Does Swiss health insurance pay for a mammogram?

What basic health insurance pays

A mammogram is an X-ray examination of the breast. For health insurance, what counts is the reason it is done. Early detection without symptoms is part of prevention: basic health insurance only pays for it if the Health Care Benefits Ordinance (KLV) lists it (Art. 26 of the Federal Health Insurance Act, KVG; Art. 12d and 12e KLV). Investigating a suspected condition is a benefit in the event of illness (Art. 25 KVG); the conditions for this are set out in Annex 1 KLV.

Art. 64 para. 6 let. d KVG allows screening to be exempt from the deductible: the Federal Council may exempt benefits from nationally or cantonally organised prevention programmes from the deductible. The provision does not mention the retention fee. You therefore pay 10 % of the invoice, up to the annual maximum of CHF 700 for adults (Art. 103 para. 2 of the Health Insurance Ordinance, KVV). In the other cases, the normal co-payment applies: first the deductible, then a 10 % retention fee (Art. 64 para. 2 KVG).

How the programme works

The requirements for an early detection programme are set out in the Ordinance on Quality Assurance in Programmes for the Early Detection of Breast Cancer by Mammography (SR 832.102.4). A programme is run in an area defined by one or more cantons, by an organisation recognised by one or more cantons (Art. 2 and 3). The organisation invites women aged 50 and over in writing and informs them about the risk of breast cancer and the meaning of the result (Art. 5). You are entitled to a consultation and information session, which you can waive in writing (Art. 5 para. 2, Art. 6). Each image is read by two independent specialists, and a third time if their results differ (Art. 8).

Monitoring at increased risk

Separate requirements apply to women with a moderately or highly increased family risk of breast cancer. The risk is classified with a risk calculation model; for the category “highly increased risk”, genetic counselling under Art. 12d para. 1 let. f KLV is required first. Before the first examination, there is a comprehensive, documented information and counselling session. A certified breast centre is responsible for the indication, counselling and monitoring; the imaging may also be done by service providers who work with such a centre under a contract. For a different centre, you need the insurer’s specific cost approval in advance. Whether monitoring is appropriate for you is something you decide with your physician.

What supplementary insurance pays

Screening outside the rules of the KLV, for example before 50 without a reason, more often than every two years or without a programme, is paid for at most by supplementary outpatient insurance. It is governed by the Insurance Contract Act (ICA); the law does not require it to contribute to preventive check-ups. Whether and how much a product pays, at what intervals and with which service providers, is set out in the insurer’s general terms and conditions.

No supplementary insurance may cover the deductible and retention fee of basic health insurance (Art. 64 para. 8 KVG); so you also pay the retention fee for screening in a programme yourself. We are building a comparison of supplementary products under Supplementary insurance. What counts is always the general terms and conditions and the information from your insurer.

Conditions

• Age and interval: Screening is covered from the age of 50, every two years. Basic health insurance does not cover earlier screening, even in the same two-year rhythm.
• Programme: Cover and the exemption from the deductible only apply within a programme under SR 832.102.4. The KLV does not say which cantons run a programme; your cantonal health department can tell you.
• Medical referral: Monitoring at increased risk and diagnostic mammograms are ordered by a physician (Art. 26 KVG, Annex 1 KLV).
• Breast centre and cost approval: Risk monitoring is done through a certified breast centre; for a different centre, you need the insurer’s cost approval (Art. 12d para. 1 let. d KLV).
• Deductible and retention fee: For screening in a programme, only the 10 % retention fee; otherwise the deductible and retention fee.

Sample calculation

Example with fictitious people and assumed costs. Three women have a mammogram in the same year, each assumed to cost CHF 200.00; the actual amount depends on the tariff. All three have a CHF 2,500 deductible and no other healthcare costs in the year. The deductible and retention fee follow Art. 64 KVG, Art. 103 KVV and Art. 12e KLV.

If you are examined regularly because of an increased risk, you bear these costs through the deductible. The deductible calculator works out the break-even point between a low and a high deductible, and the premium calculator shows the premiums for each deductible. A lower deductible must reach your insurer by 30 November, see Deadlines.

How to proceed

1. Check for a programme: If you are 50 or older, ask your cantonal health department or your physician whether there is an early detection programme in your canton.
2. Book within the interval: Note the date of your last screening mammogram; the next one is covered after two years. You can store invoices and statements of benefits in your account.
3. Mention family risk: If breast or ovarian cancer occurs in your family, raise it with your physician; Art. 12d KLV applies to risk groups.
4. Check the invoice: The statement of benefits for a screening mammogram in a programme must not show a deductible, only the retention fee.

Common mistakes

• Thinking screening is free. The deductible does not apply, but the 10 % retention fee does.
• Going for screening outside the programme. Without a programme and without a reason, basic health insurance does not pay.
• Not waiting long enough. Basic health insurance does not cover screening before two years have passed.
• Leaving symptoms until the next screening. Investigating an urgent suspicion is a separate, covered benefit; discuss any changes with your physician.

Other early detection examinations are explained in the guides Does health insurance pay for check-ups and preventive examinations? and Does health insurance pay for a colonoscopy?. You will find all benefits in the overview What does health insurance cover?, and key figures for insurers in the health insurer profiles.