Description of services

The federal Department of the Interior (EDI) is responsible for the description services reimbursed by the obligatory health insurance (OKP). The only exception to this is the description of pharmaceuticals which are subject to the list of specialities (SL) and which fall within the competence of the Federal Office of Public Health (FOPH).

Description of medical services

For the services provided by doctors or physicians as well as chiropractors, there is no exclusive list of all compulsory services (except for maternity and prevention services). The basic principle is that the compulsory health care insurance reimburses all examinations and treatments carried out (so-called principle of trust: doctors or physicians, as well as chiropractors, provide services that are effective, appropriate and cost efficient), insofar as they are not disputed. The Nursing Benefit Regulation (KLV) lists only those services that are reported and examined as disputed (' Open service Catalog '). This refers to whether the services are to be covered or not or are only to be reimbursed by the compulsory health insurance under certain conditions.

Services, which are not or not yet listed in this list, in principle need to be covered, unless the health insurer refuses reimbursement of costs based on the individual case assessment by the Permanent trustee or the competent doctor of trust.

Description the medical services covered by compulsory health insurance is in the responsibility of the FDHA on the advice of the relevant federal commission.

Description of other services

Medicinal products, laboratory analyses,, aids and equipment, prescribed by medical doctors and provided by other health professionals, dental treatment, as well as medical care related to maternity or preventive health are set down in exhaustive positive lists. Services not included on these lists are not covered and need not to be reimbursed by the compulsory health insurance (a so-called closed catalogue of services).

Again the FDHA is responsible for the description of services. The only exception is the description of pharmaceuticals covered by the compulsory health insurance, which is in the responsibility of the FOPH. The FDHA and FOPH designate the respective services on the advice of the relevant federal commissions.

Operationalisation of the criteria ‘effectiveness, appropriateness and economic efficiency’ (EAE)

Under Article 32 of the Federal Act on Health Insurance (HIA; SR 832.10), services or treatments must meet the criteria of effectiveness, appropriateness and economic efficiency (EAE criteria) to be designated under the compulsory health insurance scheme.

The foundational document ‘operationalisation of the criteria effectiveness, appropriateness and economic efficiency’ of 31 March 2022 has been produced for the purpose of operationalising the EAE criteria for assessing and designating all services covered by compulsory health insurance. It is a refinement of the 2011 working paper and supersedes it in its entirety since 1 September 2022.

Advisory commissions

Federal commission for general services and principles (ELGK/CFPP)
Federal commission for analyses, aids and equipment (EAMGK/CFAMA)
Federal pharmaceutical commission (EAK/CFM)

The administrative offices of these three commissions are run by the Medical Services and Authorisation of Pharmaceuticals departments of the FOPH. They also provide technical support in the commissions’ decision making process.