Does health insurance pay for Spitex home care?

What basic health insurance pays towards Spitex

Basic health insurance does not pay a full tariff for nursing care at home, but a fixed contribution per hour (Art. 25a para. 1 of the Federal Health Insurance Act, KVG, Art. 7a of the Health Care Benefits Ordinance, KLV). Art. 7 para. 2 KLV lists exhaustively which services are covered. The term Spitex refers to nursing care outside hospital provided by approved nurses and organisations, whether non-profit or private.

Billing is in units of 5 minutes, with at least 10 minutes per visit (Art. 7a para. 2 KLV). The contributions are the same for self-employed nurses and Spitex organisations. They usually do not fully cover the actual nursing costs. The difference is called residual financing and is the responsibility of the canton (Art. 25a para. 5 KVG); the canton itself decides how to share it with the municipalities. The glossary entry financing of long-term care explains how the insurer, the canton and you interact.

Your share of the nursing costs

In addition to the normal co-payment with deductible and retention fee, the canton may pass part of the uncovered nursing costs on to you: at most 20 % of the highest care contribution set by the Federal Council (Art. 25a para. 5 KVG). For nursing care at home, according to the FOPH this is at most CHF 15.35 per day. A majority of cantons charge less for care at home. You can find out how much it is where you live from the Spitex organisation or your municipality.

Acute and transitional care after hospital

If the doctor and nurse in hospital order nursing care on discharge, a special rule applies: acute and transitional care is paid by basic health insurance and the canton of residence for at most two weeks under the rules of hospital financing (Art. 25a para. 2 KVG). The canton pays at least 55 % (Art. 7b para. 1 KLV). After that, nursing care at home continues under the normal hourly contributions.

What is not included

Cleaning, shopping, cooking, laundry, meals on wheels, accompaniment and companionship are not nursing services. Basic health insurance does not pay for this household help, even if the same Spitex organisation provides it. It is invoiced separately at the organisation’s rates.

What supplementary insurance pays

Voluntary supplementary outpatient insurance can step in where basic health insurance stops. It is governed by the Insurance Contract Act (ICA); the act does not prescribe any minimum cover for Spitex or household help. What the general terms and conditions typically regulate:

• whether and how much the insurer pays towards household help, often as an amount per day with an annual limit,
• whether a hospital stay must precede it or whether a doctor’s confirmation is enough,
• whether only approved Spitex organisations count or private providers too,
• whether supplementary hospital insurance pays a contribution towards care at home instead of a hospital day.

Supplementary insurance may not cover the deductible and retention fee of basic health insurance (Art. 64 para. 8 KVG). We are building a comparison of supplementary products under Supplementary insurance. What counts are always the general terms and conditions and the information from your insurer.

Supplementary benefits

If you receive supplementary benefits to old-age and survivors’ insurance (AHV) or disability insurance (IV), the canton additionally reimburses proven costs for help, nursing and care at home, including those not paid by basic health insurance (Art. 14 para. 1 let. b of the Federal Act on Supplementary Benefits, ELG). You submit the bills to your canton’s supplementary benefits office.

Conditions

• Approved service providers: Only nurses under Art. 49 of the Health Insurance Ordinance (KVV) and organisations for nursing care and help at home under Art. 51 KVV can bill basic health insurance. Among other things, organisations need a cantonal licence and a cantonal service mandate. A private carer without this approval cannot bill your health insurer.
• Needs assessment: The basis of all billing is the assessment of needs by a nurse, together with you or your relatives, on a standard form showing the expected time required (Art. 8a KLV).
• Doctor’s order: Treatment care under Art. 7 para. 2 let. b KLV is only available on a doctor’s order or on a doctor’s instructions, for at most nine months; renewal is possible (Art. 8 para. 2 and 4 KLV). For acute and transitional care, the order is valid for at most two weeks. Anyone receiving a helplessness allowance for moderate or severe helplessness has an open-ended order for the related services (Art. 8 para. 3 KLV).
• Without an order: Since 01.07.2024, the nurse may provide assessment, advice and basic care without a doctor’s order (Art. 7 para. 4 KLV). A new needs assessment is then required after nine months at the latest (Art. 8a para. 8 KLV).
• Review: If the needs assessment provides for more than 60 hours of nursing care per quarter, the insurer’s medical adviser can review it (Art. 8c KLV). The ordinance does not generally require prior cost approval for Spitex.
• Deductible and retention fee: The insurer’s contribution first counts towards the deductible (Franchise); after that, a 10 % retention fee applies up to at most CHF 700 per year, CHF 350 for children (Art. 103 KVV).
• Other insurance first: After an accident, accident insurance pays for nursing care at home ordered by a doctor and provided by approved nurses and organisations (Art. 18 of the Accident Insurance Ordinance, UVV). Basic health insurance only steps in if there is no accident insurance.

Sample calculation

Example with fictitious people. Walter is 79 years old and lives alone. After an illness, his GP orders treatment care for four weeks, 20 minutes a day. In addition there are 40 minutes of basic care a day and, at the start, a one-hour needs assessment. Walter has a CHF 300 deductible and no other medical costs so far this year. The contributions are the statutory rates under Art. 7a KLV, and the patient contribution is the maximum according to the FOPH.

If you need Spitex over a longer period, you usually reach your deductible early in the year. You can calculate how a lower or higher deductible affects your annual costs in the deductible calculator; you notify a lower deductible by 30 November for the following year, and all dates are listed under Deadlines.

How to proceed

1. Arrange it early: Have Spitex organised before you leave hospital, via the hospital’s social services or via your GP.
2. Clarify approval: Ask the organisation whether it bills basic health insurance, and have nursing care and housekeeping itemised separately.
3. Keep an eye on the order: Note the expiry date of the doctor’s order and ask the doctor for a renewal in good time.
4. Ask about the cantonal contribution: Your municipality or the Spitex organisation will tell you how high the patient contribution is for you.
5. Check financial help: If your income is not enough, check supplementary benefits and the premium subsidy.

Common mistakes

• Assuming the insurer pays for everything Spitex does. Basic health insurance pays for nursing care, not for housekeeping or companionship.
• Letting the order expire. Without a valid doctor’s order, the insurer does not have to pay for treatment care.
• Using private carers without approval. You cannot submit their bills to basic health insurance.
• Overlooking the patient contribution. It comes on top of the deductible and retention fee and appears on a separate bill from the canton, municipality or organisation.

The benefits of basic health insurance are the same with all health insurers; you will find key figures and contact details in the health insurer profiles. The other pages of the overview What does health insurance cover? explain what happens after hospital with rehabilitation and when cost approval is needed.