Scope of care reimbursed from public health insurance

If a foreign national is a participant in public health insurance, they have the same entitlement to health care reimbursed from public health insurance as other insured persons.

Health care provided on the basis of public health insurance and reimbursed from this insurance covers: 

  • outpatient and institutional (inpatient) care
  • emergency and ambulance services
  • preventive care
  • dispensary care
  • supply of medicaments, medical supplies (e.g. hearing aids, bandages)
  • balneological care, care in specialized children’s hospitals and sanatoria
  • industrial health care
  • transport of the sick, reimbursement of travel expenses 
  • forensic examination and post-mortem

Health care is provided in health care facilities. If a situation so requires, it may be provided elsewhere. Health care is provided by health personnel within the scope of their qualification. The essential condition for the provision of reimbursed health care is that it must be provided in a health care facility which has a contract with the patient’s insurer. If essential and urgent health care is needed, it may be provided in exceptional circumstances by a health care facility which does not have a contract with the patient’s insurer. An exception to this rule is a pharmacy because an insured person can ask for a medicament at any pharmacy regardless of the existence of its contract with the insured person’s insurer. A prescription must be issued, however, in case of other than urgent health care by a physician who has a contract with the insured person’s insurer. Within the public health insurance system, health care is reimbursed by the insurer on the basis of its contract with the health care facility.

There are many procedures which insured persons co-finance. These are procedures or medical devices provided outside the legal framework. Some cases in point are dental procedures, some balneological care and some medicaments. Some medicaments are reimbursed in full by insurance companies whereas some are co-financed by the patients. In every category of medicaments there must be at least one reimbursed in full by an insurer. Costs of medicaments and medical devices during hospitalization are reimbursed in full by the insurer and the insured person does not pay directly.

Some health care to which public health insurance does not apply and which patients must pay directly is defined by law. Some examples of this are:

  • plastic surgery for aesthetic reasons at patient’s request
  • selected dental procedures
  • acupuncture

EXAMPLES:
You are going to see your dentist and he finds during the examination that you have caries. As a solution he offers you either a grey amalgam filling reimbursed in full from public health insurance, or a white filling which is not reimbursed from insurance.
You are going to see your physician and ask for an examination for your driving licence. In this case you pay for the examination because public health insurance funds do not cover procedures and examinations done at the personal interests of the insured person.

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Published: 16.09.2010

Last change: 16.09.2010, 11:50 AM