What medical care does compulsory (basic) insurance pay for? What hospital can you go to for treatment? What applies in case of pregnancy? Which tariffs and prices are set by the authorities?
Benefits
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”.
Tariffs
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
Under the Swiss health insurance system, healthcare costs are reimbursed after services have been provided. This is known as the reimbursement principle. Service providers can be compensated for their services in two ways:
by policyholders, whose costs are in turn reimbursed by the insurer responsible (the tiers garant system), or
by insurers, if it has been agreed with the service providers that their services will be paid for directly (the tiers payant system).
Under Art. 42 para. 1 of the Federal Health Insurance Act (KVG), the tiers garant system is applicable in the absence of any agreement to the contrary between insurer and service provider. Policyholders are responsible for compensating service providers for their services. Accordingly, the service provider’s invoice is first sent to the policyholder, who then forwards it to the insurer. The latter checks the invoice and transfers to the policyholder the amount due (minus the deductible/co-payment).
Whether the invoice has to be settled before reimbursement is received from, the insurer depends on the payment period specified by the service provider and the insurer’s reimbursement period. This is the predominant type of invoicing for ambulatory treatment: the majority of independent medical practitioners use the tiers garant system.
Under Art. 42 para. 2 KVG, it may be agreed by the insurer and service provider that the former is liable for payment (tiers payant system). The service provider’s invoice is sent to the insurer, who settles it directly. Thereafter, the insurer invoices the policyholder for the latter’s contribution. The tiers payant system is always used in the case of inpatient treatment (second sentence of Art. 42 para. 2 KVG). This type of invoicing is mainly used in hospitals (including outpatient services), in care homes and in the domiciliary care sector.
The system has also become established for the dispensing of medication in pharmacies. Under the tiers payant system, the policyholder (in accordance with Art. 42 para. 3 KVG) receives a copy of the invoice sent to the insurer.
In general, the copy of the invoice has to be sent to the policyholder by the service provider, but it may be agreed with the insurer that the latter is responsible for sending the copy to the policyholder (Art. 59 para. 4 of the Health Insurance Ordinance, KVV).
The tiers soldant system is used in accident insurance. Here, the service provider’s invoice is sent directly to the insurer. As there is no co-payment or deductible in the case of accident insurance, the insurer pays the full amount directly to the service provider. If, within the tiers garant system, the policyholder’s claim to reimbursement vis-à-vis the insurer is ceded to the service provider (in accordance with Art. 42 para. 1 KVG), the term tiers soldant is also used, although it is not strictly applicable since the policyholder is still liable for the co-payment and deductible.
In practice
Under the tiers garant system, services have to be paid for by the policyholder, who then requests reimbursement from the insurer. If the policyholder cannot meet the costs of the services provided, various options are available. For example, the policyholder’s claim to reimbursement from the insurer can be ceded to the service provider (“tiers soldant”), or an invoice with a later payment date can be requested (e.g. an additional period of 15 or 30 days). In the latter case, the invoice is to be forwarded to the insurer as rapidly as possible. In such situations, it is important to consult the service provider and/or the insurer.
In view of the time required by the insurer to check invoices and assess the cost-effectiveness of treatment, the legislation does not specify a time limit for reimbursement. Reimbursement is generally provided by the insurer within 30 days after receipt of the policyholder’s claim (tiers garant) or the service provider’s invoice (tiers payant). Insurers are required to check whether the service is reimbursable under compulsory health insurance. The reimbursement period can be extended if certain parts of the invoice are missing and the insurer requires additional information from the service provider. The checking and reimbursement periods will also be longer if the insurer’s independent medical adviser has to be consulted.
If the measures undertaken to secure settlement of invoices by the insurer within an appropriate period prove unsuccessful, the policyholder can contact the health insurance ombudsperson (www.om-kv.ch).
Medicines
Frequently asked questions about the coverage of medicines can be found on the page Medicines.
Treatment/services abroad
Compulsory health insurance only covers reimbursable treatment and services carried out in Switzerland by licensed providers.
Exceptions are made for medical treatment that is necessary during temporary stays abroad:
In EU/EFTA countries, the European Health Insurance Card issued by your health insurer entitles you to receive any medical services that are considered essential, taking account of the type of service and the expected length of your stay. Your medical insurance will cover the costs of the same medical services as would be provided to a resident of the country in question. Further information is available at: Health insurance: Tourists abroad and globetrotters
In countries outside the EU/EFTA area, costs of emergency treatments in cases where the insured person cannot return to Switzerland for medical reasons will be reimbursed up to a maximum of twice the amount that the insurer would have covered if the treatment had been provided in Switzerland. In the case of inpatient treatment, this means that the insurer will reimburse no more than 90 % of the costs that would have arisen for hospitalisation in Switzerland (this is because, in the case of hospital treatment in Switzerland, at least 55 % of the costs are borne by the cantons, which is not the case for hospital stays abroad).
In cases where you have to go abroad for medical treatment because the treatment is not available in Switzerland, your doctor must submit an application (including a statement of reasons) to your health insurer's independent medical adviser. The insurer will decide, in consultation with the independent medical advisory service, whether the costs of treatment abroad can be reimbursed.
The costs will only be reimbursed for medicines, which you require because of illness during a temporary stay abroad (cf. no. 1 above).
Coverage of maternity services
Frequently asked questions about the coverage of maternity services can be found on the page Health insurance: Maternity services.
Hospital stays
Yes, it may still prove worthwhile even though insured persons have a free choice among hospitals which are suitable for treatment of their condition and included in the Hospital List either of their canton of residence or of the canton where the hospital is situated (listed hospital). The insurer and the canton of residence make their respective contributions – up to a maximum of the costs, which would have arisen if the treatment had been carried out at a listed hospital in the policyholder’s canton of residence. If the extra-cantonal hospital tariff is higher than that of a listed hospital in the policyholder’s canton of residence, the difference has to be borne by the policyholder, or by the supplementary insurance – if such a policy has been purchased.
Compulsory health insurance covers the full costs in all cases where extra-cantonal hospital treatment is necessary for medical reasons, i.e. in an emergency or if the specific treatment is not offered at a listed hospital in the patient’s canton of residence.
Dental treatment
Generally, the costs of dental treatment are not covered. Costs are only reimbursed in cases where dental treatment is necessitated by a serious, non-preventable disease of the masticatory system or by serious non-dental condition or its sequelae, or where measures are required to treat a serious non-dental condition or its sequelae. According to Federal Supreme Court rulings, the list of conditions likely to necessitate dental treatment covered by compulsory health insurance is exhaustive, and these conditions are enumerated in Articles 17–19 of the Health Insurance Benefits Ordinance (fedlex.admin.ch, in German, French and Italian).
