The health insurers pay a fixed contribution towards care provided at home or in care homes. Insured persons also have to cover a certain but limited amount. The remaining costs are covered by the cantons and/or municipalities.
Care services under the Health Insurance Act (KVG)
In which circumstances does compulsory health insurance contribute to the cost of care services?
Certain requirements must be met in order for compulsory health insurance to contribute to the cost of care services:
- The care must be in accordance with Article 7 of the Health Insurance Services Ordinance (KLV);
- A doctor must have prescribed or ordered that the patient is in need of care services;
- The patient’s care needs must have been determined by a nurse;
- The care services must be delivered by approved healthcare providers.
Compulsory health insurance also covers acute and transitional care for a maximum of two weeks after an inpatient hospital stay if necessary and prescribed/ordered by a doctor of the hospital (cf. Art. 25a para. 2 KVG).
Care services prescribed/ordered by a doctor, determining care needs
If a patient needs care (including acute and transitional care after an inpatient hospital stay), it must be ordered or prescribed by a doctor. The doctor may deem certain care services essential (Art. 8 KLV). A nurse works together with the patient or their relatives (Art. 8a KLV) to accurately assess the patient’s needs. The needs assessment in care homes is based on an instrument which has to meet the requirements under Art. 8b KLV (KLV amendment of 2 July 2019 - category funding of care).
Who can deliver the care services?
Registered nurses, organisations for assistance and care at home as well as care homes can provide care services – ordered or prescribed by a doctor.
Service providers must meet certain requirements to be able to bill the services to the compulsory health insurer directly:
- In order to be self-employed, nurses must hold a recognised qualification and have two years’ experience working with a registered nurse, at an organisation for assistance and care at home, or an approved care home (Art. 49 KVV);
- Organisations for assistance and care at home must in particular meet cantonal requirements and have the necessary qualified staff (cf. Art. 51 KVV);
- Care homes must be listed on a cantonal care home register (cf. Art. 39 KVG).
Where are the care services provided?
The care services can be provided at home, in day and night care facilities or in a care home.
Which costs do insured persons have to cover themselves?
Insured persons usually have to contribute to the costs of care services. Their contribution is limited to 20% of the highest contribution of the compulsory health insurer (cf. Art. 25a para. 5 KVG). In addition to contributing to the cost of care services, patients must also pay the standard cost sharing.
Any other services associated with the need for care usually have to be covered by insured persons themselves. These include in particular:
- Support
- Home help services
- Board and accommodation in a care home
Insured persons may in some circumstances be eligible for supplementary benefits and/or a helplessness allowance.
How are care services funded?
In accordance with Article 7 KLV, care services are funded by three parties (cf. Art. 25a para. 1 and para. 5 KVG) :
- The compulsory health insurer pays a fixed contribution towards care services;
- Generally, the insured person also has to contribute to the cost of care services. However, their contribution is limited to a maximum of 20% of the highest contribution of the compulsory health insurer towards care services (in addition to a contribution to the cost of care services, insured persons also have to pay the standard cost sharing);
- The remaining costs are regulated by the cantons and are covered by the cantons and/or municipalities.
The costs of acute and transitional care after an inpatient hospital stay are covered proportionately by the compulsory health insurance and the cantons (compulsory health insurance: up to a maximum of 45%; cantons: minimum 55%; cf. Art. 7b KLV).
The costs of care provided at home and care provided in a care home are reimbursed differently, in other words the type and level of contributions vary:
Funding of care services provided at home
The compulsory health insurance pays the following contributions to care services (cf. Art. 7a KLV):
a. For assessment, advice and coordination: CHF 76.90 per hour;
b. For treatment: CHF 63 per hour;
c. For basic care: CHF 52.60 per hour.
Insured persons have to contribute up to a maximum of CHF 15.35 per day to the costs of care. The majority of cantons stipulate a lower personal contribution to the cost of care at home. Patients must contribute to the cost of care services in addition to the standard cost sharing.
If the costs of care are not fully covered by the contribution from the compulsory health insurance and the contribution from the insured person, the remaining costs are covered by the cantons and/or municipalities.
Funding of care services provided in care homes
If a care home resident needs care for up to 20 minutes a day, the compulsory health insurance pays CHF 9.60 per day towards care services. The contributions increase proportionally to CHF 19.20 per day if the patient needs between 21 and 40 minutes of care, to CHF 28.80 per day if the patient needs 41 to 60 minutes of care, and so on up to a contribution of CHF 115.20 per day if the care home resident requires more than 220 minutes of care per day (cf. Art. 7a KLV).
The insured person must contribute up to CHF 23 per day to the costs of care. Some cantons stipulate a lower personal contribution towards the cost of care provided in care homes. Patients must contribute to the cost of care services in addition to the standard cost sharing.
If the costs of the care services are not fully covered by the contribution from the compulsory health insurance and the contribution from the insured person, the remaining costs are covered by the cantons and/or municipalities.
Last modification 10.02.2022
Contact
Federal Office of Public Health FOPH
Health and Accident Insurance Directorate
Tariffs and Principles Division
Schwarzenburgstrasse 157
3003
Bern
Switzerland
Tel.
+41 58 462 37 23