Ordinance on the Reimbursement of Health and Disability Costs for Supplementary Benefits (KBV) - Relevant Temporal Costs (PAI)

1. Specified illness, disability, and aid device costs shall be reimbursed for the calendar year in which the treatment was carried out or the purchase was made. This regulation shall apply equally to the costs of a temporary stay in a care facility.

1. Entitlement to reimbursement of costs according to Art. 14 of the Federal Act on Supplementary Benefits to Old Age, Survivors, and Invalidity Insurance (ELG) of October 6, 2006, exists only to the extent that no other insurances cover the costs. Receiving a helplessness allowance from the old age and survivors' insurance (AHV), the invalidity insurance (IV), the accident insurance, or the military insurance is not considered cost reimbursement by another insurance.

2. If the amount of cost reimbursement increases according to Art. 14 para. 4 ELG or Art. 19b of the Ordinance on Supplementary Benefits to Old Age, Survivors, and Invalidity Insurance (ELV) of January 15, 1971, the helplessness allowance from the IV and accident insurance, as well as the assistance contribution from the AHV or IV, will be deducted from the certified care and assistance costs according to §§ 13-16 of this ordinance. However, the maximum amount according to Art. 14 para. 3 lit. a ELG must not be undercut.

3. If the health insurance, for its reimbursement of care and assistance costs at home, has accounted for the helplessness allowance from the IV or accident insurance, the helplessness allowance will not be deducted from the certified costs to the extent of the accounting.

4. When applying Art. 14 para. 5 ELG, paragraphs 2 and 3 apply accordingly.

1. Costs for illness, disability, and medical aids incurred in Switzerland are reimbursed.

2. Costs incurred abroad are exceptionally reimbursed if they become necessary during a stay abroad or if the medically indicated measures can only be carried out abroad.

3. Costs incurred abroad for spa treatments and convalescent stays are not reimbursed.

4. If a medical aid is purchased abroad, the price provided for in Switzerland shall be decisive, provided it is lower.

1. **Compensations for Illness and Disability Costs**

Compensations for illness and disability costs are typically paid annually. However, if the balance exceeds 300 Swiss Francs, an early compensation can be requested.

2. The costs of illness and disability are paid out to the beneficiary. If these costs have not yet been paid, they may be directly compensated to the invoice issuer.

1. The participation pursuant to Article 64 of the Federal Act on Health Insurance (KVG) of March 18, 1994, in the costs for services covered by the mandatory health care insurance according to Article 24 KVG, shall be reimbursed.

1. If insurance with a higher deductible is chosen according to Art. 93 of the Health Insurance Ordinance (KVV) dated June 27, 1995, a cost sharing (deductible and co-payment) of a maximum of 1000 Swiss Francs per year will be reimbursed.

1. Dental Treatment Costs (Dentist Fees, Dental Technical Work Costs, Materials, Medications) are only to be considered insofar as they correspond to a simple, economical, and appropriate treatment and execution.

2. Whether a simple, economical, and appropriate treatment and execution is present is determined according to the treatment recommendations of the Association of Cantonal Dentists of Switzerland in the area of supplementary benefits.

3. For reimbursement, the Accident, Military, and Disability Insurance Tariff (UV/MV/IV Tariff) for the remuneration of dental services and the UV/MV/IV Tariff for dental technical work are decisive. For dental technical work purchased by Swiss Dentists abroad, the foreign dental technician tariff is decisive, provided it is lower.

4. If the costs of dental treatment (including laboratory) are expected to exceed 3000 francs, a cost estimate must be submitted to the Office for Social Contributions before the treatment.

5. Cost estimates and invoices must be submitted according to the tariff positions in the UV/MV/IV Tariff.

**1. Specified Additional Costs for Medically Prescribed Essential Diets**

Costs that are incurred due to a medically prescribed essential diet for individuals who do not reside in a home or hospital are considered as medical expenses. An annual flat rate of 2100 Swiss Francs is reimbursable.

1. In the event of a temporary stay in a hospital, an appropriate amount for living expenses will be deducted from the cost participation under § 6 in the form of the amount for full board pursuant to Art. 11 para. 2 of the Ordinance on Old-age and Survivors' Insurance (AHVV) of October 31, 1947.

1. Costs for a temporary stay in a home or hospital for up to a maximum of 90 days will be reimbursed.

2. The reimbursement of home or hospital rates is governed by §§ 4 to 6 of the Ordinance on Supplementary Benefits and Cantonal Assistance for Old Age, Survivors, and Invalidity Insurance (VELG) dated December 12, 1989. The insured person must bear an appropriate deductible in the form of the amount for full board according to Art. 11 para. 2 AHVV themselves.

3. The maximum amounts pursuant to Art. 14 para. 3 lit. a ELG are increased in these cases to 40,000 Swiss Francs for individuals and full orphans, and 80,000 Swiss Francs for married couples.

1. Costs for medically prescribed recuperative cures are reimbursed if the cure is carried out in a home or hospital according to the care home list or hospital list of the canton of location. The costs of recovery stays for the relief of relatives are also considered if the stay takes place in a home or hospital according to the care home list or hospital list of the canton of location.

2. The reimbursement of home or hospital fees is governed by §§ 4 to 6 of the Ordinance on Supplementary Benefits and Cantonal Assistance for Old-Age, Survivors', and Disability Insurance (VELG) dated December 12, 1989. The insured person must bear an appropriate deductible in the form of the amount for full board according to Art. 11 para. 2 AHVV themselves.

1. Costs for medically prescribed spa treatments conducted under medical supervision and for which the health insurance covers the contribution according to Art. 25 of the Ordinance of the FDHA on Benefits in the Compulsory Health Insurance (Health Insurance Benefits Ordinance, KLV) of September 29, 1995, will be reimbursed for a maximum of 21 days per calendar year and up to a maximum of 170 Swiss Francs per day.

2. The insured person must bear a reasonable deductible in the form of the amount for full board according to Art. 11 para. 2 of the AHVV themselves.

1. The activities of basic needs mentioned in Annex 1 are considered as home assistance and care.

2. Organizations or individuals with a cantonal Spitex authorization are obligated to perform the basic needs activities according to the principles outlined in Annex 2.

3. Costs for home assistance and care shall be reimbursed if the assistance and care are necessary due to age, disability, accident, or illness, the costs do not fall within the scope of disability assistance, and the assistance and care are provided

a) * by an organization or individual with a cantonal Spitex authorization;

b) * by a legal entity;

c) * by a natural person not residing in the same household.

4. The reimbursements per household amount to

a) in the case of para. 3 lit. a, a maximum of 50 Swiss Francs per hour, not exceeding 800 Swiss Francs per month and not exceeding 9,600 Swiss Francs per calendar year; or

b) in the case of para. 3 lit. b, a maximum of 38 Swiss Francs per hour, not exceeding 608 Swiss Francs per month and not exceeding 7,296 Swiss Francs per calendar year; or

c) in the case of para. 3 lit. c, a maximum of 30 Swiss Francs per hour, not exceeding 480 Swiss Francs per month and not exceeding 5,760 Swiss Francs per calendar year.

1. When receiving necessary services through an accredited institution pursuant to § 27 of the Law on Disability Assistance (BHG) dated September 14, 2016, for persons with disabilities as defined in § 4 BHG, the costs for non-personal services are reimbursed. For all other individuals, the costs for both personal and non-personal services are covered. The maximum amounts according to Art. 14 para. 3 lit. a ELG are increased in these cases to 60,000 Swiss Francs for individuals and full orphans, and 120,000 Swiss Francs for couples.

1bis. The consideration of the costs for personal and non-personal services under para. 1 is approved by the Long-Term Care Division of the Department of Health, if the affected person

a) has reached the reference age according to the Federal Law on Old-Age and Survivors Insurance (AHVG) dated December 20, 1946, and

b) provides evidence of disability-related needs determined by the Long-Term Care Division of the Department of Health, using the Individual Help Plan (IHP) instrument according to § 5 of the Ordinance on Disability Assistance (BHV) dated November 29, 2016.

2. For individuals who receive necessary services through an accredited institution according to the cantonal list of recognized institutions for serviced residential facilities for the elderly, only the tariffs specified in the service agreement are reimbursed.

1. In the case of persons with disabilities according to § 4 of the Disability Assistance Act and those entitled to a Personal Assistance Contribution from the Disability Insurance, as well as persons with acquired rights to a Personal Assistance Contribution under Article 43ter of the Federal Act on Old-Age and Survivors' Insurance (AHVG) of December 20, 1946, costs for assistance and care can be reimbursed.

2. The basis for reimbursement is determined by the needs related to the disability as established through the Individual Assistance Plan (IHP) tool pursuant to § 5 of the Disability Assistance Ordinance (BHV) of November 29, 2016.

3. Only costs for services involving necessary assistance and care provided by natural persons are reimbursed.

4. Services according to paragraphs 1 to 3 can also be provided by family members. The professional requirements are determined by the Office for Social Contributions.

5. The reimbursements for care services according to paragraphs 1 to 4 amount to

a) a maximum of 37 Swiss Francs per hour during the day, and

b) a maximum of 50 Swiss Francs per hour during the night.

1. Care refers to all services according to Art. 7 para. 2 KLV.

a) * ...

b) * ...

c) * ...

2. Only the personal contribution according to Art. 25a para. 5 KVG will be reimbursed for the costs of services pursuant to para. 1, to the extent that it is borne by the insured person.

3. ...

1. Costs for care pursuant to Art. 7 para. 2 KLV in a recognized institution according to the Federal Act on Institutions for the Promotion of the Integration of Disabled Persons (IFEG) of October 6, 2006, are reimbursed if the care services are provided by an organization or professional with a cantonal Spitex license, and the costs have been excluded from the disability assistance.

2. The maximum amount according to Art. 14 para. 3 letter b ELG is increased to 9,000 Swiss francs in cases pursuant to para. 1.

3. Only the personal contribution pursuant to Art. 25a para. 5 KVG is reimbursed, insofar as it is borne by the insured person.

1. Costs for directly employed nursing staff will only be reimbursed to beneficiaries living at home for the portion of care and support that cannot be provided by a provider with a cantonal Spitex authorization.

2. The Long-Term Care Department of the Health Department specifies the care and support that, in the specific case, cannot be provided by a provider with a cantonal Spitex authorization, as well as the job requirements of the person to be employed. If the Long-Term Care Department is not consulted or if their specifications are not adhered to, the costs will not be reimbursed.

3. Employer contributions due for directly employed nursing staff to mandatory social insurance are included in the calculation of the reimbursement.

1. Costs for care and assistance provided by family members are only reimbursed if the family members in question

a) are not included in the calculation of supplementary benefits; and

b) suffer a long-term, significant loss of income due to the care and assistance provided.

2. The need for care must be certified by a medical certificate. Reimbursement may be subject to the approval of the Long-term Care Department of the Health Department.

3. Employer contributions owed for family members to mandatory social insurance are included in the calculation of the reimbursement.

4. The costs are reimbursed only to the extent of the loss of income.

1. For individuals living at home, expenses for assistance, care, and supervision provided in day centers, day hospitals, outpatient facilities, occupational centers, or similar daytime structures by a public or non-profit private organization are reimbursed, provided they do not fall under the scope of disability assistance. From this amount, the in-kind wage rate for meals (Art. 11 Sec. 2 AHVV) received by the person in the daytime structure must be deducted.

2. Sec. 1 applies mutatis mutandis to the reimbursement of costs for assistance, care, and supervision in night structures.

3. ...

4. For individuals living in recognized residential homes according to § 27 BHG, costs for assistance, care, and supervision provided in a daytime structure for persons of AHV age are reimbursed if necessary to cover the costs of the disability-related needs determined using the Individual Support Plan (IHP) instrument. In these cases, the maximum amount according to Art. 14 Sec. 3 lit. b ELG is increased to 12,000 Swiss Francs.

1. Reimbursable transportation costs are covered insofar as they arise in Switzerland due to an emergency transport or necessary relocation.

2. Costs incurred for transportation to the nearest medical treatment location are also reimbursed. Costs are reimbursed up to the prices of public transportation (2nd class) for direct route travels. If the insured person is dependent on using another means of transport due to their disability, the costs are reimbursed as follows

a) Private car (provided or depreciated through disability insurance): 25 cents per km;

b) Private car: no more than 65 cents per km;

c) Taxi: Actual expenses.

3. Day and night structures pursuant to § 17 are equated with medical treatment locations as per paragraph 2.

4. Costs for travel companions are not reimbursed.

1. Beneficiaries of supplementary benefits are entitled, pursuant to Article 14, paragraph 1, item f of the Supplementary Benefits Act (SBA), to reimbursement of purchase or rental costs for aids or devices (nursing and treatment devices) listed by the Department of Economic Affairs, Social Affairs, and Environment. The aids and devices for which only rental costs are reimbursed must be specified in the list.

2. Beneficiaries of supplementary benefits are also entitled to reimbursement amounting to one-third of the contribution made by the Old Age and Survivors Insurance (OASI) for aids

a) that are listed in the annex to the Ordinance on the Provision of Aids by the Old Age Insurance (OASA) dated August 28, 1978; and

b) for which the OASI has made a financial contribution.

3. Additionally, costs for spare parts and accessories used during a surgical procedure are reimbursed.

4. There is an entitlement to cost reimbursement only to the extent that the aids are not provided or reimbursed under the provisions of the OASI, Disability Insurance (DI), or health insurance. For devices listed by the Department of Economic Affairs, Social Affairs, and Environment, rental costs are reimbursed solely for home care.

5. Purchase or rental costs are reimbursed, provided the implementation of the aid is simple and appropriate.

6. The provisions of the Disability Insurance apply mutatis mutandis to the reimbursement of repair, adjustment, renewal, and usage training costs.

1. Where it appears doubtful whether an aid or appliance is necessary or whether its design is simple and appropriate, the beneficiary must provide a certificate from a physician, a specialized body for invalid assistance, or an occupational therapy organization.

2. For hearing aids, the necessity and appropriateness of the device must be certified by an expert recognized by the disability insurance for the assessment of hearing aids.

3. The costs for the assessments are considered costs within the meaning of Art. 14 para. 1 lit. f of the ELG.

1. This regulation shall be published. It shall become effective simultaneously with the amendment of the Act on the Introduction of the Federal Act on Supplemental Benefits to Old Age, Survivors, and Disability Insurance as well as on the Provision of Cantonal Assistance (EG/ELG) of November 7, 2007.