swiss family doctor health insurance model

Swiss Family Doctor Health Insurance Model Explained

Get the facts about the family doctor insurance option for obligatory health insurance in Switzerland.

Family doctor and standard options are the most widely used insurance models in Switzerland. The family doctor model is especially popular among young adults between 19 and 25 years old.

The role of a “family doctor” (a general practitioner or primary care physician) as a gatekeeper of sorts, being the first stop for any health issues, defines this model. The family doctor model limits you to visiting your doctor first, as opposed to using any doctor of your choice. After consulting your doctor, they will refer you to specialists, therapist or hospitals as necessary.

If you choose to receive treatment from a specialist without being referred by your doctor, your health insurance policy will not cover the costs. There are a few exceptions to this rule. Medical emergencies, treatment by dental surgeons, eye specialists and gynecologists are covered even without a referral from your doctor. Along with the limitations, you receive a discount on premiums.

Premiums for a family doctor-based policy can work out more than 20 percent (up to 27 percent) cheaper than standard insurance policy premiums. You receive exactly the same insurance coverage which you get with a standard obligatory insurance policy because benefits are dictated by law and are identical for all obligatory policies.

The family doctor model is the most popular savings option

Only 8 Swiss health insurers do not offer the family doctor. That means 44 of the 52 health insurance providers in Switzerland let you choose this model. For reference: The telemedicine model is offered by just 31 insurers and only 18 insurance companies offer the HMO model. However, not all of the 44 insurers provide family doctor insurance policies in every Swiss canton.

Some smaller, regional health insurance providers do not offer the family doctor model at all. But even some larger insurers don’t provide the family doctor option. KLuG Krankenversicherung is one example of a larger insurance company which does not let you choose the family doctor policy model.  

Pharmacy-specific policies are the exception

Some insurers offer multiple family doctor policies. Assura customers, for example, can choose between a “regular” family doctor policy and the Assura PharMed option. The latter limits you to purchasing pharmaceuticals at Sun Store, a Swiss pharmacy chain. In exchange, you benefit from lower premiums. Another policy, Medpharm from Swica, takes this approach a step further by having you visit a pharmacy as your first point of reference, rather than a family doctor.

Family doctor and telemedicine combinations

Groupe Mutuel lets you choose from two related models: PrimaCare and PrimaTel. PrimaTel, which combines the family doctor and the telmed models, requires that you contact the telemedicine center Medi24 for a referral before each consultation.

If Medi24 establishes that medical treatment is necessary, your case is referred to your family doctor. PrimaCare policyholders can visit their family doctor directly without consulting Medi24 first, but premiums are higher.

When a health insurance offers several variants of the family doctor model, make sure you check the exact terms and conditions of the policy carefully before signing up. The general rule is: the cheaper the health insurance policy, the more limitations you will have to deal with.

What should I know before switching to the family doctor model?

  • Your health insurance provider may not have partnerships with all general practitioners in your area. Check into which medical practices are eligible before settling on a policy. Many insurance companies provide a list of eligible family doctors, which you should look at beforehand.
  • Choose your family doctor carefully. They will be your first port of call for any health issues.

Family doctor model: Pros

  • You can profit from major savings on insurance premiums, depending on your insurer and policy. Premiums for family doctor policies are, on average, 13 percent cheaper than standard policy premiums.
  • The obligation to visit your doctor first can actually be beneficial: Your doctor will often know your medical history and special needs better than a specialist. This can help you receive more effective treatment.
  • Unlike the HMO model, the family doctor model is also widely available in more rural parts of the country. No matter which part of Switzerland you live in, your chances of finding a nearby family doctor are high.

Family doctor model: Cons

  • You don’t get free choice of medical care: Even when you are absolutely certain that you need to be treated by a specialist, you won’t usually be able to consult one directly. You first need to make an appointment with your doctor, who may then refer you to a specialist.
  • Although the family doctor model is widely used, there is a chance that your insurance provider does not offer it. In this case, adopting the family doctor model will require that you change health insurance companies. There’s also a chance that your preferred doctor will not be on an insurance company’s list of eligible medical practitioners.
     
  • Your doctor is almost solely responsible for your health issues. If you want to get a second opinion from another doctor, you will usually have to pay for it out of your own pocket.

More information:
Swiss health insurance comparison
Swiss supplementary hospital insurance comparison
Swiss supplementary outpatient insurance comparison
HMO health insurance model explained
Telmed health insurance model explained

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