Health Insurance Act of 1996.
Health Insurance Ordinance.
Compulsory health insurance (OKP)
OKP, also known as basic insurance, is regulated in the KVG. It offers all insured persons high-quality medical care and access to a wide range of medical services.
Health Insurance Supervision Act.
Ordinance on the supervision of health insurance.
Ordinance on benefits in health insurance. Also known as the “catalog of services”, it defines the medical services that are or are not covered by compulsory health insurance.
List of resources and items that are to be reimbursed as compulsory benefits under the compulsory health insurance.
Alternative insurance models (AVM) or managed care models
Insurance models in which the insured person chooses a preferred contact person for all health issues (doctor, medical telephone advice). The insured person accepts restrictions in their choice and in return receives a statutory premium discount (between 5 and 20%).
Telemedicine model / Callmed
Alternative model in which the insured person has to contact a medical telephone counseling service before consulting a doctor. The healthcare professional assesses the situation and, depending on the model, makes recommendations or what to do next. (Self-medication or consultation with a doctor or in a hospital).
Family doctor model
Alternative model in which the insured person undertakes to first consult the family doctor who, if necessary, will refer him to a specialist or a hospital.
Medical networks, HMO (Health Maintenance Organization) or group practices
Alternative model with regional medical groups or networks with different specialties (e.g. medical on-call service). The aim is to optimally coordinate the treatment chain so that unnecessary consultations are avoided and examinations that have already been carried out are not repeated. The first point of contact for the patient is always the same doctor, in principle a general practitioner, who will refer the patient to a specialist if necessary.
Agreement between medical network and health insurer
Medical networks and insurers conclude an agreement in which the medical networks generally assume joint responsibility for the budget (budget: cost target for the care of a group of insured persons; budget joint responsibility: participation of the medical network in profit or loss if the target is reached / not achieved). This creates an incentive for the network to offer the best price-performance ratio.
Daily allowance insurance
This insurance is voluntary. It protects against the risk of loss of wages or earnings as a result of illness or an accident. The KVG cover for this risk can also be supplemented with additional insurance (VVG).
Non-profit making insurance
Compulsory health insurance is not for profit. Any surpluses flow into the reserves, which the insurer uses to ensure that the benefits claimed are reimbursed in any case (see also “Reserves”).
AVB (General Insurance Conditions according to KVG)
Provisions for compulsory health insurance and voluntary daily allowance insurance.
Hospital stay in a single room with free choice of doctor.
Hospital stay in a double room with free choice of doctor.
Hospitalization throughout Switzerland
Insurance coverage for hospital stays in the general ward. With this coverage insured persons can be treated in public and private hospitals in Switzerland.
AVZ (special conditions for supplementary insurance according to VVG)
Provisions for private supplementary insurance.
Amount taken by the insurer to cover the cost of medical services. Social health insurance is financed according to the pay-as-you-go system, so the premium income of a financial year must cover the health costs of the same financial year (Art. 12 and 16 para. 3 KVAG)..
The insured participates in the costs he incurs with a deductible. With the selectable deductibles (optional deductibles), he receives a premium discount in return.
The insured contributes 10% to the costs of the treatments used that exceed the amount of the deductible. The annual maximum amount of the deductible is stipulated by law: CHF 700.– for adults and CHF 350.– for children.
The principle anchored in the KVG, which states that all health insurance benefits must be effective, appropriate and economical. All three criteria must be met at the same time (Art. 32 KVG).
Invoice control is the examination of incoming invoices according to the three profitability criteria mentioned above. Thanks to the controls carried out by health insurers, 10% less benefits are spent each year, which corresponds to more than three billion francs per year. If one compares these under-expenditures with the administrative costs of the OKP of 1.5 billion francs annually, after deducting the administrative costs, the bottom line is under-expenditures of around 1.5 billion francs; calculated over the year, this corresponds to a premium reduction of around 5%. The efficiency of controlling bills for medical services is due to competition between insurers because it is in their interests to keep healthcare costs down and their administrative costs down,
Financial premium contribution granted by the cantons to insured persons in modest economic circumstances. The criteria for receiving premium reductions (income limits,% of participation, etc.) are set by the cantons. In 2014, 2.2 million people, i.e. around 27% of the population, received premium reductions. The premium contributions paid by the Confederation and the cantons amount to 4 billion francs.
Financial compensation between health insurers. Insurers with policyholders who have higher than average risks (more costly and more frequent illnesses) are financially supported by insurers who have a portfolio of policyholders with lower risks.
Criteria: The compensation is based on four criteria: age (young and older people), gender, stays of more than three days in a hospital or nursing home and, since January 1, 2017, the cost of medication in the previous year. All four criteria are taken into account. The risk compensation amount is recalculated every year. In 2016, the total amount for risk equalization between insurers was 1.7 billion francs.
Mandatory contract (mandatory contract)
Obligation of the health insurer to reimburse the bills of all service providers who are authorized to work at the expense of the KVG.
Freedom of contract
Possibility for the insurer or service provider to decide which partners to conclude a collective agreement with.
Free choice of insurer
Possibility of the insured person to freely choose the health insurer. This option is part of the system of compulsory health insurance.
Free choice of medical doctors
Patients have the option of being treated by a doctor of their choice, whether a general practitioner or a specialist. The free choice also applies to prescription services by pharmacists and physiotherapists.
BfS - Federal Statistical Office
The abbreviation BfS stands for Federal Statistical Office. It records all of Switzerland's figures, evaluates them and makes them available to the public. It collects important statistics, which can be used as official figures for the country.
EDV is electronic data processing. EDV is a collective term for the acquisition and processing of electronic data by machines and computers. Practically most activities today are recorded by electronic data processing.
The abbreviation MiGel stands for means and items list. It can be found in Appendix 2 of the Nursing Performance Ordinance (KLV) of September 29, 1995. It defines the assumption of costs for funds and objects as a mandatory benefit of social health insurance.
VN is the abbreviation for policyholders. It is often referred to as an insured person.