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InsuranceHealth insuranceGlossaryBasic health insurance benefits
Glossary

Basic insurance – benefits under mandatory health insurance (KVG/LAMal)

Out-of-pocket expenses under basic health insurance

The annual maximum out-of-pocket amount consists of a fixed annual amount – the so-called deductible (or “franchise”) – and the coinsurance. Up to the amount of the selected deductible, policyholders have to pay the cost of medical services out of their own pocket. After that, they must pay 10% of the costs exceeding this deductible themselves (coinsurance) up to a maximum of 700 francs per year (350 francs per year for children). Maternity-related benefits are not subject to the deductible and coinsurance.

Basic insurance benefits

The cover provided under basic insurance is specified in the Health Insurance Act (KVG/LAMal) and is therefore the same from all health insurers.

Overview of benefits

The complete texts can be found in the Health Insurance Act (KVG/LAMal), in the Health Insurance Ordinance (KVV/OAMal) and in the Health Insurance Benefits Ordinance (KLV/OPAS) (not available in English).

1. General benefits

  • 1.1 Hospital stay in a general ward of a recognized hospital in the canton of residence
    Exception: Should policyholders be compelled for medical reasons to undergo treatment not performed in their canton of residence (complex operations such as organ transplants, etc.) or if they need to undergo emergency treatment outside their canton of residence, the 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-bed or 2-bed room, the right to choose your doctor freely or for a general ward cover throughout Switzerland, you can apply for the relevant supplemental insurance.

  • 1.2 Outpatient hospital treatment
    This includes semi-inpatient eye clinics and psychiatric day clinics. In these cases, patients stay in the clinic for a few hours after 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 medical prescription)

    Patients are generally allowed to consult the doctor and/or chiropractor of their choice for outpatient treatment, unless they are insured according to the Telmed, family doctor or HMO model. Nowadays, over 60% of policyholders are insured according to a model that restricts the choice of service provider and must first either call a hotline (Telmed model), consult a general practitioner (family doctor model) or visit a group practice (HMO model). This enables them to enjoy a premium reduction while maintaining the same standard of medical treatment. 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.

    Services prescribed by a doctor in the following areas of healthcare:

    – 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. Health insurance covers nine sessions per prescription; the first treatment must occur within five weeks of the date of issue of the medical prescription. For the reimbursement of further sessions, a new medical prescription is required. If the treatment is not completed after 36 sessions and reimbursement of further treatment is required, the treating physician must send a report to the insurance company's medical adviser.

    – 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 prescription; the first treatment must occur within eight weeks of the date the prescription was issued. For reimbursement of further sessions, a medical prescription is required. If the treatment is not completed after 36 sessions and reimbursement of further treatment is required, the treating physician must send a report to the insurance company's medical adviser. 

    – Nursing care
    On an outpatient basis or in a nursing home. Costs covered only with a medical prescription or doctor’s referral and if provided by healthcare professionals, nursing homes or nursing care and home help organizations. More information can be found in the Health Insurance Benefits Ordinance (Art. 7).

    – Nutrition counselling (with a doctor's prescription)
    Cover includes up to six consultations as prescribed or referred by a doctor. 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 medical advisers and suggest how the patient's treatment should continue. Health insurance covers nutrition counselling only in case of certain medical conditions and allergies.

    – Diabetes counselling (with a doctor's prescription)
    Cover includes up to ten consultations, prescribed by a doctor. Should further consultations be necessary, the doctor can renew the prescription. The amount reimbursed by the insurer varies according to the valid tariffs for your place of residence or work.

    – Speech therapy (with a doctor's prescription)
    Cover includes up to 12 consultations per prescription, which must be completed within a period of three months. For reimbursement of further sessions, a medical prescription is required. After 60 one-hour consultations within a period of one year, the treating doctor must consult one of the insurance company's medical advisers and suggest how the patient's treatment should continue.

    – Psychiatric therapy
    Health insurance only covers the cost of psychiatric therapy if there is scientific evidence for the efficacy of the methods applied. At most, 40 evaluation and therapy sessions are covered. If psychiatric therapy requires more than 40 sessions, the treating doctor must make a well-founded suggestion to the medical adviser of the health insurance company about how the therapy should continue.

    Tip: You will need supplemental insurance for outpatient treatment if treated by psychotherapists without a medical degree, unless they treat you in a practice of a specialist doctor trained in psychotherapy under medical supervision (psychotherapy delegated by a physician).

  • 1.4 Cover abroad
    Outside Switzerland, only emergency treatment is covered. Basic health insurance will only pay up to twice the amount the same treatment would cost in Switzerland. Basic cover is sufficient for travel within Europe, but for certain overseas areas – notably the USA, Canada, Australia and Japan – it is highly recommended to buy additional insurance. Usually, basic health insurance will not cover transportation costs back to Switzerland (repatriation). It only covers 50% of the total cost of emergency transportation to the nearest hospital abroad (no more than 500 francs per year). Bear in mind that if you undergo medical treatment in any EU or EFTA states, you cannot take advantage of the fact that your deductible has already been met by services performed in Switzerland, should that be the case.

    Tip: If necessary, buy adequate supplemental insurance or separate holiday and travel insurance.

  • 1.5 Transport and rescue missions
    Basic health insurance pays for 50% of the cost of medically necessary rescue missions (up to CHF 5,000 per year). For transportation in non-life threatening situations, 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 Spa therapies
    Contribution of up to CHF 10 per day towards the cost of balneotherapy in a health resort or spa for up to 21 days per calendar year if prescribed by a doctor. The cost of medical examinations, medication and recognized forms of therapy are covered by basic health insurance minus the policyholder's out-of-pocket amount.

  • 1.7 Nursing services
    Contribution towards treatment costs in a recognized nursing home. Cover of fees for nursing care at home (Spitex) and in nursing homes by basic health insurance varies from canton to canton. Doctors may generally prescribe up to 60 hours of home care (Spitex) per quarter, but this must be approved by the insurer. The scope of the required benefits influences the amount the patient must pay out of pocket for care in a nursing home. However, the patient must the pay the cost of room and board in full.

  • 1.8 Medical rehabilitation treatment performed or prescribed by a doctor

  • 1.9 Alternative medicine
    Since August 2017, five treatment methods (anthroposophic medicine, homeopathy, neural therapy, phytotherapy and traditional Chinese medicine) may be reimbursed under certain conditions. Based on the Federal Council's decision of 16 June 2017, basic compulsory healthcare insurance will continue to reimburse these types of complementary medicine indefinitely. Services will be covered if performed by doctors having obtained a qualification in the listed therapies.

2. Analyses and medicines

Cover is based on the list of analyses, the list of medicines and the specialities list (in German, French and Italian only). The list of analyses and medicines can be found in the Health Insurance Benefits Ordinance (KLV/OPAS, Art. 28, Appendix 3 and Art. 29, Appendix 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 insurance are listed in the Health Insurance Benefits Ordinance (KLV/OPAS, Art. 20, Appendix 2). Orders may be placed at: EDMZ, 3003 Bern.

4. Birth defects

Costs arising 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 Health Insurance Benefits Ordinance (in German, French and Italian only).

5. Additional benefits in case of maternity

Examinations performed by doctors or midwives and examinations prescribed by doctors during and after pregnancy. Mandatory basic health insurance covers the cost of 7 routine examinations (2 of which may be ultrasound scans, between the 11th and 14th 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).

Non-invasive prenatal test (NIPT): Screening for trisomies 21, 18 and 13 for single pregnancies only and from the 12th week of pregnancy.

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 as well as up to three breastfeeding consultation sessions.

Prenatal care: Insurers will contribute 150 francs towards antenatal classes led by a midwife on a one-to-one basis or in a group, or towards a consultation with a midwife covering the birth, the planning and organization of postnatal care at home and breastfeeding advice.

Note: Maternity benefits are subject to neither the deductible nor the coinsurance. On 1 March 2014, a legal amendment initiated by the Federal Council took effect. It stipulates that women who fall ill during or after pregnancy (e.g. in case of complications) are no longer liable to any out-of-pocket payments starting from the 13th week of pregnancy until 8 weeks after birth. This includes, for example, hospitalization to avoid premature birth, treatment of gestational diabetes and infections or psychotherapy due to post-natal depression.

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 supplemental insurance, which must be purchased in good time.

6. Legal abortion

Legal abortion (Art. 120 of the Swiss Criminal Code) is covered by mandatory basic health insurance.

7. Dental treatment

Compulsory basic insurance only covers the treatment of serious, unavoidable diseases of the masticatory system and dental treatment arising in the context of a serious general medical condition (list – in German, French and Italian only) and its consequences. It also bears the cost of dental treatment after an accident if the claim is not covered by any other insurance. The cost of dental fillings, removal of wisdom teeth, amalgam replacement and corrective dentistry is not covered by basic health insurance.

Tip: Braces for straightening children's teeth can be insured by purchasing the appropriate supplemental cover. However, it must be purchased early enough.

8. Medical prevention

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 of certain diseases. These examinations or preventive measures must be performed or prescribed by a doctor. They include:

  • 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 a higher risk of contracting HIV
  • Gynaecological examinations (two annual examinations, 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 for adults (every 10 years)
  • Tetanus booster shot following injury
  • Haemophilus influenzae vaccination for children up to 5 years of age
  • Flu vaccination for persons above the age of 65 or suffering from a severe disease
  • 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
  • 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 the age of 6 weeks)

9. Glasses and contact lenses

Mandatory basic health insurance contributes to the cost of glasses for children. For adults, part of the cost is covered only in the presence of certain medical conditions or following eye surgery.

Many types of supplemental insurance for outpatient treatment cover corrective eyewear.

Whether basic or supplemental insurance...

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