Does Swiss health insurance pay for dental hygiene?

What basic health insurance pays

Basic health insurance does not pay for ordinary dental hygiene. Dental treatment is an exception under the Federal Health Insurance Act (KVG): Art. 31 KVG only allows it if it is required because of a severe, unavoidable disease of the masticatory system or a severe general illness, if it is needed to treat such a general illness, or if it treats an accident. Regular teeth cleaning, by contrast, serves to prevent tooth decay and gum inflammation, and these are considered avoidable.

Dental hygiene does not get into basic health insurance through prevention either. Art. 26 KVG only covers certain check-ups and preventive measures, and the corresponding list in Art. 12–12e of the Health Care Benefits Ordinance (KLV) includes neither teeth cleaning nor the annual dental check-up.

In these exceptional cases, it is not dental hygiene as such that is insured, but the dental treatment of the disease. Your insurer decides case by case whether teeth cleaning is part of it. Ordinary periodontitis in adulthood is not on the list in Art. 17 KLV.

Who bills also matters: dental services are only billed to basic health insurance by dentists who are admitted for services under Art. 31 KVG (Art. 42 KVV). The list of service providers in Art. 35 para. 2 KVG does not name dental hygienists as a separate professional group.

What supplementary insurance pays

For ordinary dental hygiene, you need voluntary dental insurance or a supplementary outpatient insurance with a dental or prevention module. Both are governed by the Insurance Contract Act (ICA); the law does not prescribe any contribution to teeth cleaning. Each insurer sets out in its general terms and conditions:

• whether dental hygiene is covered at all or only treatments such as fillings,
• what percentage of the invoice it pays and up to what annual amount,
• how many sessions per calendar year count,
• whether teeth cleaning is covered with a dental hygienist, at the dental practice or both,
• whether a waiting period applies.

For dental insurance, the insurer may ask health questions before you sign and request a dental report; you must answer the questions truthfully (Art. 4 ICA). Because dental hygiene recurs every year and its price is easy to plan, a contract is only worth it if the insurance’s annual contribution is higher than its premium. We are building a benefits comparison of supplementary products under Supplementary insurance; the health insurer profiles show which insurer offers which products. What counts is always the general terms and conditions and the information from your insurer.

Conditions

• No covered case, no basic health insurance: Without a disease under Art. 17–19 KLV, basic health insurance does not pay for teeth cleaning, not even with a referral from the dentist.
• Cost approval for general illnesses: If the dental treatment is linked to a severe general illness, your insurer only pays with special prior cost approval (Art. 18 para. 2 KLV). Submit a cost estimate beforehand.
• Deductible and retention fee: If basic health insurance covers a dental treatment, it counts towards the deductible (Franchise), after which a 10 % retention fee applies up to CHF 700 per year, or up to CHF 350 for children (Art. 64 KVG, Art. 103 KVV). Ordinary teeth cleaning does not count towards the deductible because basic health insurance does not cover it.
• Supplementary insurance according to contract: Dental insurance only pays what its general terms and conditions provide for, often only when you submit the original invoice and up to the annual limit. Once the limit is reached, you pay the rest yourself.
• Supplementary benefits: If you receive annual supplementary benefits, the canton reimburses documented costs for dental treatment (Art. 14 para. 1 let. a ELG). It may limit reimbursement to the expenses needed for cost-effective and appropriate treatment (Art. 14 para. 2 ELG). Check with your canton’s office responsible for supplementary benefits beforehand whether dental hygiene is included.

Sample calculation

Example with fictitious people, assumed invoice amounts and a contract example. Nina is 34 and goes to dental hygiene twice a year. Each session costs an assumed CHF 160.00. She has dental insurance which, in the contract example, covers 50 % of the costs, up to CHF 300 per calendar year. She has no disease under Art. 17–19 KLV.

Whether the contract pays off for Nina depends on the premium: if she pays more than CHF 160 a year for the dental insurance and has no other dental treatment, the contract costs her more than it pays back. The calculation changes if the insurance also contributes to a filling or a crown in the same year.

You do not save on basic health insurance through dental hygiene, but through your deductible and insurance model. You can work out the break-even point between a low and a high deductible in the deductible calculator.

How to proceed

1. Read the general terms and conditions: Check in the terms of your dental or supplementary outpatient insurance whether dental hygiene is covered, at what rate and how often per year.
2. Plan your appointment: If you are already close to the annual limit, it may be worth moving a session to the next calendar year. Whether the treatment date or the invoice date counts is set out in the general terms and conditions.
3. Submit the invoice: The practice usually sends the invoice to you (tiers garant). Submit it to your supplementary insurance.
4. Check for an exceptional case: If you are due to have chemotherapy, radiotherapy or a heart valve replacement, ask your physician and your dentist whether dental restoration is needed beforehand, and obtain your insurer’s approval.

Common mistakes

• Submitting dental hygiene to basic health insurance. It pays nothing and does not count the invoice towards the deductible either.
• Assuming every dental insurance covers teeth cleaning. Some products only cover treatments such as fillings; others limit the number of sessions.
• Looking only at the percentage. A high reimbursement rate with a low annual limit pays little if you have expensive treatment in the same year.
• Not including the premium in the calculation. If the contract costs more than it pays back for predictable teeth cleaning, you pay less by covering dental hygiene yourself.

What else basic health insurance covers at the dentist is explained on the page Dentist, and the costs of braces on the page Braces. You will find more terms in the glossary entry dental costs, and all benefits in the overview What does health insurance cover?.