Nursing home: what health insurance pays and what you pay yourself

Three cost blocks, three payers

A place in a nursing home costs more than many people expect, and your health insurer only pays part of it. The home’s invoice consists of three blocks that are financed differently:

The division of care costs is called financing of long-term care. It has applied since 2011 and protects you against unlimited care costs. Board and support are not part of it. The home sets these charges.

Step by step: before and after moving into a care home

1. Ask for the schedule of charges. Ask the home for its schedule of charges, broken down into board, support and care for each care level. This is the only way to see what you pay yourself.
2. Have your care needs assessed. The home determines your care needs in minutes per day. The health insurer’s contribution depends on this. The classification is adjusted if your needs change.
3. Check recognition. Your health insurer only pays nursing homes that are on the canton’s list of nursing homes (Art. 39 para. 3 of the Federal Health Insurance Act, KVG). Ask before you sign a contract.
4. Register for supplementary benefits within six months. If your pension and assets are not enough for the care home costs, register with your canton’s supplementary benefits office. Within six months of moving in, entitlement applies from the month you moved into the home (Art. 12 para. 2 of the Federal Act on Supplementary Benefits, ELG).
5. Check the helplessness allowance. If you have needed constant help with everyday activities for at least six months, you may also receive a helplessness allowance from old-age and survivors’ insurance (AHV) (Art. 43bis AHVG).
6. Check your deductible. The insurer also applies the deductible and retention fee to its contribution towards care in the home (Art. 64 para. 2 KVG). A lower deductible applies from 1 January and must be notified to the insurer by 30 November. The deadline calculator shows the dates.
7. Read your supplementary insurance. Whether supplementary insurance pays anything towards board, support or care in the home is set out in its general terms and conditions. What counts is the general terms and conditions and the information from your insurer.

The legal rules in detail

What your health insurer pays

Basic health insurance makes a contribution towards care services provided on the basis of proven care needs, on an outpatient basis or in a nursing home (Art. 25a para. 1 KVG). In a nursing home, it reimburses the same services as for care at home (Art. 50 KVG). Care services are measures of assessment, advice and coordination, examination and treatment, and basic care (Art. 7 para. 2 of the Health Care Benefits Ordinance, KLV). The Federal Council sets the contributions in francs, graded according to care needs (Art. 25a para. 4 KVG). Your insurer pays for medical treatment and medicines prescribed by a physician in the home according to the usual rules of basic health insurance (Art. 25 KVG).

How much you pay towards care

Of the care costs not covered by any social insurance, at most 20 % of the highest care contribution may be passed on to you (Art. 25a para. 5 KVG). The highest contribution in a nursing home is CHF 115.20 per day; your share is therefore capped at CHF 23.04 per day, regardless of your care level. The cantons regulate residual financing and may charge less. The canton where you are resident is responsible; moving into a home does not create a new responsibility. If your canton of residence cannot find a place nearby when you move into a home, it covers residual financing according to the rules of the canton in which the home is located, and does so indefinitely (Art. 25a para. 5 KVG).

As with any benefit, the deductible and a 10 % retention fee apply to the insurer’s contribution, with the retention fee capped at CHF 700 per year (Art. 64 para. 2 KVG, Art. 103 para. 2 KVV). You do not pay the hospital contribution of CHF 15 per day in a nursing home; it only applies to hospital stays (Art. 64 para. 5 KVG, Art. 104 KVV).

After a hospital stay

If a physician and a nurse in hospital prescribe acute and transitional care, the health insurer and the canton of residence pay for it for a maximum of two weeks according to the rules of hospital financing (Art. 25a para. 2 KVG). After that, the normal financing of long-term care applies.

Care at home as an alternative

Basic health insurance also contributes to care provided by nursing care at home (Spitex) or independent nurses, with contributions of CHF 52.60 to CHF 76.90 per hour depending on the type of service (Art. 7a para. 1 KLV). It does not pay for household help and support at home. Supplementary benefits additionally reimburse the costs of help, care and support at home as sickness costs (Art. 14 para. 1 ELG).

Figures: health insurer contributions in a nursing home

The Health Care Benefits Ordinance sets 12 levels (Art. 7a para. 3 KLV). Each level covers 20 minutes of care per day and increases the contribution by CHF 9.60.

The table shows every second level; the intermediate levels are CHF 9.60 higher in each case. Your own share of the care costs is at most CHF 23.04 per day at every level, or at most CHF 8,409.60 over a year (365 days).

Sample calculation: one month in a nursing home

Example with fictitious people. Hans, 84, has been living in a recognised nursing home since March. The assessment shows care needs of 150 minutes per day, i.e. the level of 141 to 160 minutes. The home’s charges are assumed; his canton charges the statutory maximum share.

If Hans has net assets of less than CHF 100,000, the supplementary benefits office checks his entitlement to supplementary benefits. If his assets are higher, he initially pays the shortfall from his assets. You can use the deductible calculator with the premiums in your municipality to work out which deductible is cheaper for him in the home; with costs of this size, the deductible is used up in any case.

Supplementary benefits in a care home

For people who live in a home permanently or for longer than three months, supplementary benefits are calculated differently than at home. They recognise as expenses the daily rate for the days billed and an amount for personal expenses set by the canton (Art. 10 para. 2 ELG). The cantons may limit the daily rate that is taken into account, but must ensure that a stay in a recognised nursing home does not, as a rule, make a person dependent on social assistance. For basic health insurance, there is also the flat-rate amount equal to the cantonal or regional average premium, at most the actual premium (Art. 10 para. 3 let. d ELG).

Other rules that become important in a care home:

• Asset threshold: With net assets of CHF 100,000 or more, there are no supplementary benefits; for married couples, the threshold is CHF 200,000 (Art. 9a ELG).
• Use of assets: For people in a care home, the cantons may set a higher share of assets to be used up, at most one fifth (Art. 11 para. 2 ELG).
• Married couples: If one spouse lives in a care home, supplementary benefits calculate entitlement separately for each of them (Art. 9 para. 3 ELG).
• Short stays: A temporary stay in a home of at most 3 months is reimbursed as sickness costs; if it lasts longer, supplementary benefits are calculated retroactively from the date of entry according to the care home rules (Art. 14 para. 1 ELG).
• Repayment: After death, supplementary benefits received lawfully are repaid from the estate insofar as it exceeds CHF 40,000 (Art. 16a ELG).

The article Premium subsidies and supplementary benefits explains how supplementary benefits and premium subsidies interact in retirement. You will find the cantonal rules on subsidies under Premium subsidy.

Special cases

Helplessness allowance

The AHV helplessness allowance is paid to people who receive their full old-age pension or supplementary benefits and are severely, moderately or slightly helpless. It amounts to 80 %, 50 % or 20 % of the minimum old-age pension. In a care home, there is no allowance for slight helplessness (Art. 43bis AHVG). It is paid monthly (Art. 43bis para. 3 AHVG) and helps to cover the care home charges.

Care home in another canton

Your previous canton of residence remains responsible for residual financing of care (Art. 25a para. 5 KVG). When you move into the home, clarify with your insurer which place of residence applies to your basic health insurance premium. The premium calculator shows insurers’ premiums in each place, and key figures and contact channels are in the health insurer profiles.

Supplementary insurance

Basic health insurance pays nothing towards board and support. Whether supplementary insurance provides contributions towards care, support or hotel services in the home is set out solely in its general terms and conditions. Supplementary benefits do not take supplementary insurance premiums into account (Art. 10 para. 3 let. c ELG).

Common mistakes

• Assuming that health insurance pays for the care home. It only pays a contribution towards care; you bear board and support yourself.
• Registering for supplementary benefits too late. Only if you register within six months of moving into the home does entitlement apply retroactively from the month you moved in.
• Accepting more than CHF 23.04 per day for care. Your share of the care costs not covered may not be higher; board and support must be shown separately.
• Keeping a high deductible without doing the maths. With costs at care home level, any deductible is used up; compare the premium saving with the difference in deductibles.
• Giving away assets before moving into a care home. Supplementary benefits continue to take assets you have given up into account (Art. 9a para. 3 ELG).

You will find all topics relating to retirement in the section Retirement and old age. If you are planning to spend your retirement abroad, the article Pensioners abroad explains the health insurance rules.