Benefits catalogue of basic health insurance

What is the benefits catalogue of basic health insurance?

The benefits catalogue is the full set of benefits that compulsory health insurance, the OKP, must pay for. It is not a single document, but a combination of law, ordinances and lists. The law names the areas of benefits; the ordinances and lists specify which treatment, which medicine and which aid or appliance is covered in each case, and at what price.

The catalogue is the same for all health insurers. In basic health insurance, an insurer may pay neither less nor more. That is why comparing basic health insurance comes down to premium, insurance model and service. Everything beyond that, such as glasses for adults, fitness or a two-bed room in hospital, belongs in supplementary insurance under the Insurance Contract Act (ICA).

Basic health insurance covers benefits in the event of illness, accident if no accident insurance pays, maternity and congenital disorders not covered by invalidity insurance. In addition, there are certain preventive measures and, in exceptional cases, dental treatment.

How it works

The benefits catalogue is structured on three levels:

1. Act (KVG). Art. 25–31 KVG name the areas of benefits: medical examinations and treatment, hospital stays in the general ward, medicines, analyses, aids and appliances, rehabilitation, care, prevention, maternity, and dental treatment in exceptional cases.
2. Ordinance (KLV). The Health Care Benefits Ordinance governs the details: which services non-medical professionals such as physiotherapists, midwives or nutritional advisers may provide, how many sessions are covered and which preventive measures are paid for. Its Annex 1 lists medical services on which a commission has decided: covered, covered under certain conditions or not covered.
3. Federal lists. The List of Pharmaceutical Specialties contains the medicines that are paid for, with prices; the List of Analyses contains laboratory analyses; and the MiGeL contains aids and appliances such as dressings or inhalers.

For medical services, a principle of trust applies: what a doctor does to diagnose or treat an illness is covered in principle, as long as it is not excluded or restricted in Annex 1 KLV. For non-medical services, it is the other way round: only what the KLV expressly names is covered, usually on a doctor’s prescription.

Above all of this stands the rule of the effectiveness, appropriateness and cost-effectiveness criteria: every benefit must be effective, appropriate and cost-effective. The FOPH and advisory commissions review benefits periodically. If a benefit fails, it is removed.

Legal basis

Art. 24 para. 1 KVG lays down the principle: basic health insurance covers the costs of the benefits under Art. 25–31 KVG subject to the conditions in Art. 32–34 KVG. Art. 25 KVG describes the general benefits in the event of illness, Art. 26 KVG prevention, Art. 27 KVG congenital disorders, Art. 28 KVG accidents, Art. 29 KVG maternity, Art. 30 KVG non-punishable termination of pregnancy and Art. 31 KVG dental treatment.

Under Art. 32 para. 1 KVG, benefits must be effective, appropriate and cost-effective; Art. 32 para. 4 KVG excludes benefits that do not meet these criteria according to an evidence-based procedure. Art. 33 para. 1 KVG allows the Federal Council to designate medical services that are not covered or only covered under certain conditions; under Art. 33 para. 2 KVG, it specifies the non-medical services. Art. 34 para. 1 KVG prohibits insurers from covering any other costs in basic health insurance. Art. 52 KVG is the basis for the List of Analyses, the MiGeL and the List of Pharmaceutical Specialties. Art. 1 KLV refers to Annex 1, which the FOPH publishes on its website.

Example: same benefits, different premiums

Sandra is 36, lives in the city of Zurich and has the standard deductible of CHF 300. After a sports injury, her GP prescribes physiotherapy. What basic health insurance pays is the same at every insurer:

The premium for exactly these benefits, however, differs considerably. Premiums 2026, municipality of Zurich (region 1), adults born in 1990, CHF 300 deductible, with accident cover; source FOPH:

What this means for you

Because the benefits catalogue is the same at every insurer, what you mainly compare in basic health insurance is the premium. You can do this in the premium calculator with the official FOPH data. You can find the insurers’ service, availability and financial key figures under health insurers. If you want to switch, switch insurer shows you the process and the deadlines.

Before an expensive or unusual treatment, it is worth checking with the insurer. Ask specifically whether the benefit is part of the benefits catalogue and whether cost approval is required. For medicines, a look at the List of Pharmaceutical Specialties helps: if a medicine is not on it, basic health insurance only pays for it in exceptional cases.

For benefits outside the catalogue, such as glasses for adults, complementary medicine from non-medical therapists or a two-bed room, you need supplementary insurance. You choose it independently of basic health insurance, with the same insurer or a different one.

Common mistakes

• Comparing insurers by their basic health insurance benefits. The benefits are the same everywhere. Anyone advertising “more benefits” in basic health insurance means supplementary insurance or service.
• Assuming every doctor’s prescription is covered. Non-medical services are only covered if the KLV names them and an approved service provider provides them.
• Forgetting the co-payment. Benefits from the catalogue are also charged first to your deductible and then to the 10% retention fee.
• Relying on old information. The KLV and the lists change several times a year. Check the current status on the FOPH website.

We explain how we analyse premiums under how we calculate.