¹ Every person domiciled in Switzerland shall be insured for care in the event of sickness, or be insured by his legal representative, within three months of his or her residence or birth in Switzerland.

² The Federal Council may exempt certain categories of persons from compulsory insurance, in particular persons benefiting from privileges, immunities and facilities referred to in Art. 2, para. 2, of the Act of 22 June 2007 on the Host State ¹ . ²

³ It may extend the obligation to insure to persons who have no domicile in Switzerland, in particular those who:

A. ³

Operate in or stay in Switzerland (art. 13, para. 2, LPGA ⁴ );

B.

Are occupied abroad by a company with a registered office in Switzerland.

⁴ The obligation to ensure is suspended for persons subject to the Federal Military Insurance Act of 19 June 1992 (AML) ⁵ For more than 60 consecutive days. The Federal Council regulates the procedure. ⁶

Persons required to ensure freedom of choice among insurers authorized to practise social insurance under the LSAMAL ² .

Are insured by the same insurer:

A.

Persons who are obliged to ensure that they are engaged in a gainful occupation in Switzerland and members of their families who are obliged to ascertain who is resident in a Member State of the European Community, in Iceland or in Norway;

B.

Persons who are obliged to ensure that they affect a Swiss pension and members of their families who are obliged to ensure that they reside in a Member State of the European Community, in Iceland or in Norway;

C.

Persons who are obliged to ensure that they receive Swiss unemployment insurance benefits and members of their families who are obliged to ensure that they reside in a Member State of the European Community, in Iceland or in Norway.

¹ Where the affiliation takes place within the time limits laid down in Art. 3, para. 1, insurance deploys its effects from birth or from home in Switzerland. The Federal Council determines the commencement of insurance coverage for persons designated under s. 3, para. 3.

² In the case of a late affiliation, the insurance will affect its effects as soon as it is affiliated. The insured must pay a premium if the delay is not excusable. For this purpose, the Federal Council shall determine indicative rates, taking into account the level of premiums at the place of residence of the insured person and the duration of the delay. If the payment of the premium surcharge puts the insured person in trouble, the insurer reduces the amount by taking into account the situation of the insured person and the circumstances of the delay fairly.

³ Insurance coverage ends when the insured ceases to be subject to the obligation to insure.

¹ The cantons shall ensure compliance with the obligation to ensure.

² The authority designated by the canton automatically affiliated with any person obliged to ensure that the obligation has not been fulfilled in due time.

¹ The cantons shall inform on the obligation to ensure:

A.

Persons residing in a Member State of the European Community, in Iceland or in Norway and who are obliged to ensure that they are engaged in a gainful occupation in Switzerland;

B.

Persons residing in a Member State of the European Community, in Iceland or in Norway and who are obliged to ensure that they receive a benefit from Swiss unemployment insurance;

C.

Persons who are required to insure themselves because they receive a Swiss pension and who transfer their residence from Switzerland to a Member State of the European Community, Iceland or Norway. ³

² The information provided in para. 1 is ex officio for family members who reside in a Member State of the European Community, in Iceland or in Norway. ⁴

³ The authority designated by the canton automatically affiliated persons who did not comply with the obligation to ensure in due time. It shall rule on requests for exceptions to the obligation to ensure. Art. 18, para. 2 ^Bis And 2 ^Ter , is checked out.

⁴ Insurers shall provide the competent cantonal authority with the data necessary for monitoring compliance with the obligation to ensure.

¹ The insured person may, on three months' notice, change the insurer for the end of a semester of a calendar year.

² When the new premium is disclosed, it may change the insurer by the end of the month preceding the start of the validity of the new premium, subject to one month's notice. The insurer must notify each insured of the new premiums approved by the Federal Office of Public Health (Office) ¹ At least two months in advance and report to the insured that he has the right to change the insurer. ²

³ If the insured person is required to change the insurer because he or she changes residence or employment, the membership terminates at the time of the change of residence or employment with a new employer.

⁴ The affiliation terminates with the withdrawal of the authorization to practice in accordance with Art. 43 LSAMAL ³ When the insurer ceases, voluntarily or by administrative decision, to practice social insurance. ⁴

⁵ The affiliation with the former insurer terminates only when the new insurer has communicated to him that he is insured without interruption of the insurance protection. If the new insurer fails to make this communication, it must repair the resulting damage to the insured, in particular the difference in the premium. Upon receipt of the communication, the former insurer shall inform the person concerned of the date from which he no longer assures him.

⁶ Where the change of insurer is not possible because of the former insurer, the insurer must repair the resulting damage to the insured, in particular the difference in premium. ⁵

⁷ Where the insured person changes an insurer, the former insurer cannot compel him to also terminate the supplementary insurance within the meaning of Art. 2, para. 2, LSAMal with him. ⁶

⁸ The insurer cannot terminate complementary insurance within the meaning of s. 2, para. 2, LSAMal solely on the basis that the insured person changes insurance coverage for social insurance. ⁷

¹ Accident coverage may be suspended until the insured person is fully covered for that risk, as required under the Federal Act of 20 March 1981 on accident insurance (LAA). ¹ The insurer will suspend when the insured person requests it and provides proof that it is fully insured in accordance with the LAA. It reduces the premium accordingly.

² Accidents shall be covered under this Law as soon as the coverage within the meaning of the LAA terminates wholly or in part.

³ Social insurance covers the costs of accident suites which it ensured before the cover was suspended.

In connection with social insurance, the insurer must, in writing, draw the insured person's attention to the possibility of making an application within the meaning of s. 8.

¹ The employer shall inform in writing the person who leaves or ceases to be insured against non-professional accidents within the meaning of the LAA ¹ Must report it to its insurer within the meaning of this Act. The same obligation is imposed on unemployment insurance when the right to benefits of this institution expires without the person taking a new job.

² If the insured person has not fulfilled his obligation in accordance with para. 1, the insurer may require payment on the part of the premium corresponding to the cover of the accident, including the moral interest, for the period from the end of the cover within the meaning of the LAA to the point at which it became known. Where the employer or unemployment insurance has not fulfilled their obligation in accordance with para. 1, the insurer can claim the same claims against them.

¹ Insurers create a common institution in the form of a foundation. The Foundation Act and the regulations of the institution shall be subject to the approval of the Department. The Federal Council creates the joint institution if the insurers have not done so. It lays down the necessary requirements if insurers cannot agree on the management of the institution.

² The Joint Institution shall bear the costs of legal benefits in place of insolvent insurers in accordance with Art. 51 LSAMAL ¹ . ²

^2bis The Joint Institution shall rule on claims for exemption from the obligation to ensure that annuitants and family members reside in a Member State of the European Community, Iceland or Norway. ³

^2ter It is automatically affiliated with annuitants as well as members of their families residing in a Member State of the European Community, Iceland or Norway and who have not acted upon the obligation to ensure in due time. ⁴

^2c It shall assist the cantons in the implementation of the reduction in premiums provided for in Art. 65 A In favour of insured persons residing in a Member State of the European Community, in Iceland or in Norway. ⁵

^2quinquies It shall reduce premiums in accordance with Art. 66 A . ⁶

^2sexies The joint institution may assume, against compensation, other implementing tasks entrusted to it by the cantons. ⁷

³ The Federal Council may entrust the institution with other tasks, in particular in order to fulfil international commitments.

⁴ Insurers may agree to entrust certain tasks of common interest to the insurer, in particular in the administrative and technical fields.

⁵ To finance the tasks of the institution referred to in paras. 2 and 4, insurers must make contributions to the cost of social insurance. The institution claims these contributions and receives a moratorium in the event of a delay in payment. The amount of the contributions and the interest moratorium is determined by the regulations of the institution. ⁸

^5bis The Confederation shall finance the tasks referred to in paras. 2 ^Bis To 2 ^D . ⁹

⁶ The Federal Council shall provide for the financing of the tasks entrusted to the joint institution pursuant to para. 3.

⁷ The Joint Institution shall keep separate accounts for each of its tasks. She benefits from the exemption from taxes under s. 80 LPGA ¹⁰ . ¹¹

⁸ Art. 85 ^Bis , para. 2 and 3, of the Federal Act of 20 December 1946 on old-age and survivors' insurance ¹² Shall apply mutatis mutandis to appeals brought before the Federal Administrative Court against decisions of the Joint Institution founded on par. 2 ^Bis , 2 ^Ter And 2 ^D . ¹³

¹ Insurers encourage disease prevention.

² They manage in common and with the cantons an institution whose aim is to stimulate, coordinate and evaluate measures to promote health and prevent disease. The Federal Council creates the institution if the insurers and the cantons have not done so.

³ The governing body of the institution shall consist of representatives of the insurers, the cantons, the CNA, the Confederation, the doctors, the scientific community and the organisations specialised in the field of prevention.

¹ An annual contribution for general disease prevention shall be collected from each compulsory insured within the meaning of this Law.

² The department shall determine the contribution on a proposal from the institution. It shall report to the competent committees of the Federal Chambers on the use of such means. ¹

³ It monitors the activity of the institution. ² The budgets, accounts and activity report are submitted for approval to the Office.

¹ The Federal Statistical Office shall establish the statistical bases necessary for the examination of the operation and the effects of this Law. It collects data necessary for this purpose from insurers, benefit providers and the public.

² Interviewees are subject to the obligation to provide information. The information must be made available free of charge.

³ Data processing for statistical purposes is governed by the Federal Statistics Act of 9 October 1992 ³ .

¹ Compulsory care insurance covers the costs of benefits defined in art. 25 to 31 taking into account the conditions of the art. 32 to 34.

² The supported benefits are connected to the date or period of treatment. ¹

¹ Compulsory care insurance covers the costs of benefits that are used to diagnose or treat a disease and its sequelae.

² These benefits include:

A. ¹

Examinations and treatment in ambulatory, hospital or medical-social settings, as well as in hospital care by:

1.

Physicians,

2.

Chiropractors,

3.

Persons providing benefits on prescription or on the terms of office of a physician or chiropractor;

B.

Tests, drugs, means and diagnostic or therapeutic devices prescribed by a physician or, within the limits set by the Federal Council, by a chiropractor;

C.

Participation in the cost of bathing cures prescribed by a physician;

D.

Rehabilitation measures performed or prescribed by a physician;

E. ²

The hospital stay corresponding to the common division standard;

F. ³

...

F ^Bis . ⁴

Stay in case of childbirth in a birth house (art. 29);

G.

A contribution to medically necessary transportation costs and salvage costs;

H. ⁵

Pharmacy benefits when dispensing prescription drugs in accordance with the provisions of the Act. B.

¹ Compulsory health insurance provides a contribution to the care that is provided on the basis of a medical prescription and a need for acute care, in ambulatory form, in particular in daycare or night care facilities, or in Medico-social institutions. ²

² Acute care and transitional care that is necessary following a hospital stay and are prescribed by a hospital doctor are paid by the compulsory health insurance and by the insured person's canton of residence for two years. Weeks at most in accordance with hospital funding regulations (s. 49 A Compensation for hospital benefits). Insurers and benefit providers agree on packages.

³ The Federal Council designates the care and establishes the procedure for the assessment of the care required.

⁴ The Federal Council sets the amount of contributions in francs based on the need for care. The cost of care provided with the required quality and in an effective and cost-effective manner is a determining factor. Care is subject to quality control. The Federal Council sets the modalities.

⁵ The costs of care which are not covered by social insurance may be passed on to the insured person only up to 20 % of the maximum contribution set by the Federal Council. The cantons regulate residual financing.

Compulsory care insurance covers the costs of certain examinations designed to detect diseases in a timely manner, as well as preventive measures in favour of particularly threatened insured persons. Such preventive examinations or measures shall be carried out or prescribed by a doctor.

In the case of congenital infirmity (art. 3, para. 2, LPGA ² ) Not covered by disability insurance, compulsory health insurance covers the costs of the same benefits as in the case of sickness.

In the event of an accident within the meaning of Art. 1, para. 2, let. B, ¹ Compulsory health insurance covers the costs of the same benefits as in the case of sickness.

¹ Compulsory care insurance covers, in addition to the costs of the same benefits as for sickness, those of specific maternity benefits.

² These benefits include:

A.

Examinations carried out by a doctor or midwife or prescribed by a doctor, during and after pregnancy;

B. ¹

Childbirth at home, in a hospital or in a birth house, and the assistance of a physician or midwife;

C.

Advice for breastfeeding;

D. ²

The care provided to the newborn in good health and stay, as long as he remains in hospital with his or her mother.

In the event of a non-punishable termination of pregnancy within the meaning of s. 119 of the Penal Code ² , compulsory health insurance covers the costs of the same benefits as for the disease.

¹ Mandatory care insurance supports the costs of dental care:

A.

They are caused by a serious and non-avoidable disease of the mastication system, or

B.

If they are caused by another serious disease or its sequelae, or

C.

Whether they are necessary to treat a serious illness or its sequelae.

² It also pays for the costs of treating damage to the mastication system caused by an accident under s. 1, para. 2, let. B ¹ .

¹ The benefits referred to in s. 25 to 31 must be effective, appropriate and economical. Efficacy must be demonstrated by scientific methods.

² The effectiveness, adequacy and economic character of benefits are reviewed periodically.

¹ The Federal Council may refer to benefits provided by a physician or chiropractor, the costs of which are not covered by compulsory health insurance or are subject to certain conditions.

² It refers in detail to the other benefits provided for in s. 25, para. 2, which are not provided by a physician or chiropractor, as well as the benefits provided for in s. 26, 29, para. 2, let. A and c, and 31, para. 1.

³ It determines the extent to which compulsory health insurance covers the costs of a new or controversial benefit, whose effectiveness, adequacy or economic character are being evaluated.

⁴ He appointed commissions to advise him to designate benefits. It shall ensure the coordination of the work of the above-mentioned committees.

⁵ It may delegate to the department or to the Office the competences listed in paras. 1 to 3.

¹ Under compulsory insurance, insurers cannot take over other costs than those provided for in art. 25 to 33.

² The Federal Council may decide to take care, through compulsory insurance, of the costs of the benefits provided for in art. 25, para. 2, or 29 provided abroad for medical reasons. It may refer to cases where compulsory health insurance covers the costs of childbirth abroad for reasons other than medical reasons. It may limit the assumption of costs of benefits provided abroad.

¹ In the case of compulsory health insurance, providers of benefits who fulfil the conditions of the art must be admitted to practice. 36 to 40.

² These benefit providers are:

A.

Physicians;

B.

Pharmacists;

C.

Chiropractors;

D.

Midwifery;

E.

Persons providing prescription or medical care as well as the organizations that employ them;

F.

Laboratories;

G.

The centres for the delivery of diagnostic or therapeutic means and devices;

H.

Hospitals;

I. ¹

Birthing homes;

K.

Medical-social institutions;

L.

Bathing establishments;

M. ²

Transportation and rescue companies;

N. ³

Ambulatory care institutions provided by physicians.

¹ Physicians holding the federal degree and post-graduate training recognized by the Federal Council are admitted.

² The Federal Council regulates the admission of doctors holding an equivalent scientific certificate.

³ Dentists are treated as physicians for benefits under s. 31.

Institutions that provide ambulatory care provided by physicians are admitted, when these physicians meet the conditions set out in s. 36.

¹ Pharmacists who hold the federal degree and post-graduate training recognized by the Federal Council are admitted.

² The Federal Council regulates the admission of pharmacists with equivalent scientific certificates.

³ The cantons set out the conditions under which doctors who are authorised to hold a pharmacy are treated as pharmacists. In particular, they take into account the possibilities of patients' access to a pharmacy.

The Federal Council regulates the admission of the benefit providers listed in Art. 35, para. 2, let. C to g, i and m. ² It shall consult the cantons and interested organisations in advance.

¹ Establishments and those of their divisions that are used for hospital treatment of acute illnesses or for the delivery of medical rehabilitation measures (hospitals) in hospitals are admitted if they:

A.

Ensure adequate medical assistance;

B.

Have the necessary qualified staff;

C.

Have adequate medical facilities and ensure adequate supply of medicines;

D.

Correspond to the planning established by a canton or, jointly, by several cantons in order to cover the needs for hospital care, the private bodies to be taken into account adequately;

E.

Are on the cantonal list of categories of hospitals according to their mandates.

² The cantons coordinate their planning. ²

^2bis In the field of highly specialised medicine, the cantons are required to jointly establish planning for the whole of Switzerland. If the cantons do not carry out this task in time, the Federal Council determines which hospitals are included for which services on the cantonal lists. ³

^2ter The Federal Council lays down uniform planning criteria, taking into account quality and economic character. It consults in advance with the cantons, benefit providers and insurers. ⁴

³ The conditions set out in para. 1 apply by analogy to birth homes, institutions, institutions and divisions of institutions or institutions that provide care, medical assistance and rehabilitation to patients for a long period of time Duration (medico-social institutions). ⁵

¹ Bathing establishments are admitted if they are recognised by the department.

² The Federal Council sets out the conditions that these establishments must meet in respect of medical management, qualified health care staff, treatments and hot springs.

¹ In the case of outpatient treatment, the insured person has the freedom to choose between the providers of benefits admitted and able to treat his illness. The Insurer shall take charge of the costs up to the rate applicable to the place of residence or work of the insured person or in the vicinity. ¹

^1bis In the case of hospital treatment, the insured person has the free choice between hospitals capable of treating his illness and appearing on the list of his/her canton of residence or that of the canton where the hospital is located (listed hospital). In the case of hospital treatment in a listed hospital, the insurer and the canton of residence shall take over their respective shares of remuneration within the meaning of s. 49 A Up to the applicable rate for this treatment in a listed hospital in the Township of Residence. ²

^1ter L' al. 1 ^Bis Applies by analogy to birth-houses. ³

² If, for medical reasons, the insured person submits to an outpatient treatment administered by another benefit provider, the insurer will bear the costs corresponding to the rate applicable to that other provider. ⁴

³ If, for medical reasons, the insured person is subject to hospital treatment provided by a non-listed hospital in the canton of residence, the insurer and the canton of residence shall take their respective shares of remuneration within the meaning of s. 49 A With the exception of an emergency, an authorisation from the canton of residence is necessary. ⁵

^3bis Are deemed medical reasons within the meaning of s. 2 and 3 the case of emergency and the case where the necessary benefits cannot be provided:

A.

The insured person's place of residence or work, or in the vicinity, if it is an outpatient treatment;

B.

In a listed hospital in the insured's canton of residence, if it is a hospital treatment. ⁶

⁴ The insured may, in agreement with the insurer, limit the choice to the benefit providers that the insurer designates on the basis of their more advantageous benefits (s. 62, para. 1 and 3). The insurer only pays the costs of the benefits provided or ordered by those suppliers; para. 2 shall apply mutatis mutandis. The benefits that the law makes mandatory are in any case guaranteed.

¹ Within the limits of their benefit mandates and capacities, the hospitals listed are obliged to guarantee the care of all insured persons residing in the canton where the hospital is located (admission obligation).

² For insured persons residing outside the canton where the listed hospital is located, the admission requirement applies only if it is based on benefit mandates and in cases of emergency.

³ The cantons shall ensure compliance with the admission requirement.

¹ Unless otherwise agreed between insurers and benefit providers, the insured person is the debtor of remuneration to the benefit provider. In this case, the insured person has the right to be reimbursed by his insurer (system of the third-party guarantor). Notwithstanding s. 22, para. 1, LPGA ² , this right can be assigned to the benefit provider. ³

² Insurer and service providers may agree that the Insurer is the payer of the remuneration (system of the paying third party). In the case of hospital treatment, the insurer, in derogation from para. 1, is the debtor of its share of remuneration. ⁴

³ The benefit provider must provide the debtor with a detailed and understandable invoice. It must also provide it with all the necessary indications allowing it to verify the calculation of the remuneration and the economic nature of the benefit. In the pay-third system, the insured person receives a copy of the invoice that has been sent to the insurer. In the case of hospital treatment, the hospital certifies the share of the canton and that of the insurer separately. The Federal Council sets out the details. ⁵

^3bis Benefit providers must be included in the invoice within the meaning of s. 3 diagnoses and procedures in coded form, in accordance with the classifications contained in the corresponding Swiss edition published by the relevant department. The Federal Council shall lay down detailed provisions on the collection, processing and transmission of data, in accordance with the principle of proportionality. ⁶

⁴ The Insurer may require additional medical information. ⁷

⁵ The provider of benefits shall be founded where the circumstances so require, or in all cases, if the insured person so requests, to provide medical indications only to the insurer's medical officer in accordance with art. 57.

⁶ Notwithstanding s. 29, para. 2, LPGA, no formula is required to enforce entitlement. ⁸

¹ The Federal Council may decide that an insured card bearing an identification number assigned by the Confederation be given to each insured for the duration of his/her coverage of compulsory health insurance. The card contains the insured person's name and the Old Age and Survivor Insurance (OAS) insurance number. ²

² This card has a user interface and is used for billing purposes under this Act.

³ The Federal Council regulates, after consultation with interested parties, the arrangements for the introduction of the card by the insurers, as well as the technical standards which must be applied.

⁴ Subject to the consent of the insured person, the card contains personal data which may be accessed by the persons authorized to do so. The Federal Council defines, after consultation with interested circles, the extent of the data that can be recorded on the map. It regulates access to and management of data.

¹ Benefit providers draw up their invoices on the basis of tariffs or prices.

² The tariff is a basis for calculating remuneration and may include:

A.

Be based on time spent on delivery (time spent);

B.

Assign points to each benefit and fix the value of the point (benefit rate);

C.

Provide for a lump sum payment method (flat rate);

D.

To submit, on an exceptional basis, in order to guarantee their quality, the remuneration of certain benefits under conditions above those laid down in Art. 36 to 40, including those that provide that suppliers have the necessary infrastructure, basic training, post-graduate training, or continuing education (tariff exclusion).

³ The flat rate may refer to treatment per patient (package per patient) or group care (package per insured group). Packages by group of insured persons may be fixed, on a prospective basis, on the basis of the benefits provided in the past and future needs (the prospective global budget).

⁴ Tariffs and prices are fixed by agreement between insurers and benefit providers (tariff agreement) or, in cases provided for by law, by the competent authority. They shall ensure that the tariff agreements are laid down according to the rules applicable in the business economy and structured in an appropriate manner. In the case of conventions concluded between federations, organisations representing the interests of insured persons at the cantonal or federal level shall be heard before the conclusion.

⁵ The rates to be paid must be based on a uniform tariff structure, fixed by convention on the Swiss plan. If the tariff partners cannot agree on a uniform tariff structure, the Federal Council shall fix it.

^5bis The Federal Council may make adjustments to the tariff structure if it is inappropriate and the parties cannot agree on a review of the structure. ¹

⁶ The parties to the Convention and the competent authorities shall ensure that the care is appropriate and of the highest quality, while being as advantageous as possible.

⁷ The Federal Council may establish principles to ensure that tariffs are set according to the rules of sound economic management and are appropriately structured; it may also establish principles for their adaptation. It shall ensure that these tariffs are coordinated with the tariff schemes of other social insurance undertakings.

¹ Benefit providers must respect the rates and prices set by convention or by the competent authority; they may not require higher remuneration for benefits provided under this Law (protection Tariff). The provision on remuneration for diagnostic or therapeutic means and apparatus (art. 52, para. 1, paragraph a, c. 3) is reserved.

² A service provider who refuses to provide benefits in accordance with this Act (recusal) shall announce it to the body designated by the cantonal government. He has no right to remuneration within the meaning of this Act. If an insured person is for such a benefit provider, he or she must first inform the provider.

If, because of the recusal of service providers, the treatment of insured persons is not guaranteed in accordance with this Law, the cantonal government shall ensure that it is not guaranteed. Tariff protection is also applicable in this case. The Federal Council may make the necessary arrangements.

¹ The parties to a tariff agreement are one or more providers of benefits, or federations of benefit providers, on the one hand, and one or more insurers or federations of insurers, on the other.

^1bis Parties to a tariff convention may also be cantons for preventive measures within the meaning of s. 26 carried out in the framework of programmes organised at national or cantonal level within the meaning of Art. 64, para. 6, let. D. ¹

² If the party to a convention is a federation, the convention binds the members of that federation only if they have acceded to the convention. Non-members who carry out their activities in the conventional radius may also accede to the Convention. The Commission may provide that they must make a fair contribution to the costs incurred by its conclusion and execution. It regulates the terms and conditions of the declarations of accession or withdrawal, and their publication.

³ In particular, the following measures, whether contained in a tariff agreement, in a separate contract or in an agreement, where they provide for:

A.

Prohibiting group members from entering into separate contracts;

B.

The obligation of cluster members to adhere to existing agreements;

C.

A ban on competition between members;

D.

Exclusivity clauses and those that prohibit any preferential treatment.

⁴ The tariff agreement must be approved by the competent cantonal government or, if its validity extends to all Switzerland, by the Federal Council. The approval authority verifies that the agreement complies with the law and fairness and that it meets the principle of economy.

⁵ The time limit for denunciation or withdrawal of a tariff agreement under para. 2 is at least six months.

¹ If there is no tariff agreement between the benefit providers and the insurers, the cantonal government sets the tariff, after consulting the parties concerned.

² If there is no tariff convention for the ambulatory treatment of an insured person outside his or her place of residence, place of work or area, or for the treatment of an insured person outside his/her canton of residence, the The government of the canton where the service provider is permanently installed fixes the rate. ¹

³ Where benefit providers and insurers fail to agree on the renewal of a tariff agreement, the cantonal government may extend it by one year. If no agreement is reached within that period, it shall fix the tariff after consultation with the parties concerned.

¹ When approving a tariff agreement with one or more physician associations, the approval authority (s. 46, para. 4) fixes, after consulting the parties to the agreement, a framework tariff for which the minimum taxes are lower and the maximum taxes greater than those of the approved conventional tariff.

² The framework tariff comes into effect upon the expiration of the tariff agreement. A year after the expiration of the agreement, the approval authority may establish a new framework tariff without regard to the previous conventional tariff.

³ Where, at the outset, no tariff agreement may be entered into with a medical association, the approval authority may, at the request of the parties, fix a master fee.

⁴ The framework tariff is repealed for those parties that have entered into a new tariff agreement upon its approval.

¹ To remunerate hospital treatment, including hospital stay and care (art. 39, para. 1) or in a house of birth (art. 29), the parties to a convention agree on packages. ² In general, these are packages on a case-by-case basis. The packages are linked to benefits and are based on uniform structures for the whole of Switzerland. Partners in a convention may agree that special diagnostic or therapeutic benefits are not included in the package but are billed separately. Hospital rates are determined on the basis of the remuneration of hospitals that provide the mandatory guaranteed service, in the necessary quality, in an efficient and advantageous manner.

² The tariff partners establish, in conjunction with the cantons, a competent organisation for the development, development, adaptation and maintenance of structures. To finance these activities, a contribution covering the costs can be charged by case invoiced. To this end, hospitals must provide the organization with the necessary data on costs and benefits. If such an organisation is lacking, the Federal Council shall establish it in a binding manner for the tariff partners. The structures developed by the organisation and their adaptations are submitted by the tariff partners to the Federal Council for approval. If the partners cannot agree on the structures, the Federal Council fixes them. ³

³ Remuneration within the meaning of para. 1 does not include the shares of the costs of services of general interest. These benefits include, in particular:

A.

Maintenance of hospital capacity for regional policy reasons;

B.

University research and training.

⁴ In the case of hospitalization, the remuneration shall be in accordance with the rate applicable to the hospital within the meaning of para. 1, as long as the patient requires, according to medical indication, treatment and care or medical rehabilitation in a hospital setting. If this condition is no longer met, the tariff under s. 50 is applicable.

⁵ Remuneration within the meaning of paras. 1 and 4 exhaust all claims of the hospital as to the benefits provided for in this Act.

⁶ The parties to a convention agree on the remuneration of outpatient treatment.

⁷ Hospitals must have adequate management tools; in particular, they must, on a uniform basis, maintain an analytical accounting and a statistics of their benefits to calculate their operating costs and Investment and classify their benefits. These instruments must include all the data necessary to judge the economic character, to make comparisons between hospitals and to establish pricing and hospital planning. Cantonal governments and tariff partners can consult the coins.

⁸ In collaboration with the cantons, the Federal Council makes national-scale comparisons between hospitals-which it subsequently publishes-in particular with regard to costs and the quality of medical outcomes. The hospitals and the cantons must deliver the necessary documents for this purpose.

¹ Remuneration within the meaning of s. 49, para. 1, are covered by the canton and the insurers, according to their respective shares.

² The canton fixed for each calendar year, not later than nine months before the start of the calendar year, the cantonal share for the inhabitants of the canton. This is at least 55 %.

³ The canton of residence pays its share of the remuneration directly to the hospital. The terms and conditions are agreed between the hospital and the canton. The insurer and the canton may agree that the canton pays its share to the insurer, and that the insurer pays both shares to the hospital. Billing between the hospital and the insurer is governed by s. 42.

⁴ Insurers may enter into hospitals or birth homes not listed within the meaning of s. 39, but which fulfil the conditions laid down in Art. 38 and 39, para. 1, let. A to c, conventions on the remuneration of benefits provided under compulsory health insurance. This remuneration may not be higher than the share referred to in para. 2.

In the case of a stay in a medical-social institution (art. 39, para. 3), the insurer supports the same benefits as for outpatient treatment in accordance with s. 25 A Art. 49, para. 7 and 8 shall apply mutatis mutandis.

¹ The canton may, as a financial management instrument, fix an overall amount for the financing of hospitals or medical and social institutions. The breakdown of costs by s. 49 A Is reserved. ¹

² The canton consults in advance with benefit providers and insurers.

¹ After consulting the relevant committees and in accordance with the principles of art. 32, para. 1, and 43, para. 6:

A.

The department enacts:

1.

A list of analyses with tariffs;

2.

A list with tariff of active and auxiliary substances and substances used for compounding; the tariff also includes the benefits of the pharmacist;

3.

Provisions on the obligation to take care and the extent of remuneration for diagnostic or therapeutic means and apparatus;

B.

The Office shall draw up a list, with prices, of pharmaceutical preparations and made-up medicines (list of specialities). It must also include the cheaper generic products that are interchangeable with the original preparations.

² In terms of congenital disabilities (art. 3, para. 2, LPGA ¹ ), the therapeutic measures of the disability insurance benefits catalogue are included in the provisions and lists established under para. 1. ²

³ Analyses, drugs, means and diagnostic or therapeutic devices may be billed at the most following rates, rates and rates of pay within the meaning of para. 1. The Federal Council refers to analyses carried out in the office of the doctor for which the tariff may be fixed according to art. 46 and 48.

The pharmacist may replace original preparations from the list of specialties with cheaper generic versions of the list, unless the physician or chiropractor specifically requires the issuance of an original preparation. He shall inform the person who has prescribed the medication of the preparation that he has issued.

¹ The decisions of cantonal governments referred to in s. 39, 45, 46, para. 4, 47, 48, para. 1 to 3, 51, 54, 55 and 55 A May be appealed to the Federal Administrative Tribunal.

² The appeal procedure is governed by the Act of 17 June 2005 on the Federal Administrative Tribunal ² And the Federal Act of 20 December 1968 on the administrative procedure (PA) ³ . The following exceptions are reserved:

A.

The evidence and new facts may be presented only if they are the result of the contested act; any new finding is inadmissible;

B.

Art. 22 A And 53 PA are not applicable;

C.

The time limit set by the Federal Administrative Tribunal for the filing of an answer is not more than 30 days; it cannot be extended;

D.

A subsequent exchange of written entries within the meaning of s. 57, para. 2, PA is only exceptional;

E.

The grievance of the non-opportunity cannot be invoked as a ground of appeal against decisions within the meaning of s. 39.

¹ Insurers may apply to the canton, as an extraordinary and temporary measure to limit an increase in costs above average, to set a global amount (overall budget) for the financing of hospitals or institutions Medical-social.

² The canton must decide on the entry within three months from the filing of the request. It consults with institutions and insurers in advance.

¹ When, for outpatient or hospital treatment, the average cost per insured person per year in compulsory health insurance increases at least twice as much as the average for the general evolution of prices and wages. May order that the rates or prices of all or part of the benefits should no longer be increased, as long as the relative difference in the annual growth rate is more than 50 % compared to the general trend Prices and wages.

² These authorities are:

A.

The Federal Council in respect of tariff agreements approved by it under Art. 46, para. 4;

B.

The department with regard to tariffs or prices according to Art. 52, para. 1, paragraph a, c. 1 and 2, and let. B;

C.

The cantonal government in respect of tariff agreements approved by it under Art. 46, para. 4.

¹ The Federal Council may make it dependent on the establishment of proof of need for the admission of the following persons to carry out the burden of compulsory health insurance:

A.

Physicians referred to in s. 36, whether they carry out a dependent or independent activity;

B.

Physicians who practise in an institution within the meaning of s. 36 A Or in the ambulatory field of a hospital within the meaning of s. 39.

² Physicians who have served for at least three years in a recognized Swiss training institution are not subject to proof of need.

³ The Federal Council sets the criteria for establishing proof of need after consultation with the cantons, the federations of benefit providers, the federations of insurers and the associations of patients.

⁴ The cantons shall designate the doctors referred to in para. 1. They may attach conditions to their admission.

⁵ Admission expires when the holder does not use it within a certain period of time, except for reasons such as sickness, maternity or post-graduate training. The Federal Council shall fix the applicable time limit.

¹ The benefit provider must limit his or her benefits to the extent required by the interest of the insured and the purpose of the treatment.

² Benefits that exceed this limit may be denied. The benefit provider may be required to repay the sums wrongly received within the meaning of this Law. Have standing to ask for restitution:

A.

The insured person or, in accordance with s. 89, para. 3, the insurer in the system of the third party guarantor (art. 42, para. 1);

B.

The insurer in the paying party's system (s. 42, para. 2).

³ The benefit provider must pass on to the debtor the direct or indirect benefits that he receives:

A.

From another service provider acting on his or her mandate;

B.

Persons or institutions that supply drugs or diagnostic or therapeutic means and devices.

⁴ If the benefit provider does not have this benefit, the insured person or insurer may require that the benefit be returned.

⁵ Benefit providers and insurers provide in the tariff agreements for measures designed to guarantee the economic character of the benefits. In particular, they ensure that there is no unnecessary repetition of diagnostic procedures when an insured person consults with several benefit providers.

⁶ Benefit providers and insurers agree to a method of controlling the economic nature of benefits. ¹

¹ After consultation with cantonal medical societies, insurers or their federations designate medical consultants. They must comply with the conditions of admission laid down in Art. 36 and have practised in a medical practice or held a position in a hospital for at least five years.

² Medical consultants who are required to practice throughout Switzerland shall be appointed with the agreement of the medical society of the canton in which the insurer has its principal place of business or in which the federation of insurers has its registered office.

³ A cantonal medical society may challenge a medical adviser for just cause; in this case, the arbitral tribunal within the meaning of s. 89 statue.

⁴ The Medical Officer advises the Insurer on medical matters as well as on matters relating to remuneration and the application of tariffs. In particular, it examines whether the conditions for the assumption of a benefit are met.

⁵ The Medical Officer assesses cases independently. Neither the Insurer nor the benefit provider nor their federations can give him instructions.

⁶ Benefit providers must provide the medical practitioners with the guidance they need to carry out their duties under para. 4. If it is not possible to obtain this information by another means, the Medical Officer may examine the insured himself; he must inform the attending physician beforehand and communicate the result of the examination to him. Where circumstances warrant, the insured may, however, require that the examination be carried out by a physician other than the Medical Officer. Where the insured and the insurer cannot agree, the arbitral tribunal within the meaning of s. 89 instalments, in derogation from Art. 58, para. 1, LPGA ¹ . ²

⁷ The medical advisors shall transmit to the competent bodies of the insurers only the indications which they need in order to decide on the assumption of a benefit, in order to fix the remuneration, to calculate the compensation of the risks or to Give reasons for a decision. In so doing, they respect the rights of the personality of the insured. ³

⁸ Swiss umbrella associations of doctors and insurers regulate the transmission of indications within the meaning of para. 7, continuing education and the status of medical consultants. If they cannot agree, the Federal Council shall issue the necessary provisions.

¹ After consulting with interested organisations, the Federal Council may lay down scientific and systematic checks to ensure the quality or adequacy of the benefits that compulsory health insurance supports.

² It may entrust the execution to professional associations or other institutions.

³ It determines the measures used to guarantee or restore the quality or adequacy of the benefits. In particular, it may provide that:

A.

The agreement of the medical adviser is necessary before certain diagnostic or therapeutic measures are carried out, in particular those that are particularly expensive;

B.

Particularly expensive or difficult diagnostic or therapeutic measures will be covered by compulsory health care insurance only when carried out by providers of qualified health care services. It may refer to these service providers.

¹ Benefit providers who fail to comply with the economic and quality requirements of the benefits provided for in the law (art. 56 and 58) or in a contract are subject to sanctions. These are:

A.

Warning;

B.

Restitution of all or part of the honoraria for benefits provided in an inappropriate manner;

C.

Amen;

D.

In the event of a re-offending, the temporary or definitive exclusion of any activity dependent on the compulsory insurance of care.

² The Arbitral Tribunal within the meaning of s. 89 makes the appropriate sanction on the proposal of an insurer or a federation of insurers.

³ In particular, breaches of the legal or contractual requirements referred to in para. 1:

A.

Non-compliance with the economic character of benefits within the meaning of s. 56, para. 1;

B.

The failure or improper performance of the duty to provide information within the meaning of s. 57, para. 6;

C.

Obstruction of the quality assurance measures provided for in s. 58;

D.

Non-compliance with the tariff protection referred to in s. 44;

E.

Non-repercussion of benefits within the meaning of s. 56, para. 3;

F.

Fraudulent manipulation of accounts or the production of testimonials contrary to the truth.

¹ Benefit providers shall communicate to the competent federal authorities the data necessary to monitor the application of the provisions of this Law relating to the economic character and quality of benefits. The following particulars shall be communicated in particular:

A.

The type of activity performed, the infrastructure and equipment, and the legal form;

B.

The workforce and structure of staff, the number of training places and their structure;

C.

The number of patients and the structure of their workforce, in an anonymous form;

D.

The type, extent and cost of the benefits provided;

E.

Loads, products and operating results;

F.

Medical quality indicators.

² Interviewees are subject to the obligation to provide information. Data must be provided free of charge.

³ The data are collected by the Federal Statistics Office. It shall make available to the Federal Office of Public Health, the Supervisor of Prices, the Federal Office of Justice, the cantons, the insurers and the bodies set out in Art. 84 A Data by benefit provider listed in para. 1 for the purposes of this Act. These data are published.

⁴ The Federal Council shall lay down detailed provisions on the collection, processing, transmission and publication of data, in accordance with the principle of proportionality.

¹ The insurer determines the amount of premiums payable by its policyholders. Except as otherwise provided in this Act, the Insurer shall levy equal premiums with its policyholders.

² The insurer will scale the premium amounts based on differences in cantonal costs. Exceptions are possible for very small numbers. The insured person's place of residence is determinative. ¹

^2bis The insurer can scale premiums by region. The department consistently defined regions as well as maximum allowable differences in premiums based on cost differences between regions. ²

³ For insured persons under 18 years of age (children), the insurer must set a lower premium than the older (adult) policyholders. It is authorized to do so for insured persons under 25 years of age (young adults). ³

^3bis The Federal Council may fix the premium reductions referred to in par. 3. ⁴

⁴ For insured persons residing in a Member State of the European Community, Iceland or Norway, premiums shall be calculated on the basis of the State of residence. The Federal Council shall issue provisions on the fixing and encashment of premiums for these insured persons. ⁵

⁵ ... ⁶

The premiums of members of the family of a person who is insured because they engage in a gainful occupation in Switzerland, because they are in receipt of a Swiss pension or because they receive a Swiss unemployment insurance benefit, are deducted from the That person.

¹ The insurer may reduce insurance premiums involving a limited selection of the benefit provider under s. 41, para. 4.

² The Federal Council may authorise the practice of other forms of insurance, including those in which:

A.

An insured person who consents to a higher cost participation than is provided for in s. 64 benefits in return for a premium reduction;

B.

The amount of the insured's premium depends on whether or not he has received benefits for a certain period of time.

^2bis Participation in costs, as well as the loss of the premium reduction in accordance with other forms of insurance designated in para. 2 cannot be insured by either a sickness or a private insurance institution. Associations, foundations or other institutions are also prohibited from providing for the assumption of costs arising out of these forms of insurance. The provisions of public law of the Confederation and of the cantons are reserved. ¹

³ The Federal Council regulates specific forms of insurance in detail. It fixes, inter alia, on the basis of insurance requirements, the maximum limits for premium reductions and the minimum limits for premium supplements. Compensation for risks under s. 105 remains in all reserved cases.

¹ If an association of employers, an association of workers or an assisting authority is responsible for carrying out health insurance, the insurer compensates them in an appropriate manner. Notwithstanding s. 28, para. 1, LPGA ¹ , this rule is also applicable when an employer is responsible for these tasks. ²

² The Federal Council sets maximum limits for allowances.

¹ Insured persons participate in the costs of the benefits they receive.

² Their participation includes:

A.

A fixed amount per year (deductible); and

B.

10 % of costs that go beyond the deductible (quote-share).

³ The Federal Council shall determine the amount of the deductible and the maximum annual amount of the quota.

⁴ For children, no deductible is required and the maximum amount of the quota is reduced by half. Several children of the same family, insured by the same insurer, jointly pay the maximum amount of deductible and assessed contributions due by an adult.

⁵ In the event of hospitalization, the insured also pay a contribution to the cost of the stay, in accordance with the family expenses. The Federal Council fixes the amount of this contribution.

⁶ The Federal Council may:

A.

Provide for higher costs for certain benefits;

B.

Reduce or eliminate participation in the costs of long-term treatment and the treatment of serious diseases;

C.

Eliminate cost-sharing for insurance involving a limited selection according to s. 41, para. 4, where such participation is inappropriate;

D. ¹

Remove the exemption for certain preventive measures implemented in the framework of programmes organised at national or cantonal level.

⁷ The Insurer may not charge any of the following benefits:

A.

Benefits referred to in s. 29, para. 2;

B.

Benefits referred to in s. 25 and 25 A That are provided from the 13 ^E Week of pregnancy, during delivery, and up to eight weeks after delivery. ²

⁸ Participation in costs cannot be ensured by either a sickness insurance scheme or a private insurance institution. It is also forbidden for associations, foundations or other institutions to provide for the assumption of these costs. The provisions of public law of the Confederation and of the cantons are reserved. ³

¹ Where the insured person has not paid premiums or contributions to the matured costs, the insurer shall send him a summons, preceded by at least one written reminder; he shall give him a period of 30 days and shall inform him of the consequences of a delay in payment (para. 2).

² If, in spite of the summons, the insured does not pay within the prescribed period the premiums, the costs and the moral interest owed, the insurer must initiate proceedings. The canton may require the insurer to advertise to the competent cantonal authority debtors who are the subject of proceedings.

³ The Insurer announces to the competent cantonal authority the debtors concerned and, for each, the total amount of the claims covered by the compulsory health insurance (premiums and contributions to the fixed costs, moratoria and costs of Prosecution) for which an act of default of property or an equivalent title was issued during the period under review. It asks the supervisory body designated by the canton to certify the accuracy of the data submitted and to transmit the certificate to the canton.

⁴ The canton shall pay 85 % of the claims which have been the subject of the announcement provided for in para. 3. ²

⁵ The Insurer retains the acts of default of property and the equivalent securities until the full payment of the outstanding claims. As soon as the insured has paid all or part of its debt to the insurer, the insurer shall return 50 % of the amount paid by the insured to the canton.

⁶ Notwithstanding s. 7, the person who is late in payment may not change the insurer until he has paid in full the premiums and contributions to the rear costs, as well as the moratoria and prosecution costs. Art. 7, para. 3 and 4, is reserved.

⁷ The cantons may keep a list of insured persons who do not pay their premiums despite the prosecution, a list to which only the benefit providers, the municipality and the canton have access. Upon notification of the canton, the insurer shall suspend the payment of the benefits provided to those insured, with the exception of those covered by emergency medicine, and shall notify the competent cantonal authority of the suspension of its care and, When the insured have paid their claims, the cancellation of the suspension.

⁸ The Federal Council regulates the tasks of the review body and designates the titles deemed equivalent to an act of default of property. It also regulates the procedure for summing and prosecuting as well as the arrangements for the transmission of data from insurers to the cantons and the payments of the cantons to insurers.

⁹ The Federal Council lays down provisions on the non-payment of premiums and contributions to the costs of persons who are required to ensure that they reside in a Member State of the European Community, in Iceland or in Norway.

¹ The cantons grant a reduction in premiums to insured persons of modest economic conditions. They pay directly the corresponding amount to the insurers concerned. The Federal Council may take advantage of this reduction to persons who are obliged to ensure that they have no domicile in Switzerland but who are staying there for an extended period of time. ²

^1bis For low and middle income, the cantons reduce the premiums of children and young adults in training by at least 50 %. ³

² The exchange of data between the cantons and the insurers takes place in a uniform manner. The Federal Council shall settle the arrangements after having heard the cantons and the insurers. ⁴

³ The cantons shall ensure, during the examination of the conditions of grant, that the most recent economic and family circumstances are taken into account, in particular at the request of the insured. After determining the circle of entitled persons, the cantons shall also ensure that the amounts paid in respect of the reduction of the premiums are so as to ensure that the right holders do not have to meet their obligation in advance in accordance with their obligation to Pay the premiums.

⁴ The cantons shall regularly inform the insured of their right to the reduction of premiums.

^4bis The canton shall inform the insurer of the data concerning the beneficiaries of the right to the reduction of premiums and the amount of the reduction sufficiently soon so that the latter can take them into account when invoicing the premiums. The Insurer shall inform the beneficiary of the actual amount of the reduction in premiums at the latest in the following invoicing. ⁵

⁵ Insurers are required to cooperate that extends beyond the administrative assistance provided for in s. 82. ⁶

⁶ The cantons shall transmit to the Confederation anonymous data relating to insured persons, so that the latter can examine whether the social and family policy goals have been achieved. The Federal Council shall issue the implementing provisions. ⁷

The cantons shall grant a reduction in premiums to the following low-income insured persons residing in a Member State of the European Community, Iceland or Norway:

A.

Border and family members;

B.

Members of the family of persons holding a residence permit, a residence permit or a short-term residence permit in Switzerland;

C.

Persons who receive Swiss unemployment insurance benefits and members of their families.

¹ The Confederation grants the cantons annual subsidies to reduce premiums within the meaning of Art. 65 and 65 A .

² Federal subsidies correspond to 7.5 % of the gross costs of compulsory insurance.

³ The Federal Council sets out the share of federal subsidies to each township based on its resident population and the number of insured persons referred to in s. 65 A , let. A.

¹ The Confederation granted a reduction in premiums to insured persons of modest economic conditions who reside in a Member State of the European Community, in Iceland or in Norway and who receive a Swiss pension as well as members of their families. ³

² The Confederation is responsible for the financing of subsidies for the reduction of premiums for insured persons under para. 1.

³ The Federal Council regulates the procedure.