swiss health insurance managed care models explained

Swiss Health Insurance: Managed Care Models Explained

What managed care health insurance models are available in Switzerland? How much money could you save by opting for managed care? Get informed with this moneyland.ch report.

Many Swiss health insurance providers offer managed care versions of their standard compulsory health insurance policies. In every case, managed care policies are cheaper than standard policies from the same insurer.

The three managed care models most commonly-offered offered alongside standard policies are the family doctor, HMO and telemedicine models. Another managed care model offered by a handful of insurance providers is the pharmacy model.

Managed care insurance – key points:

  • In managed care insurance, a healthcare manager acts as a gatekeeper. Policyholders consult their healthcare manager as a first stop instead of going directly to doctors and specialists. Depending on which model your policy uses, your healthcare manager could be a general practitioner (your “family doctor”), a healthcare center run by a Health Maintenance Organization (HMO), or a specialized call center (telemedicine).
     
  • Managed Care is aimed at cutting the cost of insurance. Premiums for managed care policies are generally significantly lower than those of standard insurance policies which do not require you to consult with a healthcare manager before receiving treatment.
     
  • You receive exactly the same benefits and coverage no matter which model of compulsory Swiss health insurance you use because coverage is dictated by law.

Standard health insurance model

Choice of doctors:
The standard Swiss compulsory health insurance model gives you full freedom to receive treatment from doctors and specialists of your choice as you see fit. Note: Free choice of doctor applies to private practices. To be able to choose your doctors when being treated at a hospital, you need to have the right supplementary hospital insurance.

Premium discounts:
The premium which you pay for a standard insurance policy is the standard premium (100%). A handful of insurance providers offer claim-free discounts for standard policies.

Important:
Unless you need or want direct access to all healthcare providers, you can radically reduce your premiums by opting for a managed care policy rather than a standard policy.

Family doctor insurance model

Choice of doctors:
When you use a family doctor policy, you are required to visit a specific general practitioner for consultation before receiving further treatment. After consultation, your general practitioner refers you to other doctors, specialists or hospitals. Checkups at eye doctors, dental surgeons and gynecologists can be booked directly, without consulting your general practitioner. An exceptions are also made for medical emergencies.

Premium discounts:
Depending on the insurance provider and the specific family doctor policy in question, you can benefit from discounts of up to 25% off standard premiums.

Important:
If you receive treatment without consulting your general practitioner first, the insurance company will not pay your medical bills. The health insurance provider specifies which general practitioners are eligible to act as family doctors for their policies. Some insurance companies publish lists of eligible doctors.

The exact rules governing consultations vary between insurers. Some insurers require your general practitioner to provide written confirmation when they refer you to other healthcare service providers. Without this confirmation, you may not be able to claim insurance benefits for treatment from those service providers.

Ideally, you should go over the conditions of your policy with your general practitioner and have them explain your options. You can find more information about the family doctor model here.

HMO insurance model

Choice of doctor:
The HMO model requires that you visit a doctor or specialist which is part of a specific HMO network or healthcare center for primary consultation before you receive treatment elsewhere. The HMO doctor then refers you to other doctors, specialists or hospitals if necessary. Exceptions are made for treatment from eye doctors, dental surgeons and gynecologists, which can be booked without primary consultation from HMO doctors. Medical emergencies are another exception, but only if HMO services are not available.

This model is less restrictive than the family doctor model because you are generally free to visit any doctor, healthcare center or specialist which is a member of one of the specified HMO networks.

Premium discounts:
Depending on the insurance provider and HMO policy you use, premiums may be as much as 25% lower than standard premiums.

Important:
If you do not consult your HMO center or member doctor as a first stop before receiving treatment or consultation from other doctors, hospital or specialists, your health insurance provider will not pay out benefits.

Before your take out an HMO health insurance policy, make sure that the specified HMO networks operate healthcare centers or medical practices in your vicinity. Also note that even in the event of medical emergencies, you have to contact your HMO center or doctor first and can only contact another doctor if HMO doctors cannot be reached. You can find more information about the HMO model here. You can learn more about HMO policies here.

Telemedicine insurance model

Choice of doctor:
Many insurance providers now offer policies based on the telemedicine model. If you use this type of insurance policy, you have to contact a call center for medical consultation as a fist stop. The call center then refers you to a doctor, specialist, pharmacy or hospital if necessary. In addition to requiring that you contact a medical call center for consultation as a first stop, some insurers also limit your choice of doctors. Checkups at eye doctors, dental surgeons and gynecologists can normally be booked without consulting the telemedicine call center. You can also receive treatment in the event of a medical emergency without consulting the call center first.

Premium discounts:
Depending on the insurance provider and the specific telemedicine policy, you can benefit from discounts of up to 25% off standard policy premiums.

Important:
If your policy is based on the telemedicine model, you are obligated to contact the specified telemedicine call center for consultation before consulting other healthcare service providers. If you do not contact the call center and follow their referrals or prescriptions, your healthcare bills will not be covered by your insurance provider. You can learn more about the telmed model here.

Other insurance models

In addition to the standard, family doctor, HMO and telemedicine models, other models or special limitations are used by a small number of policies.

Examples:

  • Pharmacy insurance model: In this model, a pharmacy acts as your healthcare manager (instead of a general practitioner, HMO center or telemedicine center). A number of insurance providers offer pharmacy model policies.
  • Pharmacy limitations: Some policies only cover medicines which are purchased from pharmacies within specific networks. Pharmed from Assura is one example.
  • Hospital limitations: Only treatment received at certain hospitals is covered.
  • Claim settlement limitations: This option limits the way in which payment of medical bills and settlement of claims is carried out to a specific settlement model (indirect settlement, for example).
  • Claims-free discount model: Some standard insurance policies use this model. If you do not make any claims within a year, your premiums are reduced by a certain amount (typically 10%) for the following year. This discount is applied every subsequent year in which you remain claims-free, until a maximum discount is reached (up to 50% depending on the policy). If you do make a claim, your premiums go up (typically by 10%) the following year. Insurers which offer policies with claims-free discounts include: Concordia, Helsana, Visana and Groupe Mutuel. You can find out more about claims-free discounts here.
  • Multiple-policy discounts: Some insurers discount insurance premiums when you take out both compulsory and supplementary health insurance policies.
  • Family discounts: Some insurers apply a discount to the premiums of the second or third child onwards. You can find these discounts here.
  • Hybrids: Some policies use a combination of several models. For example, certain policies combine  the telemedicine and family doctor models.

Conclusion

While the standard model of Swiss compulsory health insurance is by far the least complicated, using a managed care model can greatly reduce your premiums. If you already visit a specific doctor or healthcare center for consultation as a first stop, shifting to a managed care model can make a lot of financial sense.

A moneyland.ch report

More on this topic:
Interactive health insurance comparison
Premium reductions explained
Guide to terminating a health insurance policy
Guide to cutting insurance premiums
Telmed insurance model explained
Family doctor insurance model explained
HMO insurance model explained

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