Swiss Health Insurance: Managed Care Models Explained

Many Swiss health insurance providers have managed care offers for mandatory health insurance, in addition to the standard model.

Examples of managed care models for Swiss mandatory health insurance include family doctor, HMO and telemedicine models. Another managed care model offered by a handful of insurance providers is the pharmacy model.

Key features of managed care:

• Managed care offers differ from the standard model of Swiss mandatory health insurance in that you have to consult a healthcare manager before getting specialized treatments. This healthcare manager acts as a gatekeeper. Depending on which model your policy uses, your healthcare manager could be a general practitioner (your family doctor), a medical center run by a health maintenance organization (HMO), or a remote consultation service (telemedicine).
• Insurance providers charge lower insurance premiums for managed care offers than they do for standard health insurance.
• The costs covered by Swiss mandatory health insurance are identical across both standard and managed care offers. However, managed care offers only pay these costs for medical care which is managed by the gatekeeper. That means you have to consult your family doctor, HMO, or telemedicine service as a first stop and have them refer you to specialists as needed.
• Managed care models may not fully cover the cost of brand-name medicines, with insurance benefits being limited to the cost of generic medicines.

1. The standard 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 that you pay for a standard insurance policy is the standard premium (100 percent). A handful of insurance providers offer claim-free discounts for standard policies.

• Good to know

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.

2. The family doctor managed care 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 percent 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.

3. The HMO managed care 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 percent lower than standard premiums.

• Good to know

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.

4. The telemedicine managed care 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 percent off standard policy premiums.

• Good to know

If your policy is based on the telemedicine model, you are often 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:

• The pharmacy managed care 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.
• Deductible-free preventative care: In this managed care model, your insurance deductible and coinsurance payment do not apply to preventative checkups.
• Paid telemedicine services: In this variant of the telemedicine model, the telemedicine service charges for the remote consultations required in order to get further treatment. The fees are billed just like those of doctors, and you have to cover the deductible and coinsurance. 
• Pharmacy limitations: Some policies only cover medicines if you buy them from specific pharmacies included on their partner list.
• Hybrids: Some policies use a combination of several models. For example, certain policies combine the telemedicine and family doctor models.

More on this topic:
Compare Swiss mandatory health insurance offers now
What is covered by Swiss mandatory health insurance?