The Family Doctor Model for Swiss Mandatory Health Insurance Explained

Many people value having one doctor that they can consult as a first stop, especially if doing so can also lower the cost of their mandatory health insurance.

That is what the family doctor managed care model for Swiss mandatory health insurance offers. Your personal doctor oversees your overall medical care, and coordinates any further care.

What is the family doctor model?

The family doctor model is a managed care model for mandatory health insurance. With the family doctor model, you commit to first contact your personal doctor when medical needs arise. Your doctor oversees your treatment and decides if any further steps are necessary.

Mandatory health insurance based on the family doctor model typically costs between eight and 20 percent less than standard health insurance, depending on the offer, deductible, and where you live.

The family doctor model is the most popular mandatory health insurance model in Switzerland, with 38.3 percent of residents using it.

Is the family doctor model right for me?

The family doctor model is best suited to people who have a preferred doctor whom they trust, and are willing to entrust with the management of their healthcare needs.

Before using a specific family doctor health insurance offer, you should check whether your preferred doctor is included in the insurance provider’s list of eligible doctors.

Which limitations do I have to accept when I use the family doctor model?

Like other managed care models for mandatory health insurance, the family doctor model has clear rules and requirements. The exact terms and conditions vary between insurance offers, so the limitations are determined by the rules of the general insurance conditions of the offer in question.

Rules that may apply include:

• You must contact your family doctor first: In a pure family doctor model, you have to consult with your family doctor or their official representative when you need medical care. The exception to this rule is when true medical emergencies occur, with other exceptions being clearly defined in the offer’s terms and conditions. There are also hybrid models that let you contact either your family doctor or a telemedicine hotline or app-based service.
• Only medicines bought at partner pharmacies are covered: Some insurance offers have an added limitation that requires you to buy medicines at specific pharmacies for them to be covered by the insurance. Some offers include just 9 pharmacies countrywide, while others include more than 900. Mail-based pharmacies are also covered by some offers.
• Only generic medicines are covered: Many family doctor insurance offers limit cover to generic medicines, when a generic medicine is available for your condition.
• Disease management programs: Some family doctor insurance offers require people with chronic illnesses to participate in disease management programs in order to benefit from insurance cover.

What must I do when I need medical care?

If you need medical attention, you must consult your family doctor. Your doctor will then either treat you themself, or refer you to a specialist or hospital. If your family doctor is away, you must contact their official representative.

Most family doctor insurance offers require you to always contact your family doctor first in order to claim insurance benefits. If you seek medical attention elsewhere without consulting your doctor and getting a referral, the insurance company may only cover part of the medical bills, or may not cover them at all.

The only case in which consulting your doctor first is not required is when you need emergency medical attention. But even then, you are still required to inform your doctor as soon as possible afterwards.

Depending on the insurance offer, there may be other situations in which you can get medical care without consulting your family doctor first. In some cases, you may not be required to inform your doctor in arrears either.

In which situations am I not required to consult my family doctor first?

If a genuine medical emergency occurs, you can call an ambulance or go to the emergencies ward of a hospital without consulting your doctor first.

But you still need to inform your doctor about the incident as soon as possible. The terms and conditions of many insurance offers specify time limits of just five to 20 days.

Depending on the insurance offer, there may be other situations in which you do not have to consult with or inform your doctor. Each offer has its own list of exceptions.

Common exceptions include:

• Preventative checkups from an eye doctor.
• Preventative gynaecological examinations from a gynaecologist.
• Dental treatment from a dentist.
• Medical care from a paediatrician.
• Maternity and childbirth.

Can I use my existing doctor for family doctor health insurance?

Each health insurance provider has its own list of medical practices that qualify as managed care givers for their family doctor insurance offers. Unlike standard mandatory health insurance, there is no requirement for insurance companies to work with all eligible doctors.

Some health insurance providers let you choose any family doctor you want. But many insurers publish a list of partner doctors, and you must choose a doctor from their list.

Good to know: The same health insurance provider may have different lists of partner doctors for different insurance offers.

If you do not want to change your family doctor, make sure to check whether they are included on the list of eligible medical practices when choosing a family doctor insurance offer.

What should I consider when choosing a family doctor insurance offer?

Before you sign up for a family doctor insurance offer, you should check these points:

• Is my doctor on the list of eligible doctors?
• Would I be willing to change to a new doctor?
• Do the rules let me contact a telemedicine hotline or other gatekeeper in addition to my family doctor?
• What are the exact rules, requirements, and limitations?

What are the advantages of the family doctor model?

Using the family doctor model for your mandatory health insurance has these advantages:

• Lower premiums: The cost of family doctor insurance is lower than that of standard health insurance.
• Coordinated health care: As your primary caregiver, your doctor understands your medical history, and coordinates treatment.
• Confidentiality: Many people value having just one person whom they know well and can confide in with regards to their health.

What are the disadvantages of the family doctor model?

The family doctor model also has disadvantages:

• Inconvenient: Instead of being able to go directly to a specialist, you first have to visit your family doctor to get a referral. In addition to the inconvenience, having to pay your family doctor’s fees just to get the needed referrals to specialists can end up costing you more.
• Limited choice of medicines: In addition to the family doctor requirement, you may have additional limitations. May family doctor offers limit insurance cover to generic medicines, and some only cover medicines purchased at specific pharmacies.
• Risk of penalties: Failing to follow the procedure and limitations can result in your medical bills not being covered.

Verdict: Is the family doctor model right for me?

If you have a doctor whom you trust, and you are willing to let that doctor manage your medical needs, then family doctor health insurance is a good choice for you.

A hybrid model that also lets you use a different gatekeeper instead of your family doctor, if you so choose, is worth considering if you want more freedom to choose.

It is important to note that many health insurance providers let you contact the telemedicine hotline for medical consultation free of charge. In many cases, customers with family doctor insurance can also access this service.

If you have a chronic illness, you should bear in mind that with a family doctor insurance, you will have to visit your doctor again and again for a referral before every visit to a specialist. That procedure can be time-consuming and inconvenient.

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