assumption of costs will be checked by the end of 2025 and may then change if necessary.

• Respiratory syncytial viruses(RSV): for pregnant persons in the 32nd to 36th week of pregnancy, if the due date is between October and March.

Prevention of diseases

In addition to vaccinations, basic insurance pays for some other measures to prevent diseases (Art. 12b KLV):

• Vitamin K prophylaxis:Three doses in newborns.

• Vitamin Dfor the prevention of rickets: during the first year of life.

• HIV prophylaxisafter contact: according to the FOPH recommendation forHIV post-exposure prophylaxis.

• Passive immunisationafter contact: according to the FOPH recommendation forpost-exposure passive immunisation.

• Mastectomy(removal of the mammary gland) andAdnexectomy(removal of fallopian tubes and ovaries): in women withincreased riskof breast cancer or ovarian cancer. A prerequisite for the reimbursement of costs is genetic counselling.

• Passive vaccination with hepatitis B immunoglobulin:In newborns of mothers with hepatitis B.

• Monoclonal antibodies for RSV prophylaxis:For all children up to one year. Also for children up to two years of age with an increased risk of RSV disease according torecommendation of the Nirsevimab working group. However, if the mother was vaccinated for passive immunisation against RSV before birth, basic insurance only pays in certain exceptional cases.

• Passive immunisation with Covid-19 antibodies:In people with impaired immune systems or with sickle cell anaemia. Reimbursement only for preparations that have the appropriate approval.

• HIV prophylaxisbefore contact: For persons according to the FOPH reference document forHIV pre-exposure prophylaxis.

Early detection of diseases

The health insurer also pays benefits to theEarly detection of diseases. These include examinations of the general state of health (Art. 12c KLV), measures for certain risk groups (Art. 12d KLV) and measures in the general population (Art. 12e KLV).

Theexaminations of the general state of healthare only available for preschool children (Art. 12c KLV). The health insurer pays a maximum ofeight examinationsto check the state of health and normal child development.

The measures for certainrisk groupsbelong (Art. 12d KLV):

• HIV tests:In newborns of HIV-positive mothers. Also for persons according to the BAG guideline forHIV test on the initiative of the doctor.

• Colonoscopy:In the case of familial colon cancer.

• Skin examinations:In the case of a family history of increased melanoma risk.

• Digital mammography and breast MRI:For women with moderate to high breast cancer risk according to the FOPH reference document «Monitoring protocol». Basic insurance also covers consultations and further clarifications after a conspicuous finding, provided they are carried out by a certified breast centre.

• In vitro muscle contracture testto detect the predisposition for malignant hyperthermia: in individuals after an incident in anaesthesia suspected of malignant hyperthermia. Also for people who are first-degree relatives of a person with malignant hyperthermia.

• Genetic counsellingincluding examinations and associated laboratory analyses:

  • For persons suspected of having afamilial predisposition for cancer. The persons must be first-degree relatives of someone with a cancer according to KLV (Art. 12d para. f). The tests must be carried out by a specialist in medical genetics or a member of the «Network for Cancer Predisposition Testing and Counseling» of the Swiss Association for Clinical Cancer Research.

  • For persons suspected of having aPredisposition for acute hepatic porphyria. The persons must have family members with symptomatically proven disease. The risk of inheritance must be at least 12.5%.

The measures for the early detection of diseases in thegeneral populationare (Art. 12e KLV):

• Screening examination fornewborns for the following diseases:

  • Phenylketonuria

  • Galactosaemia

  • Biotinidase deficiency

  • Adrenogenital syndrome

  • Hypothyroidism

  • Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency

  • Cystic fibrosis

  • Glutaric aciduria type 1

  • Maple syrup disease

  • Severe congenital immunodeficiencies

  • Spinal muscular atrophy

• Gynaecological examinationincluding cancer smear: every three years. The first two examinations are reimbursed at annual intervals. In the event of findings, more frequent examinations are also covered. The detection of the human papilloma virus during cervical screening is not paid for.

• Screening mammography:Every two years from the age of 50. You do not have to pay a deductible for this service.

• Early detection of colon cancer:For people aged 50 to 74. The reimbursed examination methods are:

  • Stool examination for occult blood every two years. If the result is positive, a colonoscopy is performed.

  • Colonoscopy every ten years.