Health insurance (LAMal): obligations

Anyone arriving in Switzerland soon discovers a rule that admits no exceptions: basic health insurance is mandatory for everyone. It is not a company benefit or an optional choice, but a legal obligation set out in the LAMal (Federal Health Insurance Act). Understanding how it works is essential to avoid being uncovered or exposed to unexpected costs. Here is what you need to know.

The obligation to take out insurance

The LAMal requires every person domiciled in Switzerland to take out basic health insurance. The obligation kicks in quickly: those who move to the country must, as a rule, take out insurance within three months of arrival or of taking up domicile. Once taken out, the cover takes effect retroactively to the date of arrival, so you do not “gain time” by delaying the subscription.

The obligation concerns every member of the family, including children and newborns, who must be insured individually: there is no single family cover as in other systems.

Basic insurance: what it covers

Basic insurance guarantees a catalogue of benefits defined by law, the same for all insurers. In particular, it covers:

• medical care in the event of illness and maternity;
• hospitalisation in the general ward of the canton of domicile;
• medicines included in the official lists;
• a range of preventive and specialist services provided for by law.

Since the basic benefits are identical by law, insurers differentiate themselves above all on the premium and on service, not on the content of the mandatory cover.

Premiums, deductible and cost sharing

The cost of basic insurance is made up of several elements:

• the monthly premium, which varies according to the insurer, the canton (and the premium region) and the age of the insured. Premiums are individual and do not depend on income;
• the annual deductible (the amount the insured pays out of their own pocket before the insurer steps in): you can choose a lower deductible with a higher premium, or a higher deductible with a reduced premium;
• the coinsurance (cost sharing above the deductible, up to a maximum annual ceiling);
• for hospital stays, a daily contribution towards hospital costs.

The choice of deductible is an economic decision: a high deductible is worthwhile for those who make little use of care, a low one for those who anticipate frequent healthcare expenses.

The insurance models

To keep premiums down, insurers offer alternative models to the standard model with free choice of doctor:

• family doctor model: you first turn to a reference doctor;
• HMO model: you use an affiliated practice or health centre;
• Telmed model: you first contact a telephone advice service.

These models entail lower premiums in exchange for less freedom in choosing the first point of contact. It is an important lever for optimising costs without giving up the legally required cover.

Premium reduction

Premiums can weigh significantly on the family budget. This is why the individual premium reduction exists: financial support, managed at cantonal level, for people and families on modest incomes. The criteria and amounts vary from canton to canton and must be checked with the competent authorities. Many of those entitled do not apply simply because they do not know it exists.

Basic insurance and supplementary insurance

It is important not to confuse two distinct levels:

• basic insurance (LAMal) is mandatory, with benefits set by law, and insurers cannot refuse admission;
• supplementary insurance (LCA) is optional and covers additional benefits (semi-private or private ward, complementary medicine, dental care, etc.). Here the insurer can set conditions, health questionnaires and even refuse membership.

Many people take out both, but they must be kept conceptually separate: basic insurance guarantees essential cover, supplementary insurance adds comfort and extra benefits.

The case of cross-border commuters

Cross-border commuters have a special regime: they have a right of option which allows them, within certain deadlines, to choose where to be insured for illness (in Switzerland or in their country of residence). It is a choice with lasting economic consequences, often irreversible in practice, and it must be assessed carefully at the time of hiring.

Mistakes to avoid

• Waiting beyond the deadlines to take out insurance, believing you are saving money.
• Forgetting to insure the children, who must have their own policy.
• Choosing the lowest premium without assessing the deductible, the model and real care needs.
• Ignoring the premium reduction when you would be entitled to it.

How we work at SIH ONE

We help people, families and companies hiring staff to navigate the Swiss healthcare system: checking legal obligations, setting up cover for new arrivals, coordinating with social insurance and assessing the options for cross-border commuters.

Are you moving to Switzerland or hiring staff and want to be compliant with the LAMal from day one? Discover our services related to permits and set up your cover the right way.