What Does Basic Insurance Cover?

The principle: medical necessity

Swiss law does not cover everything — it covers what is medically necessary, effective, and economical. These three criteria (wirksam, zweckmässig, wirtschaftlich) are set out in the KVG and evaluated by the federal government. If a treatment meets all three, it must be covered by every approved insurer. This is why all KVG plans cover exactly the same treatments, regardless of which insurer you choose or which model you are on.

What is covered

The Leistungskatalog (catalogue of benefits) is comprehensive for standard medical care:

• GP consultations — all visits to your family doctor or, in the standard model, any licensed doctor directly
• Specialist appointments — via GP referral in most models; directly in the standard model
• Hospital stays — in the general ward (Allgemeinstation) of a public or approved hospital in your canton of residence. Treatment in a private room, or in a hospital outside your canton, is not covered unless medically necessary or via supplementary insurance
• Prescription medications — only drugs listed on the federal Spezialitätenliste; generic substitution is common and encouraged
• Laboratory tests and imaging — blood work, urine analysis, X-rays, MRI, CT scans, ultrasounds
• Physiotherapy — when prescribed by a doctor; the number of covered sessions varies and further sessions may require re-prescription
• Psychotherapy — sessions with a licensed psychotherapist working under the delegation model of a prescribing psychiatrist or, since 2022, directly with certified psychotherapists (Anordnungsmodell)
• Emergency treatment — in Switzerland and, up to twice the Swiss tariff rate, abroad. Emergency care is always covered regardless of your model
• Maternity care — all prenatal check-ups defined by the BAG (at least 7 appointments), ultrasounds, birth preparation courses, birth itself, and 8 weeks of postnatal care. No franchise or Selbstbehalt applies to maternity
• Preventive screenings — mammography (every 2 years for women 50–69), colorectal cancer screening (every 10 years from age 50), certain vaccinations from the national vaccination schedule
• Home nursing care (Spitex) — prescribed post-hospital home care
• Medically prescribed rehabilitation — following surgery or serious illness

What is NOT covered by basic insurance

These exclusions surprise many newcomers. If any of these matter to you, look into supplementary (VVG) insurance:

• Dental care — routine check-ups, fillings, root canals, crowns, extractions, and orthodontics. The only exception: dental treatment caused directly by a serious illness (e.g. cancer treatment affecting the jaw)
• Glasses and contact lenses — for adults. Children under 18 receive a contribution (CHF 180 per year in 2024 for corrections ≥ 3 dioptres)
• Purely cosmetic procedures — anything without medical necessity
• Gym memberships and wellness — even if a doctor recommends regular exercise
• Most alternative medicine — acupuncture, homeopathy, traditional Chinese medicine, and chiropractic (beyond initial mandatory coverage) are not in the KVG catalogue. Some supplementary plans cover them
• Private or semi-private hospital rooms — you pay the upgrade yourself, or through hospital supplementary insurance
• Treatment in another canton — unless it is the nearest appropriate facility in an emergency, or there is no equivalent treatment available in your canton
• Over-the-counter medications — paracetamol, ibuprofen, vitamins, and similar products you buy at a pharmacy without a prescription

Your share: how cost-sharing works

Even for fully covered treatments, you pay a share of the costs in two stages:

• Stage 1 — Franchise: You pay 100% of costs until you reach your chosen annual deductible (CHF 300–2,500 for adults). See Franchise explained.
• Stage 2 — Selbstbehalt: After your franchise is exhausted, you pay 10% of further costs up to CHF 700 per year. After that, insurance covers 100%. See Selbstbehalt explained.

Your absolute maximum out-of-pocket per year (excluding premiums) is therefore: your franchise + CHF 700. With the minimum franchise of CHF 300, that is CHF 1,000 per year. With the maximum franchise of CHF 2,500, that is CHF 3,200 per year.

Accident coverage — a separate system

Accidents are handled differently in Switzerland. If you are employed for more than 8 hours per week with the same employer, your employer must insure you for accidents under the UVG (Unfallversicherungsgesetz). In that case you should exclude accidents from your KVG health insurance to save on premiums. If you work less than 8 hours or are self-employed, keep accidents in your health insurance. Read more in Accidents Insurance.

Maternity — fully protected

Maternity is an important exception to the cost-sharing rules. Prenatal consultations, birth, and the first eight postnatal weeks are fully covered from the first franc — no franchise, no Selbstbehalt, no matter which plan you have chosen. Switzerland takes a strong public health stance on this to encourage early and complete prenatal care.

How coverage is the same regardless of insurer

This surprises people: you can choose any of the approximately 50 approved KVG insurers, and the medical treatments they cover are identical. What differs is the monthly premium (which varies by insurer, canton, age, and franchise) and the service quality (e.g. how quickly they process claims, the quality of their hotline, and their digital tools). This is why price comparison via the official priminfo.admin.ch tool is the primary decision factor when choosing a basic insurer.