Swiss HMO Health Insurance Model Explained

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 an 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 or more off the insurance premiums, compared to the cost of the standard health insurance model.

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 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 HMO is different from the family doctor model

The HMO model is not offered by all mandatory health insurance providers. If you want to switch to the HMO model and your insurance provider does not offer the HMO model, then you will have to migrate to a different insurance provider.

Many 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. The chance of having a family doctor's practice near your home is much higher.

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 2024, only 16 of the 39 Swiss health insurance providers give you the option of choosing an HMO-based policy. On the other hand, 35 insurance companies offer the family doctor model and 31 insurers offer the telemedicine model.

Some insurance companies only offer the HMO model to residents of certain cantons.

HMO model: Hybrids

Some insurers offer several variants of the HMO model. For example, a model may combine elements of both the HMO and the telemedicine models, with a requirement to contact a telemedicine center first, and then visit an HMO center as the first stop for consultation in person. In exchange for the added limitations, you pay a lower insurance premium.

The advantages of the HMO model

• Depending on the health insurance company and the specific variation of HMO model, you can benefit from substantially lower insurance premiums. 
• The requirement to visit an HMO center first can be an advantage over visiting different specialists every time. The HMO's doctors will eventually become familiar with your health medical history and develop a better understanding of your overall medical needs.
• Most HMO medical practices offer a broad portfolio of medical services and equipment. Procedures like x-rays and laboratory analyses can often be performed in-house. Because an HMO often hosts a number of specialized doctors, there is often no need for you to visit external specialists.

HMO model: Cons

• You cannot freely choose which doctors or specialists you visit. If you want your health insurance provider to cover the costs, then you have to visit the HMO center first and get referrals from them.
• There may not be an HMO medical center near where you live or work. Even if there are HMO centers near you, it is possible that your health insurance provider does not have an HMO offer.
• It is up to your HMO's doctors to decide which medical care you need and to refer you to external healthcare service providers as they deem necessary. If you want to get a second opinion from a different doctor, the cost of that consultation will not be covered by HMO health insurance.

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