Swiss health system – Health insurance simply explained

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Swiss health system – The health insurance system seems infinitely complex, but we show how simple it can be if you only know which points to pay attention to. Since health insurance is compulsory, it is an advantage to be able to keep track of everything.

In recent years, health insurance premiums have skyrocketed. And unfortunately, far too many Swiss citizens are still paying much more than they should.

An analysis can quickly show you where you are paying too much and where savings can leave more money for tasty meals or nice trips.

In this article, we will mainly focus on basic health insurance, because supplementary health insurance is so diverse that it could take 50 pages to cover it.

The health insurance system

There are two levels of coverage:

  • Basic insurance is compulsory for every citizen living in Switzerland. This is because it covers the usual health costs, such as doctors and hospitals.
  • Supplementary insurance is not compulsory. There are many different types of supplementary insurance. For example, private hospital insurance, dental insurance, eye insurance, etc.

Regardless of the provider, basic insurance is regulated by the Health Insurance Act (KVG) and must therefore offer the exact same benefits. Since there are far too many providers, it makes things more complicated than they actually are.

Supplementary insurance is completely different from provider to provider. Even two dental insurance policies can be very different from provider to provider. This makes it very difficult to compare such insurance.

Changing health insurance

You are allowed to change health insurers every year. However, the cancellation of the previous, probably overpriced health insurance, must reach the insurer by the end of November.

Meanwhile, a six-month notice period applies to supplementary insurances.

An insurer must accept every applicant for basic insurance and cannot refuse them. An insurer cannot refuse a person because the insurance cover would be too expensive! On the other hand, an application for supplementary insurance can very well be refused.

11 most common costs covered by basic insurance

  1. Hospital visits, interventions, and emergency treatment. For hospitalisation, there is a daily charge of CHF 15, which you have to pay yourself.
  2. General treatments by doctors. However, many special treatments are excluded here.
  3. Prescriptions by the doctor
  4. Birth costs and abortions
  5. Mammograms and bowel cancer screening for people over 50
  6. Gynecological examinations
  7. Glasses and contact lenses for children up to the age of 18 (covered up to a maximum of CHF 180 per year)
  8. Emergency dental treatment. This is very restrictive for serious problems
  9. Psychotherapy under certain conditions
  10. Frequent vaccinations
  11. Some alternative therapies, such as acupuncture and homeopathy. However, this is only covered if an accredited specialist does it. And even then, there are some conditions.

How is it covered?

First of all, every insurance policy has a deductible. Any expenses below the deductible are not covered. If the deductible is CHF 300 (the lowest), the first CHF 300 of medical expenses must be paid before the insurance will cover anything.

But even after the deductible, there is still a part that has to be paid by yourself, namely the excess. For everything that is reimbursed by the insurance, 10% of it has to be paid by yourself.

However, this is only up to an annual maximum of CHF 700 for adults and CHF 350 for children. This deductible does not apply to maternity fees. The deductible is 20% on medicines for which there is a cheaper medicine on the market, such as generic medicines.

Who pays the bill first?

There are 2 options here:

  • Indirect claim settlement (Tiers Garant): The doctor sends the bills to the policyholder, who then pays them himself. The bills are then sent to the health insurance company, which reimburses the amount.
  • Direct claim settlement (Tiers Payant): The doctor sends the bills directly to the health insurance company and the insurance company pays for the insurance cover. It then sends the policyholder the bill for the excess.

Hospital fees are usually very expensive and therefore usually fall immediately into the Direct Claims Settlement in order not to jeopardise the financial situation of the policyholder.

What is not covered?

Accidents are not covered by health insurance, but by accident insurance.

Generally, you have to be treated in your own state. If you are injured in another country, you must be transferred back to Switzerland if possible.

The basic insurance does not cover anything outside Switzerland and the European Union! The costs should be covered in the European Union. If you leave Switzerland or the EU for a holiday, for example, it is worth taking out temporary travel insurance, which is usually very cheap.

What deductibles are there?

The deductible is the amount that has to be paid first before the insurance will cover something. For example, if the deductible is CHF 2,000 per year and the health costs amount to CHF 1,900, the insurance will not cover anything.

There are the following deductibles:

Adults Children  
300 Fr. 0 Fr.
500 Fr. 100 Fr.
1000 Fr. 200 Fr.
1500 Fr. 300 Fr.
2000 Fr. 400 Fr.
2500 Fr. 500 Fr.               
  600 Fr.

Consequently, the higher the deductible, the lower the monthly health insurance premium.

In order to make a choice, it is necessary to estimate how high the health expenditure will be. With so many deductible options, it sounds complicated to choose the best one.

However, for simplicity’s sake, you can remember that only the CHF 300 deductible (if you expect high health costs) or the CHF 2,500 deductible (if you expect low health costs) makes sense. Because the others are simply not worthwhile from a mathematical point of view.

Which insurance model?

Not every insurance company offers all of them, but there are four insurance models available:

  1. The standard model.
  2. Family doctor model.
  3. Telmed model
  4. HMO model.

These models have exactly the same coverage. The only difference is what he has to do when he wants to see a doctor.

Of course, one can go directly to a doctor or hospital in an emergency. These restrictions only apply to standard health concerns.

The standard health insurance model

Here you can go directly to any doctor and you can change doctors without informing the insurance company. This model is the most expensive.

The family doctor model

In the family doctor model, the client has an assigned doctor. This doctor must be seen first, except in an emergency, before being referred to a specialist.

This model is between 10% and 20% cheaper than the standard health insurance model in Switzerland.

The Telmed health insurance model

With the Telmed model, you have to call a medical call centre before seeing a doctor. This then selects the doctor to go to, either a specialist or a generalist, depending on the concern.

This model is also between 10% and 20% cheaper than the standard model.

The HMO health insurance model

Here you have to go to a specific health center. There is no assigned doctor, but an assigned health center, which is why there will often be a change of doctor here. As there are not so many health centers yet, you may have to travel 30-40 minutes to the nearest one.

This model is usually the cheapest but is not offered by all health insurance companies.

Swiss health system – accident insurance necessary?

Basic health insurance and accident insurance are closely linked. This is because accident insurance is also compulsory in Switzerland. Accident insurance must be taken out with the health insurance company.

The Swiss health system ensures that employees are automatically covered by accident insurance. In addition, anyone who works at least eight hours a week is covered by non-occupational accident insurance.

Only the unemployed have to apply for this with their basic insurance. However, these are very cheap and offer the same insurance cover everywhere.

How to save on health insurance premiums?

There’s no denying that health insurance in Switzerland is very expensive. For most, it accounts for about 15% of the budget. Some people spend up to 20% of their budget on health insurance. And every year the prices go up!

1. Do not hesitate to change insurance

Ask for comparisons and change every year is the motto of most policyholders these days. The Swiss health system benefits from the fact that the basic insurance is the same everywhere due to the Health Insurance Act (KVG).

If you can save several hundred francs a year, there is no reason not to change your basic insurance, unless the cheapest insurance offers a miserable service and a slow processing of reimbursements, etc. 2.

2. Choose the best model and the best deductible for you.

  • Choose the insurance model according to your convenience and environment. The Swiss health system offers access to many health centers, especially in cities. If there is a good one nearby, there is no reason not to choose the family doctor or telemedicine model.
  • Choose either the highest or lowest deductible rate

3. Pay premiums in advance

Most insurance companies offer a 2% discount if you pay the monthly fees all at once at the beginning of the year.

4. Ask for health insurance subsidies

If income is low, you may be eligible for county or state assistance. In some cases, if income is below a certain threshold, all insurance bills may even be covered. For those with several children and a middle income, this can be a blessing.

5. Look out for possible discounts

Some insurers offer certain discounts, such as if you only ever go to a certain pharmacy or regularly visit the gym.

The discounts vary widely, so it’s worth asking.

Swiss health system – Which health insurance to choose?

As mentioned above, the benefits of the basic insurance to protect the Swiss health system are the same for all insurance companies. Therefore, you might think that you are safe with the cheapest option.

However, you should ask yourself why an insurance company is much cheaper. Do they have enough staff, how well are the processes coordinated, how quickly are reimbursements made, how good is the customer service, how many doctors are there to choose from, etc.?

This is where our insurance specialists can help, who have years of experience with a wide range of insurance companies and know the advantages and disadvantages of each one.

Request an analysis now at ajooda, we present individually tailored proposals, our customers choose the right solution.

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