Health insurance and coinsurance: definition and information
In basic and supplemental health insurance, you contribute to your health costs – in part via what is known as coinsurance. Comparis explains what coinsurance is, and when you have to pay it.
09.08.2023
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1. What is coinsurance?
Your health insurance coinsurance is the amount you have to contribute towards costs after the deductible has been exhausted. Coinsurance is part of both basic and supplemental insurance.
For basic insurance, coinsurance is regulated by the Health Insurance Act. It amounts to 10% of your treatment costs, up to a maximum of 700 francs per calendar year. There are exceptions
for children
during pregnancy
for medicines
in the event of an accident
Unlike the deductible, you cannot change your coinsurance in basic health insurance. In supplemental insurance, different coinsurances are possible depending on the insurer.
Basic health insurance: calculate coinsurance
Here’s how to calculate your coinsurance:
(Medical expenses – maximum deductible) : 10 = coinsurance
Important: the 10% coinsurance rule does not apply until you have paid the full deductible.
If you incur additional medical expenses in the current calendar year, you will pay 10% of each of these. As soon as you have reached the maximum deductible of 700 francs, your health insurer will cover all other costs.
This means that with a deductible of 300 francs, you pay a maximum of 1,000 francs in additional health costs per calendar year. With a deductible of 2,500 francs, your health care costs will be a maximum of 3,200 francs.
2. Coinsurance and maternity
Under basic insurance, pregnant women who fall ill (e.g. in case of complications) do not have to pay out-of-pocket expenses from the 13th week of pregnancy until 8 weeks after the birth. Exception: preventative treatments and dental treatment. In addition, other maternity benefits are paid for during and after pregnancy.
3. Coinsurance for children and babies
The maximum amount of coinsurance for children is 350 francs under basic insurance. 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.
4. Coinsurance for medicines
Coinsurance for proprietary drugs with a generic available is 20%. Coinsurance for generic drugs is 10%.
Exceptions: coinsurance for the proprietary drug remains at 10% in the following cases:
There is a medical reason for not using the generic product.
The price difference between the proprietary and the generic product is less than 20%.
No generic is available.
5. Coinsurance for accidents
If you work for the same employer for more than eight hours per week, you are insured against accidents. Accident insurance as defined by the Accident Insurance Act is not subject to a deductible or coinsurance.
This means that in the event of an accident, the employer’s accident insurance covers all costs.
6. Coinsurance for hospital stays in Switzerland
The costs for hospitalization are offset against the deductible and the coinsurance under basic insurance. In addition, you pay the daily contribution to the cost of a stay in hospital of 15 francs. Exempted are:
Children up to 18 years
Young adults up to the age of 25 who are in education or training
Women receiving maternity benefits
7. Coinsurance in supplemental insurance
In supplemental insurance, the coinsurance amounts stated in the policy apply. These vary depending on the insurer and the type of supplemental insurance.
Some insurance policies have different coinsurance depending on the benefit. For certain benefits, the insurance companies also specify an annual limit in francs. You pay all costs above this limit yourself.
This article was first published on 28.07.2022
