HMO model in health insurance: what you need to know
Basic insurance includes different insurance models. One of them is the HMO model. Comparis explains the HMO model and highlights its pros and cons.
22.09.2025
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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 premium discount.
Good to know: HMO stands for health maintenance organization.
2. How does the HMO health insurance model work?
Do you have the HMO insurance model? If so, you choose a specific medical centre or group practice in advance as your first point of contact for health problems. The HMO practice coordinates further treatment steps and, if necessary, referrals to specialists.
Do I always have to contact the HMO group practice first?
In certain cases, you don’t have to contact the HMO group practice first. These exceptions include:
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 insurer.
For all other medical issues, you have to go to the group practice first. If you do not comply with these conditions, health insurers may refuse to reimburse the costs or switch your policy to the standard model in the future.
HMO model in the Comparis health insurance comparison tool
The family doctor and HMO models have the doctor as the first point of contact. The Comparis health insurance comparison tool shows you at a glance how good the availability of doctors is in your area.
3. What is the difference between the HMO and family doctor models?
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 compared to the HMO model. Whether you opt for the family doctor or the HMO practice, the benefits of the compulsory health insurance remain the same.
4. What are the advantages of the HMO model?
The HMO model offers a number of advantages. These include:
Comprehensive care and infrastructure: various specialists, therapists and general practitioners work together in an HMO group practice. They share infrastructure such as the laboratory and diagnostics. This ensures comprehensive medical care under one roof and reduces waiting times.
Coordinated medical care: with the HMO model, treatments are coordinated. This prevents multiple examinations, saves costs and ensures optimal coordination of therapies.
Substitute doctor: another doctor is always available to you if your primary doctor is unable to see you.
Premium discounts with the HMO model
If you opt for the HMO model with your health insurer, you can save up to 25% compared to the standard model. How big the premium discount really is depends on the insurance provider, place of residence, age and other factors. It’s therefore worth comparing.
5. What are the disadvantages of the HMO model?
Besides the advantages, the HMO model also has disadvantages compared to other models. These include:
Referrals: you always need a referral to see a specialist.
Limited choice of doctor: policyholders must always consult the HMO centre and the doctors working there – there is no free choice of doctor outside the network.
Limited geographical availability: especially in rural areas, there are often no HMO practices near where you live. Policyholders must therefore expect longer travel times – or the model may not be available locally at all.
6. Other frequently asked questions about the HMO model
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 insurer which health centres are located where you live.
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).
In the HMO model, various doctors and medical professionals work together to ensure comprehensive care under one roof. These include (list not exhaustive):
Family doctors
Specialists
Therapists
Complementary medicine practitioners
In other words, the HMO model directly covers a wide range of medical services and, in many cases, offers everything in one place.
This article was first published on 11.08.2022
