How the healthcare system works (after you’ve signed up)

Once you’re insured, here’s how the Swiss healthcare system generally works. If you haven’t done so already, I suggest reading my article Getting health insurance in Switzerland first to get a basic understanding of the Swiss health insurance system, including how deductibles and co-payments function.

Your first point of contact: your médecin de famille (family doctor)

Unless you opted for an HMO or Telmed model, you can visit any GP (médecin de famille) in your canton (see also: Finding a family doctor (GP/médecin traitant). This doctor becomes your main point of contact for most health concerns. Depending on your model, you may need to call a telemedicine service first. Telemedicine allows you to consult a doctor by phone or video call and is often used for minor health issues, prescriptions, or to get a referral to a specialist. In many policies, using telemedicine first is mandatory before any in-person visit.

What’s included in basic coverage

LaMal (the mandatory basic insurance) must legally cover a set of core services across all providers. This includes visits to a GP or specialist (with a referral if required), maternity care, hospitalization in a shared room in your canton of residence, emergency care, and necessary lab tests. However, it does not include dental and optical care (unless it’s from an accident), cosmetic treatments, alternative medicine (unless listed under approved methods), or private/semi-private hospital rooms. These services are optional and require an assurance complémentaire (complementary insurance).

Deductible and co-payment (franchise and quote-part)

You choose your annual deductible (franchise) when you sign up, CHF 300 to CHF 2500 for adults. This is the amount you must pay out of pocket each year before insurance begins covering costs. After reaching your deductible, you pay a co-payment (quote-part) of 10% of each bill, up to CHF 700/year for adults. Insurers typically pay your healthcare provider directly, and you receive a bill for your share, or you may pay upfront and get reimbursed later, depending on the provider and your insurance model.

Medication costs

Health insurance typically covers the cost of most prescription medications, but some may require additional out-of-pocket costs depending on the drug’s classification and whether it is covered under your plan. You can save a bit of money by requesting the generic versions of the prescribed medicine.

Hospital stays

Basic insurance covers hospital stays in a shared room in your canton of residence. If you want a semi-private or private room, or the ability to choose your surgeon or hospital, you will need assurance complémentaire. Without it, you’re generally limited to the public hospitals in your area.

Pregnancy and childbirth

Basic insurance fully covers pregnancy-related care, including prenatal check-ups, ultrasounds, childbirth, and postnatal care. You are not required to pay the deductible or co-payment for these services. However, if you want to give birth in a private clinic, have a private room, or choose your obstetrician, you’ll need a complementary insurance plan in place before becoming pregnant, as providers often don’t accept applications once you’re already expecting.

Emergencies

Emergency care is covered by basic insurance, but make sure to go to an emergency department only if it’s medically justified. Non-urgent use of emergency services may not be fully reimbursed. Ambulance transport is partially covered, only 50% up to CHF 500 per year for non-air transport, and up to CHF 5000 per year for rescue services (like helicopters).

Mental health

Sessions with a psychiatrist (a medical doctor) are covered if referred by a GP. Since July 2022, consultations with psychologists are also covered, provided they are prescribed by a doctor and the psychologist is recognized by the federal authorities. The number of sessions may be limited without follow-up approval.

Coverage outside Switzerland

Basic insurance covers emergency treatment abroad, up to double what the same care would cost in Switzerland. However, if you’re traveling or staying abroad for an extended period, especially outside the EU/EFTA, it’s strongly advised to get additional travel or international insurance. For planned treatments abroad, prior authorization is required and is usually granted only in rare circumstances.

Changing your insurer

You can switch basic health insurance providers once per year. To do this, you must cancel your current policy by sending written notice by November 30. The new policy will take effect on January 1. For complementary insurance, cancellation rules are stricter and often require three months’ notice or more. Always check your policy’s terms before switching.

Although the system is complex at first, most residents get used to how things work fairly quickly. Once you know how to navigate your coverage, get referrals when needed, and manage your invoices, the system becomes more predictable and manageable.