Co-payment

What is the co-payment?

The co-payment (Kostenbeteiligung) is your own share of the costs of benefits billed through basic health insurance. It comes on top of the premium: you pay the premium every month, even when you are healthy; the co-payment only when you use benefits. The law requires it for all insured persons, with few exceptions.

The co-payment has three components:

• Deductible (Franchise): a fixed annual amount that you pay yourself first. For adults, the standard deductible is CHF 300; the options are CHF 500, CHF 1,000, CHF 1,500, CHF 2,000 and CHF 2,500. For children there is no standard deductible; the options are CHF 100 to CHF 600.
• Retention fee: 10% of the costs above the deductible, up to CHF 700 a year for adults and CHF 350 for children. For certain medicines it is 40%.
• Hospital contribution: CHF 15 a day for an inpatient stay, not counting the day of discharge.

The co-payment only exists in basic health insurance under the Federal Health Insurance Act (KVG). Supplementary insurance has its own retention fees, set out in the contract. However, it may not cover the statutory co-payment: the law prohibits insuring the deductible and retention fee.

How it works

The insurer first counts every benefit towards the deductible. As long as the costs in a calendar year are below the deductible, you pay everything yourself. If they are higher, you pay a 10% retention fee on the excess until the annual maximum is reached. After that, the insurer covers the costs in full, except for the hospital contribution.

The date of treatment is what counts, not the date of the invoice. Treatment in December counts towards the old year, even if the invoice only arrives in the new year. If you switch insurer during the year, the new insurer credits the co-payment you have already paid.

If the doctor bills the insurer directly, the insurer pays the invoice and claims your co-payment back from you with a statement of benefits. If you pay invoices yourself, the insurer only reimburses the part above your co-payment.

There is a cap for families: if several children are insured with the same insurer, together they pay no more than the deductible and the maximum retention fee of one adult. A separate limit applies with optional deductibles. The co-payment for a child is owed by the parents who pay the premiums; the child cannot be subjected to debt enforcement for it, even after turning 18.

Children, young adults in education or training and women in connection with maternity do not pay the hospital contribution. In the case of maternity, the entire co-payment is waived: there is never one for the specific maternity benefits, nor for benefits from the 13th week of pregnancy until 8 weeks after birth.

Legal basis

Art. 64 para. 1 KVG obliges insured persons to contribute to the costs. Para. 2 sets out the components: a fixed annual amount (deductible) and 10% of the costs exceeding the deductible (retention fee). Under para. 4, no deductible is charged for children, the maximum retention fee is halved, and several children in one family with the same insurer together pay no more than one adult. Para. 5 provides for the contribution towards hospital stays, para. 7 for the exemption in the case of maternity and para. 8 for the prohibition on insuring the co-payment. Para. 1bis governs the co-payment for children.

The amounts are set out in the KVV: Art. 103 para. 1 KVV (deductible CHF 300), para. 2 (maximum retention fee CHF 700 or CHF 350), para. 3 (date of treatment is what counts) and para. 4 (crediting when switching insurer). Art. 93 KVV lists the optional deductibles, Art. 104 KVV the hospital contribution of CHF 15 a day with its exceptions, Art. 104a KVV the option of higher or lower co-payments for certain benefits and Art. 105 KVV the details for maternity. The 40% retention fee for certain more expensive medicines is governed by Art. 38a KLV.

Example: three years, two deductibles

Lea is 38 and compares her maximum co-payment with a deductible of CHF 300 and of CHF 2,500. The calculation uses the statutory values, without the premium and without medicines with a higher retention fee.

The table shows that with high costs, the co-payment is capped. You never pay more than the deductible plus CHF 700 plus the hospital contribution in one year. Whether the high deductible pays off depends on the difference in premium at your insurer.

What this means for you

Always calculate with the sum of the annual premium and the possible co-payment. A low premium with a high deductible is only cheaper as long as your costs stay low. The deductible calculator shows which combination suits you; you can find the premiums of all insurers for your municipality in the premium calculator.

Set aside the amount of your maximum co-payment, especially with a high deductible. With a CHF 2,500 deductible, an expensive year can cost CHF 3,200 plus the hospital contribution.

A change of deductible always takes effect from 1 January. For a lower deductible, the notice periods for switching insurer apply: after you have been notified of the new premium, your request must reach the insurer by 30 November. The dates are listed under switching health insurer. Submit invoices below the deductible too; only then are they credited.

Common mistakes

• Forgetting the retention fee. After the deductible, you continue to pay 10% of the costs, up to the maximum of CHF 700.
• Overlooking the hospital contribution. It is charged on top of the deductible and retention fee and is not included in the maximum.
• Looking for insurance to cover the deductible. The law prohibits insuring the co-payment.
• Paying during pregnancy what is not owed. From the 13th week until 8 weeks after birth, there is no co-payment. Check your statements of benefits.
• Assigning invoices to the wrong year. The date of treatment is what counts.

How we calculate the examples is explained under how we calculate.