JANUARY

SWITZERLAND
Insurers offer premiums for defined geographical “premium regions” limited to three per canton. Within every
region, the criteria for variation in premiums are limited to age group, level of deductible, and alternative
insurance plans (so-called managed care plans with the main characteristic of giving up free choice of first
medical contact), but variations in premiums among insurers can be significant. In 2013, 60.6 percent of
residents opted for basic coverage with a health maintenance organization, an independent practice
association, or a fee-for-service plan with gatekeeping provisions (FOPH, 2014).
Private health insurance: Private expenditure accounted for 32.1 percent of total health expenditure in 2013
(SFOS, 2015a), which is high by comparison with other OECD countries (OECD, 2011). There is complementary
voluntary health insurance (VHI, 7.3% of total expenditure) for services not covered in the basic basket of SHI,
and supplementary coverage for free choice of hospital doctor or for a higher level of hospital accommodation.
No data are available on the number of people covered.
VHI is regulated by the Swiss Financial Market Supervisory Authority. Insurers can vary benefit baskets and
premiums and can refuse applicants based on medical history. Service prices are usually negotiated directly
between insurers and providers. Unlike statutory insurers, voluntary insurers are for-profit; an insurer will often
have a nonprofit branch offering SHI and a for-profit branch offering VHI. It is illegal for voluntary insurers to
base voluntary insurance subscription decisions on health information obtained via basic health coverage, but
this rule is not easily enforced.
What is covered?
Services: The Federal Department of Home Affairs (FDHA) defines the SHI benefits basket by evaluating
whether services are effective, appropriate, and cost-effective. It is supported in this task by the FOPH and
by Swissmedic, the agency for authorization and supervision of therapeutic products.
SHI covers most general practitioner (GP) and specialist services, as well as an extensive list of pharmaceuticals,
medical devices, home health care (called Spitex), physiotherapy (if prescribed), and some preventive measures,
including the costs of selected vaccinations, selected general health examinations, and screenings for early
detection of disease among certain risk groups (e.g., one mammogram per year for women with a family history
of breast cancer).
Hospital services are also covered by SHI, but highly subsidized by cantons (see below). Care for mental illness
is covered if provided by certified physicians. The services of nonmedical professionals (e.g., psychotherapy by
psychologists) are covered only if prescribed by a qualified medical doctor and provided in his or her practice.
SHI covers only “medically necessary” services in long-term care. The FOPH and Swiss Conference of Cantonal
Health Ministers aim to eliminate the gaps in financing of hospice care. Dental care is largely excluded from
SHI, as are glasses and contact lenses for adults (unless medically necessary), but these are covered for children.
Cost-sharing and out-of-pocket spending: Insurers are required to offer minimum annual deductibles of
CHF300 (about USD219) for adults under SHI, although insured persons may opt for a higher deductible
(up to CHF2,500 [USD1,825]) and a lower premium. In 2013, 23.5 percent of all insured persons opted for the
standard CHF300 deductible; the other 76.5 percent chose a higher deductible or another model with
a gatekeeping element.
Insured persons pay 10 percent coinsurance above deductibles for all services (including GP consultations), but
is capped at CHF700 (USD511) for adults and at CHF350 (USD255) for minors (under age 19) in a given year.
There is also a 20 percent charge for brand-name drugs with a generic alternative. For treatment in acute-care
hospitals, there is a CHF15 (USD11) copayment per inpatient day. Cost-sharing in SHI and VHI accounted for
5.6 percent and 0.1 percent of total health expenditure in 2013.
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The Commonwealth Fund