Ordinance on Health Insurance in the Canton of Basel-Stadt (KVO) - Responsible Departments (KVO)

**1. Implementation of Tasks in the Field of Mandatory Health Care Insurance**

The implementation of tasks in the area of mandatory health care insurance (hereinafter health insurance), according to the Federal Law on Health Insurance (KVG) of March 18, 1994, is partly the responsibility of the Department of Health and partly the Department for Economic Affairs, Social Affairs, and Environment (Office for Social Contributions). The two departments regulate their cooperation.

**2. The following tasks are carried out by the Department of Health:**

a) Preparation for the attention of the executive council of the decisions assigned to the cantonal government by the Federal Law on Health Insurance, in particular, tariff approval, tariff setting, and ensuring medical care in accordance with Art. 25a para. 2, 43 to 51, and para. 2 of the transitional provisions regarding the amendment of June 13, 2008, of the Federal Law on Health Insurance (KVG);

b) Preparation for the attention of the executive council of extraordinary measures to curb cost development according to Art. 54 to 55a KVG;

c) Participation in the joint institution according to Art. 19 KVG;

d) Hospital planning;

e) Conducting operational comparisons;

f) Participation in the compilation of legally required statistics;

g) Cost assumption in case of medically necessary hospital stays outside the canton;

h) Regulation in the event of a service provider's absence;

i) Preparation for securing medical care for the attention of the executive council;

j) ...

k) Implementation of the remaining financing of care costs in accordance with Art. 25a para. 5 KVG;

l) Preparation for the attention of the executive council concerning examinations and treatments according to § 4a;

m) Updating the procedure codes of the Swiss Operations Classification (CHOP) according to Appendix 1 of the Ordinance of the Federal Department of Home Affairs on Benefits in Mandatory Health Care Insurance (Health Care Benefits Ordinance, KLV) of September 29, 1995.

**3. The following tasks are carried out by the Department for Economic Affairs, Social Affairs, and Environment (Office for Social Contributions):**

a) Implementation of the health insurance obligation and compensation to the insurers for uncollectible premiums and cost contributions from insured persons residing in the Canton of Basel-Stadt according to Art. 64a KVG;

b) Allocation and control of contributions to health insurance premiums;

c) Implementation of the Law on Health Insurance in the Canton of Basel-Stadt (GKV) of November 15, 1989;

d) Application of §§ 5 and 6 of the Ordinance on the Law concerning Public Dental Care (Dental Care Ordinance) of October 30, 2001;

e) Allocation and control of cantonal contributions to hospital and nursing home fees according to § 8a;

f) Allocation and control of cantonal contributions to the costs of outpatient care according to § 8c.

**4. The Office for Social Contributions conducts an analysis within the framework of tariff business preparations according to para. 2 letter a, on any potential effects of tariff adjustments, particularly on the level of health insurance premiums, contributions to health insurance premiums, social assistance, supplementary benefits, and cantonal subsidies, as well as on the insurance obligation. It receives the necessary documentation for this purpose from the Department of Health at least 19 days before the executive council meeting for a statement prepared for the executive council.**

1. The canton participates in the joint institution pursuant to Art. 19 of the KVG for the promotion of health and the prevention of diseases.

1. The Department of Health determines the foundation for establishing an adequate hospital care supply and for determining the need for nursing beds.

2. In doing so, it takes into account efforts towards regional and inter-cantonal cooperation.

1. The Department of Health prepares, for the attention of the Government Council, the lists of approved cantonal and out-of-canton hospitals, clinics, and nursing homes, categorized according to service agreements.

2. The Government Council issues the lists.

1. The Executive Council designates elective examinations and treatments that can, as a rule, be performed more effectively, appropriately, or economically on an outpatient basis rather than inpatient (Appendix 3).

2. The Canton contributes to the costs of inpatient examinations and treatments according to paragraph 1 for patients only if special circumstances require inpatient care. Special circumstances exist particularly when the patient

a) is exceptionally severely ill;

b) suffers from severe comorbidities;

c) requires special treatment or care;

d) lives under special social circumstances.

2bis. Special circumstances, due to age, exist for patients who have not yet reached the age of 16 or have already reached the age of 75, concerning the following examinations and treatments

a) Cataract;

b) Hand surgery;

c) Foot surgery (excluding hallux valgus);

d) Osteosynthesis material removal (OSME);

e) Circumcision;

f) Extracorporeal shock wave lithotripsy (ESWL).

3. The hospital documents the special circumstances for the attention of the Health Department. The latter may provide for exceptions to the documentation requirement.

4. The Health Department may access patient records at any time.

1. The Department of Health conducts the operational comparisons mandated by the Government Council and the Federal Council.

1. The Department of Health coordinates, in consultation with the statistical office, the creation of statistics and the collection of data by individuals and organizations obligated to cooperate under federal law. It may delegate these tasks to third parties.

1. The Department of Health regulates the assumption of costs for out-of-canton hospitalizations pursuant to Art. 41 of the Health Insurance Act (KVG) in consultation with the cost bearers.

1. The Maximum Personal Contribution of the Insured Person According to Art. 25a para. 5 KVG to the Costs of Inpatient Care is 20 Percent of the Highest Nursing Contribution Set by the Federal Council.

1. a) Hospital

If a health insurer reduces its benefits per hospital day pursuant to Art. 49 para. 4 KVG and the insured person neither receives an AHV or IV pension nor a daily allowance from the IV or social assistance, the canton shall, upon request, provide contributions for the insured person's stay in hospitals listed on the cantonal hospital list until the 360th day of care.

2. b) Nursing Home

For the stay of the insured person, who neither receives an AHV or IV pension nor a daily allowance from the IV or social assistance, in a nursing home or in a nursing ward of a hospital, which is listed on the cantonal nursing home list, the canton shall, upon request, provide contributions until the 360th day of care.

3. c) Contribution Amount

1. The amount of contributions is determined according to the income groups applicable for the individual premium reduction (IPV) and corresponds to the difference between the hospital and nursing home rates set by the government council or agreed in contracts between the government council and service providers, and the following maximum personal contribution of the insured person.

| IPV Income Group | Max. Personal Contribution Fr. per Day * |

| --- | --- |

| 1 | 10 |

| 2 | 10 |

| 3 | 10 |

| 4 | 10 |

| 5 | 10 |

| 6 | 10 |

| 7 | 10 |

| 8 | 10 |

| 9 | 10 |

| 10 | 14 |

| 11 | 18 |

| 12 | 22 |

| 13 | 26 |

| 14 | 30 |

| 15 | 34 |

| 16 | 38 |

| 17 | 42 |

| 18 | 46 |

| no IPV entitlement | 50 |

1. The maximum personal contribution of the insured person pursuant to Art. 25a para. 5 KVG towards the costs of outpatient care amounts to 10 percent of the highest care allowance per day set by the Federal Council. The maximum personal contribution is only applicable for a service duration of one hour; for shorter service durations, the applicable personal contribution is proportionally reduced (pro rata temporis).

2. When two or more service providers are used per day, the maximum personal contribution increases overall to 20 percent of the highest care allowance per day set by the Federal Council. The applicable personal contribution is to be divided among the service providers proportionally to their respective service duration (pro rata temporis), whereby each individual service provider may charge a maximum personal contribution according to para. 1.

1. Insured persons who are entitled to individual premium reduction and who do not receive an old-age or disability pension (AHV or IV), a daily allowance from the IV, or social assistance may, upon request, receive contributions from the canton towards the costs of outpatient care. The amount of the cantonal contribution corresponds to the maximum personal contribution according to § 8b.

2. A claim for cantonal contributions arises only for a service volume of 20 hours of outpatient care per calendar year. Paragraph 6 remains reserved.

3. The Department of Health may restrict the eligible service volume.

4. The contributions are subsidiary to benefits from third parties.

5. For children and adolescents up to 18 years of age, the personal contribution according to § 8b will be assumed by the canton in the incurred amount.

6. Contributions are only provided to persons residing in the canton.

1. a) Nursing Homes

1. The standard nursing costs are determined by multiplying the point value in Swiss Francs, as determined by the government council, with the index values per level of care (Appendix 1 § 2).

| Level of Care | Daily Care Effort in Minutes | Daily Care Costs in CHF |

| --- | --- | --- |

| * | ... | ... |

| 1 * | ... | ... |

| 2 * | ... | ... |

| 3 * | ... | ... |

| 4 * | ... | ... |

| 5 * | ... | ... |

| 6 * | ... | ... |

| 7 * | ... | ... |

| 8 * | ... | ... |

| 9 * | ... | ... |

| 10 * | ... | ... |

| 11 * | ... | ... |

| 12 * | ... | ... |

2. b) Outpatient Care

1. The following recognized care costs apply for the calculation of the residual financing by the canton.

| Care Costs per Hour in CHF | First Hour | From Second Hour |

| --- | --- | --- |

| Needs Assessment | 96 | 80 |

| Treatment Care | 90 * | 80 * |

| Basic Care | 80 * | 70 * |

| Basic Care Provided by Caregiving Relatives * | 69.25 | 61.60 |

1. The government council sets the rate for pension and care for nursing homes typically every four years in a nursing home framework agreement.

2. It determines the rate based on cost, performance, and demand data. In setting the rate, it takes into account the costs and needs, as well as particularly the regulatory and fiscal policy conditions, and the price and wage developments of the factors relevant to long-term care costs. It may also consider comparative values from other cantons.

3. During the term of the rate established in the nursing home framework agreement, an automatic inflation adjustment to the entire rate for pension and care is granted annually on January 1st. This is based on the development of the Basel Consumer Price Index for annual inflation as of June (June Index) of the previous year. If the June Index shows a negative development, no adjustment of the rate occurs. An inflation adjustment is only granted again when the cumulative value is positive.

3. The intra-cantonal jurisdiction for the provision of residual financing, contributions to hospital and nursing home tariffs, contributions to the costs of outpatient care, and acute and transitional care is regulated in a contract between the Canton of Basel-Stadt and the municipalities of Bettingen and Riehen.

1. The canton may make contributions towards the costs of medically prescribed domestic services. The amount of these contributions is determined according to the premium reduction levels applicable for Individual Premium Reduction (IPR).

1. If a service provider refuses to provide statutory services according to the tariffs and prices established by contract or authority, they must report this in writing to the Department of Health. The Department will publish a corresponding list.

1. If no collective agreement is concluded between the service providers and the health insurers, or if, due to the standstill of service providers in accordance with § 9 of this regulation, the treatment of insured persons under the Health Insurance Act (KVG) is not guaranteed, the government council shall set the tariff after consulting the parties involved.

2. According to § 1 paragraph 2 letter a of this regulation, the preparation of the tariff setting for the government council is the responsibility of the health department. This also applies to the preparation of the setting of framework tariffs as well as the approval decisions by the cantonal government in accordance with the KVG. The Department of Economic, Social, and Environmental Affairs reports in accordance with § 1 paragraph 4 of this regulation.

1. In the implementation of health insurance pursuant to the KVG, the canton coordinates its tasks with the approved health insurers.

2. For this purpose, it may enter into a contractual agreement with the health insurers, taking into consideration the relevant federal law.

3. ...

1. As the audit authority pursuant to Article 64a paragraph 3 of the Federal Health Insurance Act (KVG), the canton designates the supervisory body of health insurers according to Article 86 of the Federal Ordinance on Health Insurance (KVV).

2. The audit authority pursuant to paragraph 1 confirms to the canton in its annual report according to Article 64a paragraph 3 KVG,

a) that the insurer possesses an operational collection concept which has been reviewed by the audit authority,

b) that in the event of non-payment of premiums and deductibles, the federal legal dunning and enforcement regulations are adhered to,

c) that the insurer actively manages or arranges to manage the certificates of loss and equivalent legal titles.

3. Health insurers must grant the Office for Social Contributions unrestricted access to the internal collection and debt recovery regulations upon request and annually inform the office about the revenues from the management of loss certificates, their ratio to the premium volume of the insurer in the canton, as well as the gross expenses of the loss certificate costs (before offsetting against the revenues).

1. A certificate of loss as per Art. 64a para. 3 KVG is equivalent to disposals regarding the awarding of supplementary benefits or equivalent legal titles that demonstrate the insured person's lack of financial means. The Office for Social Contributions determines the equivalency of legal titles in the documents submitted with the health insurers' billing.

1. The Office for Social Contributions enforces the insurance obligation according to the Health Insurance Act (KVG). It

a) provides information about the mandatory health insurance according to the KVG,

b) regularly checks compliance with the insurance obligation as per the KVG,

c) decides on exceptions from the insurance obligation, and

d) assigns individuals who fail to comply with their insurance obligation in accordance with Art. 3 KVG in a timely manner to an approved health insurer. Such assignment is made proportional to the market share (insured population) that health insurers operating in the Canton of Basel-Stadt report based on the previous year's figures.

2. Together with the Residents' Registration Office, the Civil Registry Office, and the Office for Economic Affairs and Labor, the Office for Social Contributions ensures that the individuals mentioned in Art. 3 and Art. 6a para. 1 KVG are informed about the insurance obligation. The aforementioned authorities continuously provide the necessary personal data electronically for this purpose.

3. In order to verify compliance with the insurance obligation according to the KVG for all residents of the Canton of Basel-Stadt, the Office for Social Contributions is authorized to obtain the necessary personal data from the Residents' Registration Office electronically and align it with the insurance data of the health insurers as per the KVG.

1. The Office for Social Contributions charges a fee of 75 Swiss Francs for the processing of applications for exemption from the insurance obligation pursuant to § 12 sec. 1 lit. c of this Regulation.

2. The examination of the applications is subject to the prior payment of the fee.

1. Health insurers operating in the Canton of Basel-Stadt are obligated to regularly inform individuals insured with them, who reside in the Canton of Basel-Stadt, as well as individuals insured with them pursuant to Art. 65a letters a to c of the Health Insurance Act (KVG), about the possibility of applying for contributions to health insurance premiums (Art. 65 et seq. KVG).

1. The canton shall, upon application, provide contributions towards the health insurance premiums of economically disadvantaged individuals residing in the Canton of Basel-Stadt, as well as individuals pursuant to Art. 65a KVG who are insured in the Canton of Basel-Stadt, provided that the legal requirements are met.

1. Upon relocation to the Canton of Basel-Stadt from another canton, any potential claim for contributions to health insurance premiums until the end of the respective calendar year shall be determined according to the laws of the canton in which the insured person resided on January 1.

2. Upon relocation to the Canton of Basel-Stadt from abroad, the claim for contributions to health insurance premiums arises from the month of insurance coverage according to the Swiss Health Insurance Act (KVG), provided that enrollment with a health insurer authorized under the KVG and the application for contributions to health insurance premiums occur within 3 months of relocation.

3. For individuals according to Art. 65a letters a to c KVG, the claim for contributions to health insurance premiums arises from the month of insurance commencement under the KVG, provided that the application for contributions to health insurance premiums is made within 3 months from the start of insurance.

1. If the documents submitted for the claim review are incomplete, the Office for Social Contributions shall request the missing documents. The missing documents must be submitted within two months from the receipt of the request letter. If this deadline is not met, a new application must be submitted.

2. For the assessment of eligibility, the Office for Social Contributions may issue summonses and/or require written statements and/or the submission of specific documents. Employers of employees who have applied for contributions towards health insurance premiums are obliged, upon request of the Office for Social Contributions, to issue and send salary certificates to the office.

1. Basis for the Determination and Calculation of a Claim for Contributions to Health Insurance Premiums are the Harmonization of Social Benefits Act (SoHaG) of June 25, 2008, as well as the Ordinance on the Harmonization and Coordination of Need-based Social Benefits (SoHaV) of November 25, 2008.

2. ...

1. The assessable income according to § 7 SoHaG of persons referred to in Art. 65a lit. a to c KVG is converted in accordance with the purchasing power index of the respective country of residence. This regulation does not apply to any potentially assessable hypothetical earned income (§§ 19 ff. SoHaV).

2. The purchasing power index mentioned in paragraph 1 is determined according to the Ordinance of the Federal Department of Home Affairs (EDI) on Price Level Indices and Minimum Premiums for the Entitlement to Premium Reductions in the European Community, in Iceland, and in Norway of November 22, 2007.

3. The purchasing power-adjusted assessable income as per paragraphs 1 and 2 is converted into Swiss Francs according to the exchange rates announced by the Administrative Commission of the European Communities for the Social Security of Migrant Workers for the implementation of Regulation (EEC) No 574/72.

1. If a fee is imposed due to a violation of notification obligations and both the fee and the recovery are disputed, an objection must be lodged with the issuing authority within 30 days of the issuance of the decision.

2. If only the fee is contested, an appeal must be lodged with the Department of Economic Affairs, Social Affairs, and Environment within 10 days of the issuance of the decision. The grounds for the appeal must be submitted within 30 days from the same date. It must include the requests of the appellant and a justification with an indication of the evidence to be presented.

1. In determining the amount of contributions to health insurance premiums for the three categories of persons specified in Art. 61 para. 3 KVG "adults," "young adults," and "children," the Government Council is guided by the amount of the respective premiums for health insurance, including premiums for special forms of insurance pursuant to Art. 62 KVG, as well as other permissible premium reductions.

1bis. Eligible persons who are insured under a special form of insurance pursuant to Art. 62 para. 1 KVG receive a supplement to the monthly contribution to health insurance premiums. The relevant insurance certificate must be submitted with the application and subsequently on an annual basis. The Office for Social Contributions may require that the insurance models considered for the supplement have a minimum discount compared to the regular health insurance coverage of the relevant insurer.

2. For the implementation of Art. 65 para. 1bis KVG, the Government Council is guided by a reference premium. This is set at 90 percent of the expected cantonal average premium for the respective category of persons according to para. 1.

3. For the implementation of Art. 65a KVG, the Government Council is guided by the average premiums applicable in the respective states, which are derived from the ordinance of the EDI concerning price level indices and minimum premiums for eligibility for premium reductions in the European Community, in Iceland, and in Norway as of November 22, 2007. If these average premiums are not more than 10 percent below the average premium of the canton of Basel-Stadt, the same provisions apply to persons according to Art. 65a lit. a to c KVG as to persons residing in the canton of Basel-Stadt. In the case of deviations exceeding 10 percent, the Government Council may make appropriate gradations.

1. Contributions to health insurance premiums are only granted if the relevant income of the household unit, according to § 6 para. 2 lit. d SoHaG, does not exceed the benefit limit calculated according to § 11 para. 2 SoHaV. For household units of up to eight people, the benefit limits can be found in the table T 1 below. For household units of nine or more people, the benefit limits increase, based on the benefit limit of the preceding household unit, in accordance with the calculation method of § 11 para. 2 SoHaV, by CHF 4,000 per person.

2. The premium group and the amount of the respective contributions to the health insurance premiums are determined based on the relevant income according to § 6 para. 2 lit. d SoHaG and by applying § 21 of this regulation, as shown in the tables T 2, T 3, and T 4 below. The maximum amount of the contributions to the health insurance premiums corresponds at most to the actual premium owed in the specific case for the mandatory health insurance.

1. The costs incurred due to contributions to health insurance premiums are borne on the one hand by the Confederation (Art. 66 KVG) and on the other hand by the Canton.

2. It is the responsibility of the Office for Social Contributions to claim the federal funds.

1. To the extent that health insurance premiums are paid under the Social Assistance Act of June 29, 2000, the entitlement to contributions for health insurance premiums is transferred to the authorities providing social assistance.

1. The payment of contributions to health insurance premiums is made to the health insurers.

1. The Office for Social Contributions regularly reports to the health insurers, in accordance with uniform data exchange under federal law, which of their insured persons are entitled to health insurance contributions from the Canton of Basel-Stadt, and simultaneously informs them of the amount thereof.

2. Subsequently, the health insurers inform the entitled insured persons with them about the entitlement reported according to paragraph 1 and reduce the health insurance premiums accordingly.

3. The Office for Social Contributions, upon request, reports to a health insurer operating in the Canton of Basel-Stadt the entire list of rulings of the persons insured with this health insurer according to the Health Insurance Act (KVG) for the purpose of data matching.

1. Health insurers operating in the canton of Basel-Stadt shall provide the Office for Social Contributions with information about the insurance status of individual persons under the KVG, upon request, for the purpose of verifying health insurance contributions and evidence of the insurance relationship.

2. Health insurers shall report to the Office for Social Contributions, upon request, the personal data of all persons insured in the canton of Basel-Stadt as per Art. 105g KVV. These reports are used for matching the premium reduction data inventories and verifying compliance with the insurance obligation. Health insurers shall also report additional data to the ASB upon request (Art. 106c para. 6 and 106d para. 1 KVV) so that the premium reduction surcharge can be determined according to § 21 para. 1bis of this ordinance.

3. The reports pursuant to paras. 1 and 2 shall be carried out via a uniform data exchange in accordance with the Ordinance of the EDI on the Data Exchange for Premium Reductions (VDPV-EDI).

1. In each current calendar year, the Office for Social Contributions makes an advance payment to health insurers with insured persons who are entitled to contributions towards their health insurance premiums by the end of June for the current calendar year. The amount of this advance payment is determined by an estimate based on the figures of the current year.

2. After the end of the calendar year, health insurers pursuant to paragraph 1 shall invoice the Office for Social Contributions for the difference between the reduced health insurance premium and the premium actually owed for compulsory health insurance by insured persons entitled to health insurance contributions, after deduction of the advance payment made under paragraph 1. They shall provide the Office for Social Contributions with all the necessary data and documents to verify the claimed amount.

3. The Office for Social Contributions shall pay the health insurers entitled to any remaining amount following the appropriate verification under paragraph 2 by the end of June of the following year.

4. The Office for Social Contributions may order the refusal or cessation of such contributions if the affected health insurers do not adequately cooperate in establishing and verifying the entitlement to contributions.

5. Unjustly paid contributions may be reclaimed by the Office for Social Contributions at any time.

1. The Department of Health and the Department of Economic, Social, and Environmental Affairs (Office for Social Contributions) are charged with the execution.

1. The Ordinance on Health Insurance in the Canton of Basel-Stadt (KVO) of November 7, 1995, is repealed.

1. Regulation on the Act Concerning Public Dental Care (Dental Care Regulation) of October 30, 2001, is amended as follows

1. Determining the care needs of residents, care homes may use the needs assessment tool in accordance with previous law until December 31, 2025.

1. This regulation is to be published. It shall become effective on January 1, 2009.