Hospitalisation

What is a hospitalisation?

A hospitalisation is a stay in hospital during which you stay overnight. The technical term is inpatient treatment. The distinction is precisely defined: a stay is inpatient if it is for examination, treatment and care and lasts at least 24 hours, or if it is shorter but a bed is occupied overnight. Transfers to another hospital and deaths also count as inpatient.

Everything else is outpatient: an operation in the morning with a return home in the evening, treatment in the emergency department without an overnight stay, an examination in the hospital’s outpatient clinic. The distinction matters because inpatient and outpatient services are currently financed and billed differently.

Basic health insurance pays for a hospitalisation if it is medically necessary and takes place in a hospital that is on a cantonal Hospital List. The stay in the general ward is covered, i.e. in a multi-bed room with treatment by the doctors on duty. A single or double room and the free choice of doctor in hospital are only insured through supplementary insurance.

Hospitalisation is a term from basic health insurance, but it also applies to accidents if your health insurer provides the accident cover. If you are insured through your employer under the Accident Insurance Act (UVG), the accident insurer pays in the event of an accident.

How it works

A planned hospital stay usually works like this:

1. Referral: your doctor refers you to a hospital. In a GP or HMO model, the referral must go through the agreed point of contact.
2. Cost approval: the hospital checks with your insurer whether it will cover the costs. In an emergency, this happens afterwards.
3. Stay: the hospital bills a flat rate per case. For acute somatic care this is the SwissDRG tariff structure: each case receives a flat rate depending on the diagnosis and treatment, regardless of the exact number of days.
4. Financing: your canton of residence and your insurer share the flat rate. The canton bears at least 55%, the insurer the rest.
5. Co-payment: you receive a statement from the insurer with the deductible, the retention fee and the hospital contribution.

You are free to choose among all hospitals on the Hospital Lists of your canton of residence and of the canton where the hospital is located. If you go to a hospital in another canton without a medical reason, the insurer and the canton pay at most the tariff that applies in a listed hospital in your canton of residence. If the tariff there is higher, you pay the difference yourself unless a supplementary insurance covers it. If there is a medical reason, such as an emergency or a treatment not offered in your canton, the insurer and the canton cover the full tariff; except in an emergency, this requires authorisation from your canton of residence.

The hospital contribution is CHF 15 per day and covers part of the cost of the stay. The insurer does not count the day of discharge or days of leave. Children up to 18, young adults up to 25 in education and women in maternity do not pay it.

Legal basis

Under Art. 25 para. 2 let. e of the Federal Health Insurance Act (KVG), basic health insurance covers the hospital stay according to the standard of the general ward. Art. 39 KVG only admits hospitals that comply with cantonal planning and are on a Hospital List. Art. 41 para. 1bis KVG gives you free choice among the listed hospitals of the canton of residence and the canton where the hospital is located, but limits reimbursement to the tariff of the canton of residence; para. 3 and 3bis govern the exceptions for medical reasons.

Art. 49 para. 1 KVG requires performance-related flat rates for inpatient treatment, generally flat rates per case based on uniform structures across Switzerland. Art. 49a KVG divides the reimbursement between the canton and the insurer; under para. 2ter, the cantonal share is at least 55%. What counts as inpatient is defined in Art. 3 of the Ordinance on Cost Calculation and Service Recording in Health Insurance (VKL). The hospital contribution is governed by Art. 64 para. 5 KVG; the amount of CHF 15 per day and the exemptions are set out in Art. 104 of the Health Insurance Ordinance (KVV).

Example: five nights in hospital

Thomas, 45, has a deductible of CHF 1,000 and no costs so far this year. He is admitted to a listed hospital in his canton of residence on a Monday and discharged on Saturday. Let us assume that the insurer bills him for CHF 6,000 for this stay.

You pay the deductible and the retention fee only once per calendar year, no matter how many hospital stays or doctor’s visits you have.

What this means for you

Before a planned procedure, clarify three points:

1. Is the hospital on a Hospital List of your canton of residence or of the canton where it is located? Only then does basic health insurance pay.
2. Has the cost approval been given? Ask the hospital or the insurer, especially for a hospital in another canton. You can read more about this under cost approval.
3. Which ward do you want? Basic health insurance pays for the general ward. If you want a semi-private or private ward, you need a supplementary insurance that is in place before the procedure.

For an expensive year, calculate with the maximum: deductible plus CHF 700 retention fee plus CHF 15 per day in hospital. If a procedure is foreseeable for next year, a lower deductible may be cheaper; your notice must reach the insurer by 30 November (see deadlines). You can compare premiums and deductibles in the premium calculator, and you can find data on the insurers under health insurers.

Common mistakes

• Confusing outpatient and inpatient. A day operation without an overnight stay is not a hospitalisation; no hospital contribution is charged for it either.
• Going to a hospital in another canton without checking. Without a medical reason, basic health insurance pays at most the tariff of the canton of residence.
• Expecting a semi-private ward. Basic health insurance only covers the general ward.
• Thinking the hospital contribution is a mistake. It is added to the deductible and retention fee and is provided for by law.
• Forgetting accident insurance. After an accident, the UVG insurer pays if you are insured through your employer. Report the accident there.