hmo model health insurance switzerland

Swiss HMO Health Insurance Model Explained

How do HMO models of the Swiss obligatory health insurance policies work? Get informed in this guide.

HMO, or health maintenance organization, is a health insurance model which first debuted in the USA over 100 years ago. In Switzerland, the HMO model is built around grouped medical practices. HMO networks help reduce costs by limiting medical care within a network of healthcare service providers.

The HMO model is not as widely used as the three other health insurance models (standard, family doctor and telemedicine models). But there has been a moderate upward trend among new HMO model adoptions. Young adults and urban dwellers are most likely to use the HMO option.

Like the family doctor model, the Swiss HMO model is based on the “gatekeeping” principle. If you require medical attention, you first visit the gatekeeper, in this case an HMO center. An HMO doctor with access to your medical history will coordinate medical treatment.

So your first point of consultation will be limited to a doctor from your HMO center. In exchange, you pay a lower health insurance premium. Premium reductions for HMO policy holders can knock up 20 percent (up to 27 percent) off the insurance price-tags, compared to premiums for standard policies.

Doctors employed by the HMO practice can refer you to specialists, therapists or hospitals. If for any reason you consult a medical practitioner directly, without consulting the HMO practice first, the insurance company will not, as a rule, cover the cost. Exceptions to this rule include emergency treatments and, depending on your insurer, certain other medical services.

The actual coverage you receive with an HMO-based policy is identical to the coverage you get with all obligatory health insurance models, in accordance with Swiss law.

How is HMO different from the family doctor model

Compared to the family doctor model, the HMO model is offered by much fewer health insurance companies. If you want to switch to the HMO model, you may have to move to another health insurer if your insurance provider doesn’t provide the HMO option.

Most HMO medical centers are located in urban areas. If you live relatively far from urban centers, the distance between your home and your nearest HMO center may be large. It’s generally a lot easier to find a nearby family doctor.

An HMO center will often designate a specific doctor to coordinate your medical care. But in many cases you will also be able to receive consultation or treatment from other doctors in the same HMO medical practice.

Premiums for HMO policies and family doctor policies can also differ, depending on the insurance provider. On average, the HMO model works out somewhat cheaper.

Not all health insurance companies offer the HMO model

The majority of health insurers in Switzerland do not offer the HMO option. In 2019, only 18 of the 51 Swiss health insurance providers give you the option of choosing a HMO-based policy. For reference: 44 insurance companies offer the family doctor model and 32 insurers offer the telemedicine model.

Your place of residence is a defining factor in whether or not you can take advantage of the HMO option. The HMO model is less widely used in the French-speaking part of Switzerland than it is in the German-speaking area.

HMO model: Hybrids

Some insurers offer several variants of the HMO model. At health insurer Atupri, you can choose between a “regular” HMO policy and what it calls the “FlexCare” model. The latter combines HMO with elements of the telmed model.

After a primary phone call to establish your case, the HMO medical center informs you of the next steps to take. This helps the insurer avoid paying for unnecessary medical consultations, and you as the policyholder benefit from lower premiums.

HMO model: Pros

  • You may profit from very attractive discounts on your premiums, though the reductions will vary depending on the insurance provider. On average, HMO policy premiums are 16 percent lower than standard obligatory health insurance policy premiums.
  • Being obligated to visit an HMO medical practice when health issues come up has its benefits. The doctor responsible for your care will typically understand your overall medical history and needs better than a medical specialist who isn’t familiar with your case.
  • Most HMO medical practices offer a broad portfolio of medical services and equipment. Centers may, for example, have their own radiological department or laboratory, so getting an x-ray or blood test can often be handled internally. Because many HMO centers employ a range of specialized medical staff, you can often avoid having to consult third-party specialists at all.

HMO model: Cons

  • Your freedom to choose where to receive primary care is limited. When medical issues arise, you have to visit the HMO center first in order for costs to be covered by your policy.
  • There may not be an HMO medical center in your immediate vicinity. Centers are particularly scarce in more rural areas.
  • Your HMO doctors have the first word about your medical care. If you want to get a second opinion from a non-HMO doctor, you may have to foot the bill yourself.

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

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