Health insurance and the HMO model: what is HMO?
Basic insurance includes different insurance models. One of them is the HMO model. Comparis explains the HMO model and highlights its advantages and disadvantages.
14.07.2023
iStock/Rossella De Berti
1. What is the HMO model?
The HMO model is an alternative insurance model for basic insurance. In the event of illness, you must always consult a particular group practice or doctor’s network first. In return, you receive a discount on premiums.
Good to know: HMO stands for Health Maintenance Organization.
Premiums discount of up to 25%
If you opt for the HMO model with your health insurance company, you can save up to 25%. How big the premiums discount really is depends on the insurance provider, place of residence, age and other factors. It’s therefore worth comparing.
2. Do I always have to contact the group practice first?
In certain cases, you do not have to contact the group practice first. There are exceptions for:
emergencies
annual gynaecological check-ups
eye tests by an ophthalmologist
The exceptions vary from insurer to insurer. They are defined in the general insurance conditions of the health insurance company.
For everything else, you have to go to the group practice first. The doctor will then refer you to a specialist if necessary.
Please note: if you do not abide by these conditions, health insurance companies may refuse to reimburse you or may assign you the standard model in the future.
3. What is the difference between the HMO model and the family doctor model?
With the family doctor model, your personal family doctor is the first point of contact for medical services. Your choice of doctor is limited here, as well.
The family doctor model usually gives lower discounts for premiums in comparison to the HMO model. Whether you opt for the family doctor or the HMO model, the benefits of the compulsory health insurance remain the same.
4. What is an HMO practice?
An HMO practice is a group practice or health centre. In addition to family doctors, specialists and therapists from various medical fields also work there. You therefore have access to a broad selection of medical services, depending on the size of the practice.
HMO practices have catchment areas. This means that each practice offers its services within a particular area. You can find out from your health insurance company which health centres are located where you live.
5. What is an HMO doctor?
HMO doctors are also referred to as “gatekeepers”. “Gatekeeper” refers to them being the first point of contact for medical problems.
The gatekeeper principle allows the HMO to coordinate the treatment of its patients outside the HMO itself (e.g. with other outpatient service providers, hospitals and rehabilitation clinics).
6. HMO model: advantages and disadvantages at a glance
Advantages of the HMO model
Premiums reduction: you receive a reduction of up to 25% compared to the standard model.
Various services and disciplines under one roof: individual doctors cannot always afford expensive equipment such as x-ray and ultrasound machines. HMO doctors share the infrastructure and therefore have access to more facilities. In addition, referrals are usually simpler because they work more closer with specialists.
Replacement doctor: there is always a replacement doctor available to you if your primary doctor isn’t available.
Disadvantages of the HMO model
Referrals: you always need a referral to see a specialist.
This article was first published on 11.08.2022
