Health insurance: Premiums and co-payment

Insurers set the premiums paid by policyholders. They essentially charge the same premiums for all policyholders. Policyholders’ co-payment takes the form of a deductible, a retention fee and a contribution to the costs of hospital stays.

Premiums

• Insurers set the premiums paid by policyholders. Unless otherwise stipulated by law, they charge the same premiums for all policyholders.
• Premium levels vary in accordance with differences in costs within cantons and depend on the policyholder’s place of residence. 
• Insurers may charge different premiums for different regions. Standard premium regions are defined by the FOPH.
• Premiums are payable in advance, generally monthly.

Co-payment

Services are subject to co-payment by policyholders. This comprises:

• Standard deductible: CHF 300 per year. Children and adolescents under 18 are exempt.
• Retention fee: 10% of the costs exceeding the deductible, up to a maximum of CHF 700 per year (CHF 350 for children and adolescents under 18).
• Contribution to the costs of a hospital stay: CHF 15 per day. Children and adolescents under 18, young adults up to the age of 25 in education/training, and women receiving maternity-related services are exempt.
  

FAQ cost sharing

• What is cost sharing?

  Insured persons have to contribute to the cost of the services they receive. This contribution comprises an annual fixed amount (deductible) and 10 per cent of any further costs above this fixed amount (retention fee).

  The date of treatment determines when the deductible and the retention fee are charged. The insured person pays for any treatment received up to the amount of the deductible in any given calendar year, regardless of when the invoice is dealt with by the insurance fund.
  

• How high is the minimum cost share?

  The standard deductible amounts to CHF 300 per calendar year and the maximum annual retention fee to CHF 700 for an adult. In other words, for an insured person with an annual deductible of CHF 300, the maximum cost share is CHF 1000 per calendar year. Children up to their 18th birthday do not pay a deductible and the maximum retention fee is CHF 350. However, the deductible can be increased voluntarily.
  

• What is the advantage of an increased annual deductible?

  By opting for an increased annual deductible, I do bear some financial risk in the event of illness, but I also save on my premium payments. For adults, the available deductibles are 500, 1000, 1500, 2000 and 2500 francs, and for children 100, 200, 300, 400, 500 and 600 francs. The health insurer does not have to offer the full range of deductibles. It may offer different deductibles for adults and young adults (between the ages of 19 and 25).

  The health insurer is required to charge a minimum premium equivalent to 50 per cent of the ordinary premium with accident cover for the age group and premium region of the person concerned. This amount cannot be reduced even in the case of insurance policies without accident cover, or combined with a policy limiting the choice of service provider. In addition, a discount amounting to not more than 70 per cent of the additional risk accepted may be granted.
  

• Do I also have to pay a cost share for hospital care?

  Yes, if the cost share limit for other outpatient’s treatment has not yet been reached, I still have to pay the deductible and retention fee (cost share) as well as for outpatient treatment as for inpatient hospital stay.
  
  

• What about pregnancy and childbirth – does cost sharing still apply?

  Cost sharing does not apply to costs for special maternity services, i.e. check-ups during and after pregnancy, including ultrasound examinations, childbirth and obstetrics, birth preparation and breastfeeding counselling. For more detailed information on the scope of special maternity services, please refer to the document “Frequently asked questions about benefits”, V. Coverage of maternity services, no. 1 to 9, on the page Health insurance: Maternity services.

  In addition, women are not obliged to contribute to the cost of general treatment and care in the event of illness from the 13th week of pregnancy and until 8 weeks after the birth. They are therefore not required to share in the cost of treatment of any diseases that are unrelated to the pregnancy either.

• Do the deductible and the retention fee also apply to contributions my insurance provider makes for spa treatments or the costs for aids and devices which are on the List of Medical Aids and Devices?

  Yes. If those costs are not otherwise covered, you will receive no or only a partial contribution. You may be able to get a contribution from a supplementary insurance fund.
  

• If I change my health insurance provider in the middle of the year, must I then pay the annual deductible and retention fee twice?

  No, the deductible and retention fee are payable only once each year. An attestation must therefore be obtained from the previous insurance provider to the effect that the deductible and/or the retention fee have already been reached in part or in full.
  

• What is the CHF 15 hospital contribution?

  Under the current Health Insurance Act (KVG), a hospital stay is considered a statutory benefit. However, over and above the deductible and retention fee, insured persons are required to pay a contribution to the costs of the hospital stay; this contribution is graduated according to the financial burden on the family concerned. The daily contribution to the costs of the hospital stay is CHF 15. Children under 18 years, young adults (up to the age of 25) in training and women receiving maternity services are exempt from the hospital contribution.
  

• Do I still have to pay the deductible and retention fee when the costs of treatment following an accident (e.g. dental injuries) are covered by my health insurance insurer?

  Yes. Accident benefits are statutory benefits and are also covered by the rules on cost sharing (deductible and retention fee) if the relevant limits have not already been reached. In the case of young people in particular, consideration should be given to the need for possible follow-up treatment when choosing the annual deductible.
  

• If I am being treated across the end of one year and into the next, what happens to the cost sharing arrangement?

  The cost share is made up of a fixed annual amount (deductible) and 10 per cent of the costs which exceed the deductible (the retention fee). As the definition shows this deductible is payable per calendar year. Therefore, an insured person must pay the deductible for each calendar year, regardless of whether the same course of treatment extends across two different years. In the worst-case scenario, you will therefore have to pay the cost share twice.
  

• Can I adjust the annual deductible each year without difficulty?

  Under the current law, you may change from a higher to a lower elective deductible or to the basic deductible, regardless of your state of health, by giving notice to the end of the calendar year. The health insurance provider must be notified in writing by 30 November of the desired lower deductible. If you want to switch to a higher deductible that will take effect from the start of a calendar year. It is recommended to notify the health insurer in time, no later than mid-December.

• If I change to a different insurer in the middle of the year, can the deductible be changed from the ordinary amount to the elective deductible?

  No. The change to a higher deductible is only possible with effect from the start of a calendar year. It is advisable to notify your health insurer of your intention in writing in good time and no later than mid-December.

• If I opt for a model with a restricted choice of service providers (e.g. HMO, general practitioner model), can I then also choose a higher annual deductible?

  Yes, that is possible. However, the maximum discount must be taken into account. The maximum discount by comparison with the ordinary model with an annual deductible of CHF 300 including accident cover must not amount to more than 50 per cent.
  

• When I take out the bonus insurance, can I also opt for a higher annual deductible?

  No. The bonus insurance must not be offered in conjunction with an elective deductible.
  

• When do I pay a 40 per cent retention fee instead of 10 per cent on pharmaceuticals prescribed by a doctor?

  The health insurer charges a retention fee of 40 % if there is a medicine on the List of Pharmaceutical Specialties which is interchangeable with an equivalent lower-cost (by a certain margin) medicine.

  Information about medicines with a 40 per cent retention fee is available on the page Differentiated cost shares for medicines. If the doctor expressly prescribes an original product on medical grounds, despite the fact that a cheaper generic product exists, the retention fee is 10 per cent.

Further information

• Links

  Overview of premiums for compulsory health insurance (KVG) (in French/German/Italian)

• Legislation

  CC 832.102 Ordinance on Health Insurance (KVV) (in French)