5. Juli 2024 – In its decision of 29 May 2024, the Federal Supreme Court ruled on the appeal by health insurer B. against Spitex A. The case concerned the reimbursement of nursing care services provided by Spitex A. to residents of a home for the disabled. The main legal question was whether the tariff for services provided by organizations for home nursing pursuant to art. 7 para. 1 lit. b of the Ordinance on Healthcare Benefits (Krankenpflege-Leistungsverordnung, KLV) instead of the tariff for nursing homes pursuant to art. 7 para. 1 lit. c of the Ordinance on Healthcare Benefits (Krankenpflege-Leistungsverordnung, KLV) applies to the services provided by Spitex A. For the first, the compulsory health insurance (Obligatorische Krankenpflegeversicherung, OKP) covers contributions of CHF 63 per hour and for the second CHF 52.60 per hour (art. 7a para. 1 lit. b and c KLV). Moreover, it was disputed whether contributions from the cantonal disability assistance could reduce or eliminate the reimbursement owed by health insurer B.

The Cantonal Arbitration Court for Health Insurance Disputes ruled that the tariff for services provided by organizations for home nursing must be applied and that cantonal contributions did not affect the compulsory health insurance benefits.

The Court upheld the decision of the Cantonal Arbitration Court. It confirmed that the services provided by Spitex A., as an undisputedly recognized organization for home nursing, must be reimbursed on the basis of the tariff for home nursing, even though the services are provided in an institution for the disabled that is not an accredited nursing home. The Court held that the main factor in classifying the services was the distinction between outpatient care and inpatient care provided in a recognised nursing home. Outpatient care was possible in the context of different forms of living, as long as they were provided outside a recognised nursing home. It was not decisive whether the person in need of care lived in private premises or in a home for the disabled.

The Court also rejected the argument of the health insurer B. that the reimbursement should be reduced due to the overlap with cantonal disability assistance contributions. The court emphasized that there was no legal basis in federal law for such a reduction and that the priority of social insurance benefits over cantonal subsidies was clearly established.

The court also rejected health insurer B.’s claim of an abuse of rights, affirming that Spitex A. operates within the scope of its approval as a provider for home nursing, irrespective of the fact that all its services are rendered to residents of a single institution.

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