How to Use Managed Care Models to Lower Your Health Insurance Premiums

Whether you have a mild cough or a serious illness, the way in which you will have to go about getting help depends on which health insurance model you use. That is why it is important to look at limitations as well as the price when choosing your mandatory health insurance.

Swiss mandatory health insurance providers offer many different versions of mandatory health insurance. Only the standard model is identical across all insurance providers. But with all managed care models, insurance companies have a lot of freedom to adapt their terms and limitations. As a result, there are big differences between offers.

The family doctor model is the most popular

According to statistics from 2023, the family doctor model is the most widely used mandatory health insurance model, with 34.6 percent of residents using this managed care model. It is followed by the HMO model (26 percent), the standard model (21 percent), and the telemedicine model (14 percent).

The standard model is expensive, but has no limitations

The standard model does not have any restrictions on how you must go about getting medical care. You can visit any doctor or specialist of your choice directly, without having to consult a gatekeeper first. As long as the medical care in question is covered by mandatory health insurance, a health insurance with the standard model will cover it.

The downside of the standard model is that the insurance premiums you have to pay are higher than those of managed care offers from the same insurance provider.

Managed care models: Many limitations, but lower premiums

Managed care models for Swiss mandatory health insurance are very different from the standard model. You cannot simply visit a doctor or specialist of your choice. Instead, you have to first visit a specific doctor or medical center, or contact a remote gatekeeping service. How you have to go about getting medical care depends on the terms and conditions of your managed care health insurance.

It is important to understand, though, that the actual mandatory health insurance coverage is identical across all managed care models and the standard model.

The limitations of managed care models only apply to the way that you go about getting the medical attention you need.

How do managed care models work?

The main feature shared by all managed care models is that you, as the insured person, have to contact a predefined gatekeeper as a first step. Some models have multiple gatekeepers that you can choose between when seeking medical help.

You must wait until you get the gatekeeper’s approval before using healthcare services. Only a few managed care offers give you the option of choosing whether or not you want to visit the doctors or specialists recommended by the gatekeeper. The health insurance company may specify which doctors you must visit, or which pharmacy you have to purchase medicines from.

In exchange for accepting the restrictions, you receive a discount of between 10 and 20 percent, compared to the standard model. The discount may be bigger or smaller, depending on your place of residence. In some cases, a managed care model can be as much as 25 percent cheaper than the standard model.

Which gatekeepers do Swiss managed care models use?

The kind of gatekeeper used varies between individual managed care insurance offers. Some offers specify just one gatekeeper that you have to consult, but there are also hybrid models that give you more than one way to get approved for further care.

Gatekeeper models that are widely used for Swiss managed care insurance offers include:

• Family doctor: You choose a specific family doctor, and you must always consult this general practitioner first. If this doctor is unavailable, you must contact their representative.
• HMO: In addition to conventional HMO medical centers, your choices for a gatekeeper may also include other joint medical practices and family doctors. You must consult the center or general practitioner as a first stop.
• Telemedicine: Before visiting any doctor, you have to contact a specific telemedicine service by phone, or in some cases video call or chatline. The telemedicine center can prescribe medicines for collection at a pharmacy. Most health insurance providers do not charge for the medical consultation you receive from telemedicine centers. But there are insurers that charge between 30 and 70 francs per call, plus variable markups.
• Pharmacy: If you use an insurance offer based on the pharmacy model, you have to visit a pharmacy for your initial consultation. The insurance company provides a list of eligible partner pharmacies.
• Mobile app: Before getting any medical care, you must use a mobile app provided by the insurance company to describe your symptoms and answer some questions (typically around 20). The app provides you with an initial assessment based on the information you provided, and gives you a proposal for further treatment.

There are special exceptions for which you do not need to contact your gatekeeper first. In the case of acute emergencies, you do not have to get the gatekeeper’s approval before receiving treatment. However, you still have to report the incident to the gatekeeper in arrears. Most insurance providers simply require you to do this as soon as possible, but some specify a specific period within which you have to report a medical treatment. In the latter case, the reporting periods range between five and 20 days.

Preventative checkups by eye doctors and gynaecologists do not require approval by a gatekeeper. The same applies to treatments by dentists and, to some extent, paediatricians. Healthcare related to maternity and birth also does not require approval from a gatekeeper.

Which rules do I have to follow?

Managed care health insurance models cost less than standard health insurance, but they come with strict rules and detailed requirements that you must adhere to. The exact rules are laid out in the terms and conditions of individual offers, but you can get an overview of typical requirements below.

• Family doctor model: You must visit a specific general practitioner, and they will refer you to other doctors or specialists if necessary. If your general practitioner is not available, you must visit their appointed representative.
• HMO model: Before signing up to an offer based on the HMO model, make sure to check whether you can choose a medical center near you as your gatekeeper. There are huge differences between insurance providers, with the selection of available gatekeepers ranging from less than 100 medical centers countrywide to more than 20’000.
• Pharmacy model: Before getting this type of health insurance, check which pharmacies you can buy medicines from. The list of eligible pharmacies can include anywhere from 9 to more than 900 pharmacies countrywide. You may also be able to use mail order pharmacies.
• Limitations on medicines: Many health insurance providers require you to use generic equivalents of brand-name medicines when a clone containing the same active ingredients is available.
• Require participation in disease management programs: Some health insurance providers require customers with chronic illnesses to participate in special programs.
• Limited cover for second opinions: Some insurance providers only cover the cost of getting a second opinion from another doctor or specialist if the results end up being different from the first.

Which insurance model should I use?

The most important thing is that the health insurance model you use matches your needs.

If being able to visit any doctor, specialist, or medical center you want is important to you, and you are willing to pay more for that freedom, then the standard model is likely the best option.

If you are willing to accept the restrictions and requirements of managed care models, make sure to check whether a specific managed care offer gives you the option of choosing your preferred gatekeeper.

Which products are offered by individual health insurance providers?

This table provides an overview of standard model offers and managed care offers from the 12 biggest Swiss mandatory health insurance providers.

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