Treatment outside your canton

What is treatment outside your canton?

Treatment outside your canton (ausserkantonale Behandlung) is any treatment outside your canton of residence: an operation at a clinic in a neighbouring canton, physiotherapy where you work or a hospital stay after an accident on holiday. In basic health insurance, the term matters because Switzerland plans and finances its hospitals at cantonal level. Each canton keeps its own Hospital List and pays part of the hospital costs of its residents.

For cost coverage, you need to distinguish between two cases. Outpatient treatment at a practice, an outpatient clinic or in therapy is covered in the same way throughout Switzerland. Inpatient treatment with an overnight stay in hospital is possible outside your canton, but payment is limited to the tariff of your canton of residence.

These rules apply to basic health insurance under the Federal Health Insurance Act (KVG). Anything beyond that, such as the difference to a more expensive hospital or the semi-private ward, is only covered by supplementary insurance under the Insurance Contract Act (VVG).

How it works

Outpatient

You choose freely among the authorised service providers suitable for your treatment, regardless of the canton. Your insurer covers the costs according to the tariff that applies to the practice you choose. A restriction only applies if you have an insurance model with a restricted choice of service provider, such as a GP or HMO model; in that case, you must follow the rules of your model.

Inpatient

Since the introduction of the free choice of hospital, you can choose any hospital on the hospital list of your canton of residence or of the canton where the hospital is located (listed hospitals). The fee is shared between your canton of residence and your insurer: the canton pays at least 55%, the insurer the rest. Each canton sets this share at the latest nine months before the start of the year; more under cantonal share.

If you choose a listed hospital outside your canton without a medical reason, the canton and the insurer pay at most the tariff that applies at a listed hospital in your canton of residence for the same treatment. If the tariff at the hospital you chose is higher, you or your supplementary insurance pay the difference.

You have full cost coverage if there are medical reasons:

• Emergency: if you have to go to hospital outside your canton in an emergency, the canton and the insurer pay the full tariff of the treating hospital.
• Treatment not available: if the necessary treatment is not offered at any listed hospital in your canton of residence, the full tariff also applies. Except in an emergency, this requires authorisation from your canton of residence.

As always, the deductible, the retention fee and the hospital contribution of CHF 15 a day are added to the tariff costs. More about hospital stays under hospitalisation.

Legal basis

Art. 41 para. 1 KVG gives you a free choice among the authorised service providers for outpatient treatment; the insurer pays according to the tariff of the chosen provider. Art. 41 para. 1bis KVG allows you to choose, for inpatient treatment, among the listed hospitals of the canton of residence and of the canton where the hospital is located, and limits payment to the tariff of a listed hospital in your canton of residence. Under Art. 41 para. 3 KVG, the insurer and the canton of residence pay their share of the full fee if there are medical reasons; except in an emergency, authorisation from the canton of residence is required. Art. 41 para. 3bis KVG defines the medical reasons: an emergency or the treatment not being available in the canton of residence.

Art. 49a para. 2ter KVG requires each canton to set its share of the hospital fee at the latest nine months before the start of the year, at a minimum of 55%. Art. 39 para. 1 KVG governs the authorisation of hospitals through the cantonal hospital lists. Art. 104 of the Health Insurance Ordinance (KVV) sets the hospital contribution at CHF 15 a day.

Example: knee operation in a neighbouring canton

Sara is 52 years old, has only basic health insurance and has an operation at a listed hospital in the neighbouring canton without a medical reason. Hospital tariffs vary by hospital and canton and are not published centrally. The amounts in the table are therefore assumed figures to illustrate the legal rule; only the canton’s minimum share of 55% and the hospital contribution of CHF 15 a day are set by law.

What this means for you

For doctor’s appointments and therapies outside your canton, you do not need to do anything special, apart from following the rules of your insurance model. For planned hospital stays, a quick check is worthwhile:

1. Is the hospital on a hospital list? The list of your canton of residence or of the canton where the hospital is located must include it for your treatment. The cantonal health departments publish the lists.
2. Is there a difference to the tariff of your canton of residence? Ask your insurer before admission. You will find its contact details in the profiles under Health insurers.
3. Is there a medical reason? If the treatment is not offered in your canton, have the authorisation from your canton of residence obtained in advance, usually through the hospital or your doctor.
4. Do you need supplementary insurance? If you want to be able to choose freely among hospitals throughout Switzerland on a regular basis, supplementary hospital insurance with a choice of hospital throughout Switzerland covers the difference. You can compare offers in the supplementary insurance comparison.

Premiums for basic health insurance are not affected by this; you compare them in the premium calculator.

Common mistakes

• Confusing outpatient and inpatient. The tariff limit of your canton of residence only applies to inpatient treatment in hospital, not to visits to a practice.
• Assuming every hospital is covered. If the hospital is not on the hospital list of your canton of residence or of the canton where it is located, basic health insurance does not pay as it would for a listed hospital, except in an emergency.
• Forgetting the authorisation. For medical reasons other than an emergency, full coverage requires authorisation from your canton of residence.
• Hesitating in an emergency. Emergencies are fully covered at any hospital in Switzerland; the cantonal border plays no role.