Compulsory health insurance provides benefits in the case of illness, accident and maternity.
Compulsory health insurance provides benefits in the case of illness, accident and maternity. These include examinations and treatments by doctors and in hospital as well as nursing and some non-medical services. In the case of accidents, however, the health insurance provider steps in only if the insured person has no other coverage. It furthermore covers the costs of medical prevention measures. The basic aspects of those benefits are explained below.
All health insurers that provide compulsory health insurance coverage must provide the identical scope of benefits, as mandated by law, as well as ensuring equal treatment of all insured persons. Additionally, the insurers are prohibited from covering any additional, “voluntary” services.
As prescribed by law, compulsory health insurance covers only those services that are effective, useful and cost-effective. Both new and existing services that may not meet these criteria are evaluated under the Health Technology Assessment (HTA) programme.
If a service provider (e.g. a doctor) provides services that are not part of the mandatory benefits of the compulsory health insurance, he or she is obligated to inform the patient of that fact.
For additional practice-oriented information, please consult the guidebook “Your questions, our answers: The compulsory health insurance in Switzerland”.
The service providers generate their invoices based on tariffs and rates, and that is how they are reimbursed for their services. Those tariffs and rates are agreed among insurers and service providers, or, in the cases stipulated by law, are determined by the responsible authority. Tariff contracts require authorisation by the respective responsible authority. The tariffs have to conform to the law and to the precept of cost-effectiveness and equity. The goal of the rate structure is high-quality and useful healthcare at the best possible price.
Tariffs, rates and maximum levels of reimbursement are determined by the authorities in the following areas:
- List of analyses with tariff
- List of products, active ingredients and additives used in the formula with tariff (list of medicines); that tariff includes pharmacy services as well
- Provisions on the service obligation and the scope of coverage in the case of aids and devices (List of Aids and Devices) used for examination or treatment
- List of pharmaceutical specialities and assembled medicines with prices
Last modification 05.12.2022