Regulations on the reimbursement of sickness and disability costs for supplementary benefits (RKEL) - Principle (RKEL)

1. Designated medical, disability, and auxiliary equipment costs within the meaning of Article 14, paragraph 1 of the ELG are reimbursed up to the amount of the costs of an economical and expedient implementation.

2. The Compensation Fund of the Canton of Solothurn (hereinafter referred to as AKSO) may have the cost-effectiveness and appropriateness reviewed.

1. The maximum amounts that can be reimbursed for illness, disability, and aid costs in addition to the annual supplementary benefits correspond to the amounts specified in Article 14 paragraphs 3 to 5 of the ELG.

1. Expenses related to illness and disability are reimbursed for the calendar year in which the treatment was administered or the purchase was made.

2. The AKSO is authorized to generally refer to the date of invoice issuance.

3. The submission deadline for claiming costs is 15 months from the date of invoice issuance.

4. If an insured person included in the calculation of the annual supplementary benefits has died, the expenses incurred by them for illness and disability, as well as costs for aids, are reimbursed if their legal successors request this within twelve months of their death.

1. Entitlement to reimbursement for illness and disability costs exists only to the extent that other insurance does not cover these costs.

2. If the amount of cost reimbursement increases pursuant to Article 14 paragraph 4 ELG or Article 19b of the Ordinance on Supplementary Benefits to the AHV and IV (ELV), the helplessness allowance of the IV and accident insurance shall be deducted from the proven care and support costs. However, the maximum amount according to Article 14 paragraph 3 ELG must not be fallen below.

3. If the health insurance has credited the helplessness allowance of the IV or the accident insurance for its reimbursement of home care and support costs, the helplessness allowance shall not be deducted from the proven costs to the extent of the credit.

1. Medical and disability costs incurred abroad will be reimbursed as an exception if they become necessary during a stay abroad or if the medical measures could only be carried out abroad.

2. Costs incurred abroad for spa treatments will not be reimbursed.

1. Participation according to Article 64a of the Federal Health Insurance Act (KVG) in the costs of services covered by the compulsory health care insurance under Article 24b KVG will be reimbursed.

2. Reimbursements of cost participation under paragraph 1 can only be made on the basis of detailed statements from the health insurance.

3. Invoiced contributions towards catering costs for inpatient treatments (hospital contributions) will not be covered.

4. The patient's participation within the framework of the reorganization of nursing financing for recipients of supplementary benefits at home (SPITEX) or nursing home residents (SPITIN) will be fully covered.

1. If an insurance with a higher deductible is chosen according to Article 93 of the Ordinance on Health Insurance (KVV), a cost contribution of up to 1,000 Swiss francs per year will be reimbursed.

1. Costs for simple, economical, and appropriate dental treatments are reimbursed according to the treatment recommendations of the Swiss Cantonal Dentists. Additionally, the conditions outlined in paragraphs 4 to 8 must be met.

2. The tariff for accident, military, and disability insurance (UV/MV/IV tariff) concerning the remuneration of dental services and the UV/MV/IV tariff for dental technical work is decisive for the reimbursement.

3. Cost estimates and invoices must be submitted according to the tariff positions of the UV/MV/IV tariff and must be conclusive.

4. Costs under 1,000 francs can be submitted without a cost estimate if the treatment is conclusive. If treatment over 3,000 francs is carried out without an approved cost estimate, EL covers a maximum of 1,000 francs.

5. If the costs of a dental treatment, including the dental technical laboratory, are expected to exceed 1,000 francs, a cost estimate and the X-rays must be submitted to the AKSO before treatment.

6. If the costs of a dental treatment exceed 3,000 francs, before treatment, the clarification form, a cost estimate for the dental services as well as any possible dental technical laboratory, and the X-rays must be submitted to the AKSO.

7. To confirm coverage of anesthesia costs, a medical certificate must be presented. The necessity of a general anesthesia must be related to a physical or mental disability. Additional costs of up to 2,000 francs can be reimbursed. Priorly, a contribution from disability insurance or health insurance should be considered.

8. For orthodontic treatments, the clarification form, treatment plan, as well as the orthopantomography (OPT/OPG) and the study model must be submitted to the AKSO before the start of treatment. If this procedure is not followed, the total costs for orthodontic treatment will not be reimbursed.

9. The AKSO may arrange for an assessment directly with a trusted dentist.

1. Additional costs for a medically prescribed life-essential diet for individuals who do not reside in a nursing home or hospital are considered as medical expenses. An annual lump sum of 2,100 Swiss Francs is to be reimbursed.

2. Diabetes mellitus Type 1 and Diabetes mellitus Type 2 do not incur additional costs.

**1. Temporary Stay in a Home or Hospital**

In the case of a temporary stay in a home or hospital, the contribution from the health insurance and an amount for living expenses, equivalent to the income in kind according to the rates applicable in the Old Age and Survivors Insurance (AHV), shall be deducted from the cost reimbursement.

1. Costs for medically prescribed recuperative treatments conducted in Switzerland following a hospital stay are reimbursed after deducting a reasonable amount for living expenses corresponding to benefits in kind based on the rates applicable in AHV (Old-Age and Survivors Insurance),

a) for recuperative treatments, if the treatment was carried out in a home or hospital;

b) if the insured person was under medical supervision during the treatment stay.

2. Reimbursement is only possible if the treatment is conducted in an institution recognized by the health insurance fund.

3. A maximum of 21 days per calendar year will be reimbursed.

4. The limitation on costs for the stay in a home or hospital applies accordingly to recuperative treatments.

1. Costs for medically prescribed spa treatments in Switzerland are covered after deducting a reasonable amount for living expenses equivalent to natural income, based on the rates applicable under the AHV (Old Age and Survivors Insurance), provided that the insured person was under medical supervision during the spa stay.

2. Reimbursement is only possible at health spas that are recognized by the health insurance.

3. A maximum of 21 days per calendar year will be reimbursed.

1. Necessary household assistance within one's own home will be reimbursed up to a maximum of 25,000 Swiss Francs per calendar year, provided that the assistance is rendered by a recognized Spitex organization.

2. Documented expenses for necessary household assistance can be reimbursed up to a maximum of 25 Swiss Francs per hour and up to a maximum of 4,800 Swiss Francs per calendar year, if the assistance is provided by a person who

a) does not live in the same household, or

b) is not included in the supplementary benefits calculation, or

c) is not deployed through a recognized Spitex organization.

3. Only expenses for cooking, laundry, cleaning, and shopping are covered.

4. The necessity of household assistance must be confirmed by a medical certificate. The AKSO may commission an external specialist office for needs assessment.

5. No costs for household assistance services will be covered if the assistance is rendered by spouses, individuals in registered partnerships, or by persons who are directly related (children, parents, grandparents, grandchildren).

6. For assisted living (integration for independent management of a household), a maximum of 4,800 Swiss Francs per calendar year (disability insurance or old age and survivors' insurance) can be covered.

1. Costs for care and assistance, which become necessary due to age, disability, accident, or illness and are provided by recognized outpatient care organizations, shall be reimbursed.

2. Care encompasses both treatment and basic care. Basic care includes necessary assistance with getting up, dressing, bathing, eating, and other essential physical activities.

3. In the case of a tiered tariff based on income and asset conditions, only the lowest tariff is considered. If a surcharge for the obligation to train is imposed on the tariff, the tariff including the surcharge is considered, provided it complies with the guidelines of the government council.

4. Care and assistance costs incurred in a public or non-profit daycare center, day hospital, or outpatient clinic are also reimbursed.

5. Costs for services provided by private entities are reimbursed insofar as they correspond to the costs of public or non-profit entities.

6. ...

1. Costs for directly employed nursing staff will only be reimbursed to recipients of a helplessness allowance from the IV (Invalidity Insurance) and the UV (Accident Insurance) for severe and moderate helplessness, for the part of care and support that cannot be provided by a recognized Spitex organization as defined in Article 51 KVV (Health Insurance Ordinance).

2. The AKSO (Assistance and Care Service Organization) may commission an external specialist agency (such as the Cantonal Spitex Association) to conduct a needs assessment. Without a needs assessment or if the requirements of the external specialist agency are not met, no costs will be covered.

1. Costs for care and assistance provided by family members will only be reimbursed if the respective family members

a) are not included in the EL calculation, and

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

2. The costs shall be reimbursed to the extent of the lost earnings, but not exceeding the amount of costs that would be incurred if a professional caregiver were engaged.

3. Any potential surplus of income will be offset.

1. Costs for assistance and care of disabled or elderly persons in day care centers, employment facilities, and similar day structures will be reimbursed if

a) the disabled or elderly person stays there for more than five hours per day; and

b) the day structure is operated by a public or charitable private organization.

2. Costs are reimbursed up to a maximum of 50 francs per day, on days when the disabled or elderly person was present in the day structure.

3. No costs are reimbursed

a) for employment with a monetary remuneration exceeding 100 francs per month;

b) in cases of residence in a care home with supplementary benefits calculation pursuant to Article 10 paragraph 2 of the Supplementary Benefits Act (ELG).

1. Reimbursed transportation costs are covered, provided they are incurred within Switzerland due to an emergency transport or a medically necessary transfer.

2. Verified costs for transportation for services under the KVG and dental treatments to the nearest medical treatment site are also reimbursed. Costs are reimbursed equivalent to the prices of public transportation (2nd class) for direct routes. If the insured person is dependent on using another transportation service or means of transportation due to their disability or place of residence, the costs will be reimbursed. For private vehicles, a maximum of 65 cents per kilometer is reimbursed.

3. Daycare facilities are equated with medical treatment sites in the sense of paragraph 2 of this provision.

4. Costs for travel companions, parking fees, empty trips, and waiting times will not be reimbursed.

5. Costs for half-fare cards, route subscriptions, and general subscriptions are generally not reimbursed. If cost savings compared to individual travel costs can be demonstrated, the former will be reimbursed.

1. Beneficiaries of supplementary benefits are also entitled to the rental costs for the temporary provision of electric beds, provided it is certified by a doctor that these are necessary for home care; rental costs of up to 75 Swiss Francs per month for an electric bed are covered (+ VAT).

a)* ...

b)* ...

2. The acquisition and transportation costs are fully covered for

a)* Patient lifts, provided it is certified by a doctor that a patient lift is necessary for home care;

b)* Lift stands;

c)* Automatic additions to sanitary installations, provided that a person living at home is unable to independently perform the relevant personal hygiene without these additions;

d)* Commodes for persons living at home.

2bis. The acquisition costs for face masks are covered up to an annual amount of 30 Swiss Francs, provided that the federal or cantonal authorities mandate the wearing of such masks in public spaces. The costs are covered upon submission of the receipt from the first day the mask mandate is enforced.

3. Beneficiaries of supplementary benefits are entitled, under Article 14 paragraph 1 letter f of the Federal Act on Supplementary Benefits, to reimbursement for the acquisition costs of

a)* Expensive orthopedic modifications and shoe adjustments on ready-made shoes;

b)* Cataract glasses or contact lenses after cataract operations.

c)* ...

d)* ...

4. For the aids listed in the following annex, there is an entitlement to a reimbursement equal to one-third of the cost contribution by the Old Age and Survivors Insurance (AHV), according to the circular on the provision of aids by the Old Age Insurance (KSHA), if the AHV has contributed to the costs.

5. The provisions of the Invalidity Insurance are applicable mutatis mutandis to the reimbursement of costs for repairs, adjustments, renewals, and usage training.

1. Where it appears doubtful whether an auxiliary aid or device is necessary or whether its design is simple and expedient, the insured person must provide a certificate from a doctor, a specialized center for disability assistance, or an occupational therapy facility.

2. For hearing aids, the necessity or expediency of the device must be certified by an expert recognized by the disability insurance for the evaluation of hearing aids.