Nursing home

What is a nursing home?

A nursing home is a facility where people live who need care, medical support or rehabilitation on a long-term basis. The Health Insurance Act describes it in exactly these terms: institutions, facilities or their departments “that provide care and medical support as well as rehabilitation for long-term patients”. In everyday language people also speak of an old people’s and nursing home or a residential centre for older people. For the health insurer, the name does not matter; what counts is whether the facility is licensed as a nursing home and is on the canton’s list of nursing homes.

A nursing home is clearly distinguished from a hospital. In hospital you are treated for an acute illness until you can go home or move to another facility. In a nursing home you live, often for years. This distinction determines who pays for what: in hospital, the insurer and the canton pay a case-based flat rate that covers almost everything. In a nursing home, the insurer only pays a contribution towards care, and you bear a noticeable part yourself.

There are intermediate forms between hospital and nursing home. Acute and transitional care after a hospital stay lasts at most two weeks and is paid for under the rules of hospital financing. If you continue to live at home, you receive care from Spitex, and the insurer pays for it on the same principles as in a nursing home.

How it works

The costs of a stay in a nursing home consist of three parts. Only one of them concerns the health insurer.

The amount of the insurer’s contribution depends on your care needs. The nursing home assesses them with a recognised instrument and classifies you in minutes of care per day. The Health Care Benefits Ordinance sets 12 levels: for up to 20 minutes per day the insurer pays CHF 9.60, for each further 20 minutes CHF 9.60 more, and for more than 220 minutes CHF 115.20 per day. The contribution is the same throughout Switzerland and does not depend on which insurer you are with.

What care actually costs is usually more than the insurer’s contribution. For this difference there is a cap in your favour: you may be charged at most 20% of the highest insurer contribution. At CHF 115.20 that is CHF 23.04 per day. Any care costs beyond that which remain uncovered are paid by the canton as residual financing. The interplay of these three payers is called the financing of long-term care.

The ordinary co-payment of deductible and 10% retention fee also applies to the insurer’s contribution, as with every benefit of basic health insurance. Because the insurer’s contribution exceeds the deductible within a few weeks when care needs are high, many nursing home residents reach the maximum retention fee during the year.

The canton in which you lived before moving into the nursing home is responsible for residual financing. If you move into a nursing home in another canton, your previous canton of residence remains responsible. By law, a stay in a nursing home does not create a new responsibility.

Legal basis

Under Art. 25a para. 1 KVG, compulsory health insurance pays a contribution towards care services provided on the basis of a demonstrated need for care, on an outpatient basis or in a nursing home. Art. 50 KVG states that for a stay in a nursing home the insurer pays the same benefits as for outpatient nursing care. What counts as a nursing home is set out in Art. 39 para. 3 KVG; the requirements for hospitals apply by analogy, including cantonal planning and the list.

The Federal Council sets the amounts in francs under Art. 25a para. 4 KVG. This is implemented in Art. 7a para. 3 KLV with the 12 levels from CHF 9.60 to CHF 115.20 per day. Art. 25a para. 5 KVG limits your share of the uncovered care costs to at most 20% of the highest care contribution and assigns residual financing to the cantons. The co-payment of deductible and retention fee is governed by Art. 64 KVG. Board and support are not regulated in the KVG because they are not compulsory benefits.

Example: one month in a nursing home

Rosa is 86 and has lived in a nursing home for a year. The assessment shows care needs of 130 minutes per day. The amounts below are the statutory values of the KLV, calculated for 30 days. Board and support are not included because each nursing home has its own rates.

Item	per day	30 days
Health insurer’s contribution (level 121–140 minutes)	CHF 67.20	CHF 2,016.00
Rosa’s share of the uncovered care costs (maximum)	CHF 23.04	CHF 691.20
Residual financing by the canton of residence	rest of the care costs	rest of the care costs

If Rosa’s care needs later rise to more than 220 minutes, the insurer pays CHF 115.20 per day. Her own share of the care costs remains at most CHF 23.04 per day, because the cap does not depend on the level.

What this means for you

In a nursing home, basic health insurance covers all care services provided for by law, in the same way at every insurer. When choosing an insurer, the main factors are therefore the premium and the service. Many nursing home residents have high healthcare costs; for them a low deductible is usually cheaper. The premium calculator shows the premiums of all insurers for your municipality, and under health insurers you will find key figures for each insurer.

Three questions help you before moving into a nursing home:

1. What care level is to be expected? The classification determines the insurer’s contribution. Ask the nursing home how it assesses care needs and how often it reviews them.
2. How high are the board and support rates? Ask for the schedule of rates. You pay these costs yourself.
3. Is the income enough? If your pension and assets do not cover the nursing home costs, you can apply for supplementary benefits. Apply early, as the assessment takes time.

Check your deductible too. A switch to the standard deductible of CHF 300 is only possible with effect from 1 January and must reach the insurer by 30 November. The dates are listed under deadlines.

Common mistakes

• Believing the health insurer pays for the nursing home. It only pays a contribution towards care. You bear the costs of board and support yourself.
• Wanting to take out supplementary insurance for care costs. Basic health insurance covers the statutory care services. Standard supplementary insurance does not pay board rates.
• Not checking the care level. If care needs increase, the classification must be adjusted, otherwise money for care is missing. Ask if the person’s condition changes.
• Keeping the high deductible. With high costs in a nursing home, a CHF 2,500 deductible costs you more every year than you save on the premium.
• Applying for supplementary benefits too late. Do not wait until your assets are used up. The supplementary benefits office of your canton will advise you.

How we prepare examples and figures is explained under How we calculate.