Health insurance: care services

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)

Care services

The compulsory health insurance (OKP) contributes to care services. There are three types of care services (cf. Art. 7 para. 2 of the Health Insurance Services Ordinance [KLV]):

  • assessment, advice and coordination measures
  • examination and treatment measures (‘treatment-related care’)
  • basic care measures (‘basic care’)

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 para. 2 KLV;
  • Examination and treatment measures shall be prescribed by a doctor (cf. Art. 8 KLV). No doctor’s prescription is required for assessment, advice and coordination measures, or for basic care measures;
  • The patient’s care needs must have been assessed by a nurse in collaboration with the patient or their relatives (cf. 8a KLV); in a care home, the care needs assessment must be based on an instrument that meets the requirements of Article 8b KLV (cf. amendment to the KLV of 2 July 2019);
  • The care services must be delivered by approved healthcare providers.

Acute and transitional care

The OKP and the insured person’s canton of residence also cover, in accordance with the rules governing hospital financing, 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 in collaboration with a nurse (cf. Art. 25a para. 2 and Art. 49a KVG). To this end, insurers and healthcare providers agree on flat-rate fees.

Who can deliver the care services?

Registered nurses, organisations for assistance and care at home as well as care homes can provide care services – this may require a prescription  by a doctor when required (cf. requirements above).

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). The applicable maximum contributions for calculating the maximum patient co-payment are defined in the KLV (Art. 7c KLV).

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. The contribution depends on the duration of the care provided; in the case of care at home, it also depends on the type of care services provided. Acute and transitional care is covered in accordance with the rules governing hospital financing (see below);
  • 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.

Care services provided at home and those provided in care homes are covered differently.

Funding of acute and transitional care

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).

Funding of care services provided at home

The compulsory health insurance pays the following contributions to care services (cf. Art. 7a KLV):

  • For assessment, advice and coordination: CHF 76.90 per hour;
  • For treatment: CHF 63 per hour;
  • 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

Care services in a care home are reimbursed based on the level of care required. The OKP makes a flat-rate contribution towards the costs of care services. This contribution varies across twelve levels and is paid for each day that care services are received.

The lowest OKP contribution is CHF 9.60 (for care needs of up to 20 minutes), whilst the highest OKP contribution is CHF 115.20 (for care needs of more than 220 minutes) (cf. Art. 7a KLV).

The insured person in a care home 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.

Further information

Federal Office of Public Health FOPH

Health and Accident Insurance Directorate
Tariffs and Principles Division
Schwarzenburgstrasse 157
Switzerland - 3003 Bern