Out-of-pocket expenses under basic health insurance
The annual maximum out-of-pocket 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 pocket. After that, they must pay 10 per cent 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 benefits under basic insurance are specified in the Health Insurance Act (KVG) and therefore consistent among all health insurers.
Overview of benefits
- 1. General benefits
- 1.1 Hospital
- 1.2 Outpatient treatment
- 1.3 Examinations, treatment and nursing care
– Psychiatric therapy
– Diabetes counselling
– Occupational therapy
– Nutrition counselling
– Nursing care
– Speech therapy
- 1.4 Coverage abroad
- 1.5 Transport and rescue missions
- 1.6 Health resorts and spas
- 1.7 Nursing services
- 1.8 Rehabilitation
- 1.9 Alternative medicine
- 2. Analyses and medication
- 3. Medical aids and devices
- 4. Birth defects
- 5. Additional benefits in case of maternity
- 6. Legal abortion
- 7. Dental treatment
- 8. Medical prevention
- 9. Glasses and contact lenses
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 (complex operations such as organ transplants, etc.) or if he needs to undergo emergency treatment outside his 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 or 2-bed room, a right to choose your doctor freely or for a general ward cover throughout Switzerland, you can apply for corresponding supplemental insurance.
1.3 Examinations, treatment and nursing care performed on an outpatient basis, at the patient's home, in hospitals or nursing homes by:
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 per cent of policyholders are insured according to a model that restricts the choice of service provider and must first either call a hotline (Telmed model) or visit a general practitioner (family doctor model) or 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 therapy 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 fiduciary physician.
– 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 therapy 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 fiduciary physician.
– Nursing care
On an outpatient basis or in a nursing home. Coverage of costs only upon medical prescription or if commissioned by a doctor and if provided by healthcare professionals, nursing homes or nursing care and home help organisations. More information in the legal text (Health Insurance Benefits Ordinance Art. 7).
– Nutrition counselling (with a doctor's prescription)
Coverage includes up to 6 consultations with a doctor's prescription or as commissioned 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 fiduciary physicians and suggest how his patient's treatment should continue. Health insurance covers nutrition counselling only in case of certain medical conditions or allergies.
– Diabetes counselling (with a doctor's prescription)
Coverage includes up to 10 consultations with a doctor's prescription. Should further consultations be necessary, the doctor can renew the prescription. The amount reimbursed by the insurer varies according to valid tariffs for your place of residence or work.
– Speech therapy (with a doctor's prescription)
Coverage includes up to 12 consultations per prescription, which must be completed within a period of 3 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 fiduciary physicians and suggest how his 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 work-up and therapy sessions are covered. If psychiatric therapy requires more than 40 sessions, the treating doctor must make a well-founded suggestion to the fiduciary physician of the health insurance company about how the therapy should continue.
Tip: You will need supplemental health 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 Coverage 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 coverage 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). Only 50 percent of the total cost of emergency transportation to the next hospital abroad are reimbursed (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 percent of the cost of medically necessary rescue missions (up to 5,000 francs per year). For transportation in non-life threatening situations, also 50 percent of costs, but no more than 500 francs 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 10 francs per day towards the cost of balneotherapy in a health resort or spa for up to 21 days per calendar year if ordered by a doctor. The cost of medical examinations, medication and recognised forms of therapy are covered by basic health insurance after deducting the policyholder's out-of-pocket amount.
1.7 Nursing services
Contribution towards treatment costs in a recognised nursing home. Coverage of fees for nursing care at home (Spitex) and in nursing homes by basic health insurance varies from canton to canton. Doctors may generally order 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, he must fully bear all costs for room and board himself.
1.9 Alternative medicine
Since August 2017, four healing methods have been allowed under certain conditions: anthroposophic medicine, homoeopathy, phytotherapy and traditional Chinese medicine (including acupuncture). Based on the Federal Council's decision of 16th June 2017, basic compulsory healthcare insurance (OKP, basic 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 medication
Covered according to the list of analyses, the list of medicinal products and the list of specialities. The analyses and medication lists can be found in the Health Insurance Benefits Ordinance (Krankenpflege-Leistungsverordnung, KLV, 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 (Krankenpflege-Leistungsverordnung, KLV, Art. 20, Appendix 2). Orders may be placed at: EDMZ, 3003 Bern.
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 Health Insurance Benefits Ordinance (KLV).
5. Additional benefits in case of maternity
Examinations performed by doctors or midwives and examinations ordered 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 neither subject to the deductible nor to 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 encompasses, for example, hospitalisation 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 early enough.
6. Legal abortion
Legal abortion (Art. 120 of the Swiss Criminal Code) is covered for by mandatory basic health insurance.
7. Dental treatment
Basic health insurance only 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. It also bears the cost of dental treatment after an accident if the claim is not covered by any other insurance. The costs for dental fillings, removal of wisdom teeth, replacing amalgams or corrective dental work are not covered.
Tip: Braces for straightening children's teeth can be insured by buying 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 for certain diseases. These examinations or preventive measures must be performed or prescribed by a doctor. This includes:
- 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 higher risk of contracting HIV
- Gynaecological examinations (the second examination after one year, 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 shots 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 optical aids 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 optical aids.