Since 1st January 2025, there have been significant changes in the rules for reimbursement under supplementary health insurance policies in Switzerland, in particular for semi-private and private hospitalisation. This reform, initiated by FINMA (the Federal Financial Market Supervisory Authority) and implemented with the support of the Swiss Insurance Association (SIA), aims to boost the transparency of supplementary services, but it is also the source of tension locally, especially in French-speaking Switzerland.
The movement for reform began in 2020, when FINMA found irregularities in invoices for supplementary services. Some seemed difficult to understand, and even excessive, and they lacked transparency. In response, the SIA has drawn up an industry framework entitled Additional benefits under the Insurance Policy Law (LCA), with the aim of establishing clear rules for presentation and invoicing. These new requirements, applicable from 2022, were subject to a transition period ending in 2024.Since 1st January 2025, only services covered by pricing agreements that comply with these requirements may be reimbursed. This reform has helped stabilise premiums in many instances, thanks in particular to the review of prices that were initially disproportionate.The new regulations relate exclusively to supplementary insurance policies governed by the LCA (Swiss Federal Law on Insurance Policies), particularly with regard to semi-private or private hospitalisation. It does not affect insurance policies that are compulsory under the Federal Law on Accident Insurance (LAA) and has a lesser impact on LAA supplementary insurances, known by the acronym LAAC.
The harmonisation of prices did not, however, go smoothly without disputes. In Geneva and the canton of Vaud, there is still no agreement between certain supplementary insurance companies and the providers of services. This disagreement on prices is currently preventing full coverage of certain hospital services, particularly semi-private hospitalisation. The main bone of contention is that local medical practitioners - in particular the Association of Genevan Doctors (AMGe) - want to impose their own pricing models, which insurers do not consider to be compliant with FINMA criteria. Agreements were reached in the rest of the country thanks to a more fragmented approach taken to negotiations. Nonetheless, some doctors do not meet the new requirements, and their services are not reimbursed. In French-speaking Switzerland, negotiations are more complex due to the centralized role of canton associations. This situation has led to a temporary standstill, with actual impact on policyholders, in particular the risk of having to cover part of the cost of a hospital stay themselves.
Legitimate issues are raised under these circumstances, both for policyholders and for companies that have taken out semi-private cover for their employees. It is important to remember that policyholders remain fully covered: contractual cover remains valid, even in the event of a temporary contractual void with certain service providers. If the institution or the doctor of the insured is not covered by an agreement - and as a result, the cost of care is not reimbursed, insurance companies systematically offer alternatives. They refer policyholders to other partner hospitals or doctors, to ensure that treatment continues to be covered as provided in the policy. Policyholders are strongly advised to check beforehand that their chosen healthcare establishment or provider is recognised, and, if necessary, to ask for written confirmation of coverage. This will avoid any misunderstandings at the time of hospitalisation. The Qualibroker Swiss Risk & Care group is also there to advise companies and their employees.
Since 1st January 2025, only services covered by pricing agreements that comply with these requirements may be reimbursed.
Since January 2025, certain semi-private and private services are temporarily no longer covered in certain establishments. To ensure that your supplementary insurance policy duly reimburses you:
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It must be emphasised that insurance cover remains in force and contractual warranties unchanged. Policyholders therefore remain protected, and the quality of the care provided shall not be compromised under any circumstances. Insurer companies pursue their role of providing protection by redirecting policyholders, where necessary, to other partner establishments or doctors that are fully recognised. The aim of this reform is clear: to boost transparency in invoicing, avoid duplication between basic and supplementary insurance, and ensure fair pricing for all parties. For companies offering semi-private cover to their employees, we recommend informing the relevant employees, monitoring the evolution of agreements with hospital care providers, and using their broker to ensure clear and secure communication.
Brokers play a key role here. As the insurance companies’ main contact, they are aware of the evolution of prices, valid agreements and transitional measures. Their expertise enables them to anticipate the potential impact on policyholders and guide companies towards concrete, or indeed alternative, solutions. Brokers will advise on the steps to take, given the current lack of agreements, and can suggest alternatives. Brokers act as a trusted interface for both employer and employee, at a time when it is sometimes difficult to understand the scope of services provided.
We are dealing with a complex equation: controlling costs while guaranteeing high quality healthcare. This is a collective challenge, but it is also an opportunity. This pricing crisis, although difficult to deal with in the short term, could contribute to restoring the balance of the supplementary insurance system in the long term, by boosting transparency and defining clear standards. Our group sees this period as a necessary transition to a more stable and better-structured system. We expect the pricing environment to stabilise by 2026. Until then, our clients can count on our support: our teams are ready to provide rigorous advice and concrete answers to policyholders and companies alike.
This article was published in Insurance Inside n°38 - June 2025.
Cyrielle Suzat, Healthcare BU Director
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