Financing of long-term care

What is the financing of long-term care?

The financing of long-term care is the rule that determines how the costs of long-term care are shared. It applies to care at home by Spitex or self-employed nurses, to day and night care facilities and to care in a nursing home. Unlike medical treatment by a doctor, the health insurer does not cover the costs of care in full. It pays a fixed contribution, the amount of which the Federal Council sets in francs.

Three parties share the costs of care: the health insurer with its contribution, the person receiving care with a limited share, and the canton of residence with the residual financing. Depending on the canton, the municipalities bear all or part of this share. This is why it is also called the “residual financing of care”; in German the whole system is known as Pflegefinanzierung.

The distinction is important: the financing of long-term care only covers care services, that is assessment and advice, examination and treatment, such as giving medicines or dressing wounds, and basic care such as help with washing and dressing. Accommodation, meals, support and housekeeping are not included. Residents pay these costs themselves, with the help of supplementary benefits if needed.

A special rule applies to acute and transitional care after a hospital stay. For at most two weeks, it is paid for by the insurer and the canton under the rules of hospital financing, without the limited personal share of the financing of long-term care; the deductible and retention fee do, however, apply.

How it works

The starting point is the assessment of care needs. A nurse determines what care is needed and how much time it takes. The care must be prescribed by a doctor or, in the cases specified by the Federal Council, determined by a nurse.

At home and with self-employed nurses, the health insurer pays contributions per hour, graded according to the type of service:

Billing is in units of 5 minutes, with a minimum of 10 minutes. In a nursing home the insurer pays per day, graded in 12 levels according to daily care needs: from CHF 9.60 for up to 20 minutes to CHF 115.20 for more than 220 minutes. Each level covers 20 minutes and increases the contribution by CHF 9.60.

The insurer’s contribution is a benefit of basic health insurance. The deductible and retention fee therefore apply as for other benefits. In addition, the canton may pass on to you a share of the uncovered care costs, at most 20% of the highest federal care contribution. Each canton decides how much of this it actually charges. The public sector covers the rest of the care costs. The canton in which you are resident is responsible; moving into a nursing home does not change this.

Legal basis

Art. 25a para. 1 KVG obliges basic health insurance to contribute to care services provided on the basis of a demonstrated need for care, on an outpatient basis, in day or night care facilities or in a nursing home. Under Art. 25a para. 4 KVG, the Federal Council sets the contributions in francs, differentiated according to care needs. Art. 25a para. 5 KVG limits the insured person’s share of the care costs not covered by social insurance to at most 20% of the highest care contribution and assigns the residual financing to the cantons: the canton of residence is responsible, for outpatient care the rules of the canton where the service provider is located apply, and a stay in a nursing home does not create a new responsibility. Acute and transitional care is governed by Art. 25a para. 2 KVG.

The amounts are set out in Art. 7a of the Health Care Benefits Ordinance (KLV): para. 1 sets the hourly rates for Spitex and nurses, para. 2 the billing in 5-minute units, para. 3 the 12 daily levels in a nursing home, and para. 4 day and night care facilities. Art. 7 KLV describes which services count as care. For nursing home residents receiving supplementary benefits, Art. 10 para. 2 ELG recognises the daily rate as an expense.

Example: one month in a nursing home

Ruth is 86 and lives in a nursing home. The assessment shows care needs of 130 minutes per day; this corresponds to the level of 121 to 140 minutes, with an insurer contribution of CHF 67.20 per day. Assume that the nursing home reports care costs of CHF 150 per day and that the canton charges the highest personal share allowed by law.

Over a year, the maximum personal share of care costs in a nursing home is CHF 8,409.60 (365 days × CHF 23.04). How much it actually is depends on the canton.

What this means for you

If your family is planning a move into a nursing home or the use of Spitex, ask the nursing home or the Spitex service about the classification of care needs and how the costs are split. The bill should show care, accommodation and support separately. Only the care part is covered by the financing of long-term care.

The amount of the personal share and the rules for residual financing are set by your canton of residence; the municipality or the cantonal health department can give you information. Find out early whether supplementary benefits might apply.

For the health insurer, the following applies: the care contributions are the same at all insurers. The differences are in the premium. Especially with regular care costs, it is worth checking your deductible and insurer: if you expect high costs, the lowest deductible is usually the better option. You can compare in the premium calculator, and you will find the insurers’ key figures in the health insurer profiles. For the last phase of life, see also palliative care.

Common mistakes

• Equating nursing home costs with care costs. The financing of long-term care only covers care. You pay for accommodation, meals and support separately.
• Thinking the personal share is unlimited. Your share of the uncovered care costs is capped by law at 20% of the highest federal contribution, in a nursing home CHF 23.04 per day.
• Forgetting the deductible. The insurer’s contribution to care is a normal benefit of basic health insurance, with deductible and retention fee.
• Asking the wrong canton. The canton of residence is responsible for residual financing, even if the nursing home is in another canton.

How we calculate amounts and examples is explained under How we calculate.