Understanding basic health insurance: rules, invoices, rights

What basic health insurance is: five basic rules

Basic health insurance, called “compulsory health insurance” in the law, is mandatory for everyone in Switzerland. It covers treatment for illness, maternity and, where no accident insurance pays, accidents (Art. 1a of the Federal Health Insurance Act, KVG). It is provided by many private insurers; there is no state-run single health insurance fund. Five rules shape the system:

Income plays no role in the premium; social balance comes from the cantons’ premium subsidies (Art. 65 KVG). Basic health insurance is strictly separate from voluntary supplementary insurance, which is governed by the Insurance Contract Act (ICA). The funds of basic health insurance may only be used for basic health insurance (Art. 5 let. f of the Health Insurance Supervision Act, KVAG).

This topic area explains how basic health insurance works in everyday life: what it pays for, how invoices are made up, what rights you have, where the premium comes from and which reforms are coming. How to switch insurer is covered in the topic area Switching health insurer, and how to save on premiums under Saving money.

What does basic health insurance pay for?

Basic health insurance pays for examinations and treatment used to diagnose or treat an illness and its consequences (Art. 25 para. 1 KVG). Every benefit must be effective, appropriate and cost-effective (Art. 32 para. 1 KVG). What is included in detail is laid down by the Federal Council and the Federal Department of Home Affairs in ordinances and lists, such as the Health Care Benefits Ordinance (KLV) and the List of Pharmaceutical Specialties (SL) for medicines. All benefits from A to Z are explained in the topic area What does health insurance cover?.

Medicines and generics

Basic health insurance pays for medicines prescribed by a doctor if they are on the List of Pharmaceutical Specialties, at most at the prices listed there (Art. 25 para. 2 let. b KVG). Normally, you pay a 10 % retention fee after the deductible. If your product costs at least 10 % more than the average of the cheapest third of products with the same active ingredient, the retention fee is 40 % (Art. 38a para. 1 KLV), unless the more expensive product is medically necessary (Art. 38a para. 7 KLV). How to avoid the higher retention fee and what applies to medicines not on the list is explained in Medicines and generics: 40 % retention fee and reimbursement in individual cases.

What you pay yourself

On top of the premium, you pay the deductible (Franchise) of CHF 300 to CHF 2,500 and a 10 % retention fee on the costs above it, at most CHF 700 a year for adults and CHF 350 for children (Art. 103 paras 1 and 2 of the Health Insurance Ordinance, KVV). What counts is the date of treatment, not the invoice date (Art. 103 para. 3 KVV). How to add up premium and co-payment to get your total cost is shown in What does health insurance really cost?.

How do you read a doctor’s invoice, and how do you get your money back?

Since 01.01.2026, doctors’ practices have billed outpatient services under the TARDOC tariff and around 300 outpatient flat rates; both replace TARMED (FOPH). On the invoice, TARDOC has tariff code 007 and a flat rate code 005, and a treatment is never billed under both. The amount is calculated as tax points multiplied by the cantonal point value. The invoice must contain the dates of treatment, the services in the detail of the tariff and the necessary diagnoses, and it must be understandable to you (Art. 59 KVV). If it goes directly to the insurer, you must receive a copy without having to ask (Art. 42 para. 3 KVG).

For basic health insurance benefits, no one may charge more than the tariff (tariff protection, Art. 44 para. 1 KVG). How to recalculate an invoice step by step is shown in Checking a TARDOC invoice. If you find services that did not take place or an amount that is too high, report this first to the practice and then to the insurer; how to proceed is described in Invoice too high? How to check and dispute it.

Tiers garant and tiers payant

There are two ways an invoice is paid. Under the tiers garant system (you pay and claim reimbursement), you owe the practice the invoice amount and are entitled to reimbursement from the insurer (Art. 42 para. 1 KVG). Under the tiers payant system (the insurer pays the provider directly), the practice sends the invoice directly to the insurer, and you receive a copy. No form is needed to claim reimbursement; the detailed invoice is enough (Art. 42 para. 6 KVG). The insurer deducts the deductible and retention fee and transfers the rest to you. You can submit invoices up to five years after the end of the month in which the benefit was due (Art. 24 para. 1 of the Federal Act on the General Part of Social Insurance Law, ATSG). A sample calculation with four invoices in one year is in the article Reimbursement claim form: how to get your money back.

What can you do if your insurer does not pay?

Request a written decision and lodge an objection. If the insurer does not agree with you, it must issue a written decision on request (Art. 49 para. 1 ATSG). You can lodge an objection to it with the insurer within 30 days; the procedure is free of charge (Art. 52 paras 1 and 3 ATSG). You can appeal against the decision on the objection to the Cantonal Insurance Court (Art. 56–60 ATSG).

Beforehand or in parallel, the Office of the health insurance ombudsperson can help. It is free of charge for insured persons and mediates with the insurer, but it cannot issue decisions and does not stop any deadlines: you must submit the objection yourself in time. How to check a refusal, which documents you need and when going to court is worthwhile is explained in Benefit refused: your rights, objection and ombudsperson.

How is the premium set, and who earns from it?

Each insurer’s premiums must cover the expected costs of its insured persons in the canton; the FOPH reviews them and refuses premiums that do not do so or that are inappropriately high above them (Art. 16 paras 3 and 4 KVAG). Premiums therefore rise because costs rise. In 2024, basic health insurance paid for benefits worth CHF 42.2 billion; in 2010, the figure was CHF 24.3 billion (FOPH). Doctors’ practices (22 %), medicines (22 %) and inpatient hospital treatment (19 %) together accounted for almost two thirds of costs in 2024. The average premium for 2026 is CHF 393.30 per month, 4.4 % more than in 2025 (FOPH). The cost drivers and how the new premium is set step by step are explained in Why do premiums rise every year?.

Profits for shareholders are not allowed in basic health insurance. Of every CHF 100 in premiums, an average of CHF 94.90 went to treatment, medicines and care in 2024 (FOPH, supervisory data). Administrative costs in 2024 amounted to CHF 1.7 billion, or CHF 193 per insured person per year. Surpluses go into the reserves. How to check your insurer’s figures is shown in Who earns from my premium?. You can find the key figures of each insurer, from reserves to administrative costs, in the profiles:

If an insurer becomes insolvent, the Common Institution under the Federal Health Insurance Act (Gemeinsame Einrichtung KVG) takes over the statutory benefits through its insolvency fund (Art. 18 para. 2 KVG, Art. 47–51 KVAG); the fund does not cover supplementary insurance. What this means for your insurance and your premium is described in What happens if my health insurer goes bankrupt?.

Moving house and losing your job: what changes in basic health insurance

Basic health insurance depends on where you live, not on your work. Two life events nevertheless have a direct effect.

Moving house. The premium depends on where you live: insurers grade premiums by canton and may grade them by premium region within a canton (Art. 61 paras 2 and 2bis KVG). Report your move to your insurer with the date and your new address. You can only switch insurer during the year because of the move if your insurer does not operate in your new place of residence (Art. 7 para. 3 KVG). An example shows how much the premium can change: in 2026, the median for adults with a CHF 300 deductible and accident cover was CHF 580.00 per month in Zurich and CHF 384.90 in Zug (FOPH). The procedure is explained in Reporting a move to your health insurer.

Losing your job. Your insurer, deductible and model stay the same, and you continue to pay the premium yourself. Your employer’s non-work-related accident insurance ends on the 31st day after your entitlement to salary ends (Art. 3 para. 2 of the Accident Insurance Act, UVG). If you receive unemployment benefit, you are then insured against accidents through Suva. Without unemployment benefit, you must notify your insurer within one month that it must cover accidents again (Art. 11 para. 2 KVV). What to do after losing your job is set out in Unemployed: what applies to your health insurance.

Which reforms are coming?

Basic health insurance is continually being adjusted. Uniform financing has been adopted; several other proposals are under discussion. The status on 25.09.2026:

EFAS: From 01.01.2028, the cantons will pay 26.9 % of the net costs of all basic health insurance benefits and premiums 73.1 % (FOPH). Today, the canton pays at least 55 % of inpatient hospital costs, while outpatient services are paid for by premiums alone (Art. 49a para. 2ter KVG). Benefits, deductible and retention fee stay the same.

Minimum deductible: The Federal Council proposes raising the standard deductible from CHF 300 to CHF 400 and then adjusting it automatically. For now, CHF 300 continues to apply (Art. 103 para. 1 KVV).

Emergency fee: The proposal would allow the cantons to add a surcharge of at most CHF 50 to the retention fee for each visit to a hospital emergency department without a referral. Currently, there is no emergency fee; the matter is back with the National Council.

E-GD: The electronic health record (E-GD) is to replace the electronic patient record (EPR). Under the proposal, every person would automatically receive a record, with the option to object. Today, a patient record only exists with your consent.

Two fundamental questions keep coming back in politics. One is the question of a public health insurer: voters rejected a single health insurance fund at federal level in 2007 and 2014; the state of the debate in Geneva and Vaud is set out in Single health insurance fund and public health insurer. The other is the flat per-person premium, in other words a premium that does not depend on income; what income-based premiums would mean is explained in Initiative for income-based premiums.

Common misconceptions

• “A more expensive insurer pays more.” No. All insurers pay exactly the statutory benefits (Art. 34 para. 1 KVG). You can only get more through supplementary insurance.
• “No insurer will take me with a pre-existing condition.” In basic health insurance, every insurer must accept you, without health questions (Art. 5 let. i KVAG).
• “The premium depends on income.” No. On a modest income, the canton’s premium subsidy helps; it is paid directly to the insurer.
• “The invoice date decides which year counts.” For the deductible and retention fee, what counts is the date of treatment (Art. 103 para. 3 KVV).
• “The ombudsperson stops the deadline.” No. You must submit an objection to a written decision yourself within 30 days.

Where to start?

1. You have received an invoice. Check it with Checking a TARDOC invoice and submit invoices with the reimbursement claim form.
2. Your insurer does not pay. Request a written decision and read Benefit refused before the 30 days run out.
3. Your premium has gone up. Read why premiums rise and compare the offers in your municipality in the premium calculator.
4. You are moving house or losing your job. The sections above give the reporting deadlines; the articles on moving house and unemployment take you through step by step.
5. You want to know what is changing. The reforms are in the table above, each with its status and date.