Out-of-pocket expenses for health insurance: what basic insurance covers
Those with basic insurance in Switzerland must pay a share of their healthcare costs. Comparis shows how out-of-pocket expenses work.
12.08.2024
iStock/Scharvik
1. What are the out-of-pocket expenses for basic insurance?
If you use a medical service and claim it on basic insurance, you have to pay part of the costs yourself. These costs are calculated on an annual basis. The date of treatment is important for working out the out-of-pocket expenses.
Out-of-pocket expenses during pregnancy
From the 13th week of pregnancy up to eight weeks after birth, women do not have to pay any out-of-pocket expenses towards the cost of general medical treatment and care if they fall ill. Read more about maternity benefits here.
2. What do out-of-pocket expenses consist of?
They consist of the deductible and the coinsurance payment. Inpatient hospital treatment attracts an additional hospital cost contribution.
Deductible
You only have to pay in the deductible once per calendar year. It is between 300 and 2,500 francs for adults. With a low deductible, you don't need to contribute as much to your treatment costs. In return, you pay a more expensive insurance premium. If you have a high deductible, your insurance premium is lower. In return, the out-of-pocket expenses will be higher. Once the deductible has been fully paid, the health insurance company covers the remaining costs, minus the coinsurance.
Good to know: health insurance premiums vary depending on where you live, your insurance model, deductible and health insurance company. It’s therefore worth comparing different health insurance companies.
Coinsurance
Once the health care costs exceed the deductible, you have to pay coinsurance of 10% up to a maximum of 700 francs. In other words: you only start paying the coinsurance once the deductible has been fully paid.
The maximum coinsurance for children is 350 francs. If three or more children from the same family are insured with the same health insurance company, the coinsurance for all children together is limited to 1,000 francs.
Good to know: you generally pay a coinsurance of 10% for prescribed medicines. Do you use proprietary medicines even though generic drugs are available? In this case, the coinsurance is 40%.
Contribution to hospital costs
If you stay overnight in a hospital, basic insurance covers costs for treatment as well as food and accommodation. Patients usually have to contribute to these costs. The hospital cost contribution is 15 francs per night. The hospital contribution fee is waived in some cases. For example, for maternity benefits.
3. How high can out-of-pocket expenses go?
The maximum amount of out-of-pocket expenses depends on your chosen deductible. For adults with the highest deductible, the maximum out-of-pocket expenses is 3,200 francs per year. With the lowest deductible, the maximum is 1,000 francs per year. If you require inpatient hospital treatment, you also have to pay the hospital cost contribution on top of this.
4. What are the out-of-pocket expenses for accidents?
If you are insured against accidents with your employer (AIA-insured), you do not need to share costs. On the other hand, if you’re insured against accidents via your health insurance company, you must pay a share of the costs.
5. Example calculation of out-of-pocket expenses
Cost of medical bills
A policyholder has a deductible of 300 francs and medical costs of 2,400 francs over a year:
| Treatment with Dr Müller | CHF 1,300 |
|---|---|
| Treatment with Dr Meier | CHF 700 |
| Medicines (generics) | CHF 400 |
| Total | CHF 2,400 |
Annual health insurance statement
| Your medical costs: | CHF 2,400 |
|---|---|
| –Deductible | –CHF 300 |
| –Coinsurance of 10% (after paying the deductible) | –CHF 210 |
| Your health insurer pays | CHF 1,890 |
This article was first published on 16.08.2022
