Cost Sharing under the KVG (Franchise, Co-Payment, Hospital Contribution)

Concept and Legal Basis

Swiss mandatory health care insurance requires insured persons to share in the cost of the benefits they use (Art. 64 KVG). Cost sharing has three components: a fixed annual amount (the franchise or deductible), a percentage co-payment on costs above the deductible, and a contribution to the cost of hospital stays. The amounts are set by the Federal Council in the KVV ordinance. Under Art. 103 KVV the ordinary deductible for adults is CHF 300 per calendar year; the co-payment is 10 % and capped at CHF 700 per year (children up to 18: no deductible, co-payment capped at CHF 350). The hospital contribution under Art. 104 KVV is CHF 15 per day; children, young adults in education up to age 25 and women receiving maternity benefits are exempt. The date of treatment, not the invoice date, determines the year to which costs are allocated.

Elective Deductibles and Discounts

As a special form of insurance (Art. 62 KVG, Art. 93 et seq. KVV), adults may choose higher deductibles of CHF 500, 1,000, 1,500, 2,000 or 2,500, and children levels from CHF 100 to 600. The premium discount is capped by law at 70 % of the additional risk assumed, which for the CHF 2,500 deductible equals a maximum discount of CHF 1,540 per year. The insurer must also charge a minimum premium of 50 % of the ordinary premium. Moving to a higher deductible is possible only at the start of a calendar year; moving to a lower deductible is possible with the applicable notice period regardless of health status. Special maternity benefits are fully exempt from cost sharing; originator medicines with cheaper generics carry an increased co-payment of 40 %.

Country Comparison and Practice Note

Swiss cost sharing is high by European standards and deliberately designed as a steering instrument against over-consumption. German statutory health insurance has no deductible but statutory co-payments (e.g. 10 % per medicine, minimum EUR 5 and maximum EUR 10, with a burden cap of 2 % of gross income under § 62 SGB V); Austria levies a prescription fee and a hospital cost contribution. For employers, cost sharing matters because group supplementary insurance and employee benefit programmes can partly cushion it, whereas basic insurance itself cannot be concluded on a group basis.