Basic insurance covers the same care everywhere. What you choose when you take it out is therefore not cover at all, but the way you pay for part of it yourself: the deductible and the model.
What you pay yourself, and up to what point
Cost-sharing has two layers. First the deductible, a fixed amount per calendar year that you pay alone; then the co-payment, which is 10 per cent of the costs above the deductible. The ordinary deductible for an adult is 300 francs per calendar year.
The co-payment is capped. The ordinance sets its annual maximum at 700 francs for adults and 350 francs for children. A year of heavy treatment therefore costs you at most the deductible you chose, plus that cap, plus the contribution towards hospital stay costs.
A low deductible or a high one
Besides the ordinary 300 francs, the law provides optional deductibles for adults, from 500 francs to 2,500 francs, in steps of 500 francs. The higher the deductible, the lower the premium — but within fixed limits, not freely.
The ordinance caps the rebate in two ways. The premium reduction may not exceed 70 per cent of the cost-sharing risk the insured person takes on by choosing a higher deductible. And across all special forms of insurance together, the premium may never fall below 50 per cent of the ordinary premium.
No authority publishes a threshold above which a high deductible "pays off". What the Federal Office of Public Health does say is blunt: if you choose a high deductible, you must be able to pay that amount yourself if you fall ill. It is a question of cash before it is a calculation.
The models do not change the benefits
The models sold as family doctor, HMO or telemedicine all rest on the same legal basis: the insured person may, by agreement with the insurer, limit their choice to the providers the insurer designates. The law adds a guarantee that is often forgotten: the benefits the law makes compulsory are guaranteed in any case. The FOPH puts it plainly on its side, saying compulsory health insurance offers every insured person the same catalogue of benefits.
The matching rebate must reflect real differences in cost, demonstrated by figures established over at least five accounting years. Without that demonstration, premiums for these models may be at most 20 per cent below those of ordinary insurance. The 50 per cent floor applies here too.
What you accept in exchange is a constraint on the route: going first to the designated doctor or service. If seeing a specialist directly matters to you, that is the point to look at, not the size of the rebate.
When you can change, and in which direction
The two directions do not follow the same rules. A higher deductible may only be chosen for the beginning of a calendar year. Moving to a lower one is only possible for the end of a calendar year, with the notice the law requires.
Changing insurer during the year, where that is allowed, does not reset the choice: the deductible you chose is kept, and the deductible and co-payment already billed are taken into account by the new insurer. You do not start again from zero in the middle of the year.
Children and families
For children, no deductible is charged and the maximum co-payment is halved. Optional deductibles exist all the same, from 100 to 600 francs. The insurer also sets a lower premium for children and young adults than for other insured people.
Where several children of the same family are insured with the same insurer, the law caps their joint cost-sharing, so that siblings do not pay as many deductibles as the family has children.
What to look at before deciding
- The amount you can find in a year without difficulty, deductible and co-payment together.
- Treatment already planned: a known course of care changes the arithmetic, and a pregnancy removes part of it.
- The constraint of the model, that is, who you agree to go through before a consultation.
- The date: a deductible can only be raised on 1 January and only lowered for the end of a calendar year.
These rules are federal and apply in every canton. What differs from one canton and one insurer to another is the premium — not what you get in return.