Insurance and costs

Insurance coverages

Patients domiciled in Ticino or the rest of Switzerland are affiliated with one or more health insurers.

In the case of planned hospitalizations, patients are asked to inquire about their insurance coverage prior to the hospital admission itself.

Upon admission to the hospital, they will be asked to present their insurance card or health insurance fund/insurance certificate.

Inpatient room

Insurance coverage determines the type of inpatient room:

• Private coverage: one-bed room with free choice of physician.
• Semi-private coverage: two-bed room with free choice of physician.
• Shared coverage: room with two or more beds.

As a rule, the hospital checks with the health insurance company, the coverage for private and semi-private room. If adequate coverage is not available, patients are required to pay a guarantee deposit upon admission, which may vary depending on the assumed days of stay and the condition being treated.

Billing

• Outpatient setting: billing of services is through the Comprehensive Outpatient Rate System (outpatient flat rates and TARDOC).
• Acute inpatient setting: service billing is done through the SwissDRG system.
• Sub-acute inpatient setting (RAMI): billing of services is done on the basis of days of care.
• Rehabilitation scope: billing of services is done through the ST-Reha system.

If you have accounting and administrative questions and need more in-depth insurance information, you can call the Central Accounting and Billing Service:
+41 (0)91 811 14 11

Cost sharing

In general, for interventions and benefits recognized under the KVG (basic benefits) or accident insurance (LAInf), the mandatory patient participation is as follows:

• Cases charged to health insurance:
  • Deductible costs as stipulated in the contract with the insurer.
  • 10% of costs up to an annual ceiling of CHF 700, respectively CHF 350 for persons up to 18 years of age.
  • 15 CHF/day in case of hospitalization (exempted are minors and young adults up to 25 years old who are in training).
    Benefits provided to women from the thirteenth week of pregnancy, during childbirth and up to eight weeks after childbirth are exempt from the above listed co-payments.
• Cases covered by accident insurance:
  • No participation by the insured.
  • Additional costs generated by a request from the insured (e.g., transfer to another hospital), are borne by the insured. Eligible costs are both transportation costs and additional costs generated for the hospitalization itself.
• Stays at Minor Acute Departments (RAMIs).
  A stay at a RAMI ward provides cost sharing of CHF 30 per day for a maximum of CHF 600/year (amount equivalent to the stay of the first 20 days/year).

Supplementary insurance benefits

Benefits not recognized under the KVG are in principle billed to the patient, who can claim reimbursement, if appropriate, from his or her supplementary insurance.
For this type of service, EOC reserves the right to ask for an advance payment.

In cases where EOC has contracted with an insurer in which third-party payer (TP) is provided, the benefits are billed directly to the guarantor:

• additional inpatient benefits for private/semi-private room: contract in TP with 99% of Swiss insurers;
• additional benefits in day hospital in case of outpatient surgery: no contracts in place at the moment.
  

Foreign patients

Patients from a European Community country are asked to present their valid insurance card (European Health Card) recognized in Switzerland, keeping in mind that only treatment costs in the emergency setting (illnesses or accidents occurring on Swiss territory only within the medical emergency and first aid services and, if necessary, with hospitalization in a shared room) are allowed.

For foreign patients and those without sufficient insurance coverage, the Patient Management Service is entitled to request a deposit or advance payment.

Useful information

• Outpatient setting: service billing is done through the Tarmed system.
• Acute inpatient setting: benefit billing is done through the SwissDRG system.
• Sub-acute (RAMI) setting: billing of services is done on the basis of days of care.
• Rehabilitation scope: billing of services is done through the ST-Reha system.

If you have accounting and administrative questions, for insurance insights, you can call the Central Accounting and Billing Service:
+41 (0)91 811 14 11