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InsuranceHealth insuranceGlossary
Health insurance

Alternative insurance models

Alternative insurance models are versions of compulsory basic health insurance. They include:

HMO = Health Maintenance Organization:
The policyholder of an HMO model agrees to always consult a specified doctor based at the HMO centre in the event of illness. This doctor is referred to as a gatekeeper. Emergencies as well as the annual gynaecological check-up and regular eye examinations are exempt from this duty.

The HMO doctor receives a lump sum every month for the medical treatment of his registered policyholders. This covers all services claimed by policyholders either from the HMO doctor, from external specialists or from hospital treatments.

The gatekeeper principle allows the HMO doctor to coordinate treatment of his patients. By receiving a lump sum, the doctor can limit himself to giving the patient the treatment he or she really needs - there is no incentive to extend the treatment beyond this. Therefore, premiums for HMO insurance products are up to 25 percent lower than for standard basic insurance, while offering the same benefits.

Emergencies for HMO policyholders: 
In case of an emergency, the policyholder always contacts his HMO doctor first. If he cannot be contacted, or the policyholder is not at his usual place of residence or work, the nearest available emergency doctor should be consulted. After the emergency treatment, the policyholder should contact his HMO doctor to discuss further procedure.

Policyholders of family doctor models forgo free choice of physicians and commit themselves (as with HMO) to always consulting their fixed family doctor (gatekeeper). Emergencies as well as the annual gynaecological check-up and regular eye examinations are exempt from this duty.

The health insurance companies define which doctors can be chosen by the policyholders as an own "family doctor" (i.e. family doctor) in the family doctor model. These doctors are either affiliated to the family doctor networks or independently practising doctors. While some health insurance companies have explicit lists of doctors, others allow their policyholders to choose among all internal specialists, GPs and paediatricians within the insurance company's region.

The family doctor is responsible for the medical care of the policyholders who have chosen him/her. If it is medically necessary, he will refer them to a specialist.

It is expected that the selective referral of policyholders to specialists will bring about a reduction of costs in comparison to the standard basic insurance. Therefore, premiums for family doctor insurance products are about 15 to 20 percent lower than those for standard basic insurance.

For every newly appearing health problem, the policyholder has to call a consultation hotline before consulting a doctor for the first time. There, medical experts give advice, make recommendations on how to behave or refer patients to a doctor, a hospital or a therapist. Emergencies, the annual gynaecological check-up, regular eye examinations (in some cases this only applies to children) and other benefits different with every insurer are exempt from this duty to contact the helpline prior to seeing a doctor. Thanks to the consultation by phone prior to consulting a doctor, costs can be saved. Policyholders in the Telmed model receive a premium reduction of about 15 to 20 percent compared to the standard basic insurance.

Follow this link to find a list of Telmed products.

In this category, special insurance models are listed which only have restrictions that cannot be assigned to any of the other insurance models, such as:

  • Treatment only in a hospital that is on the health insurance provider's list
  • Purchase of medication always at a certain pharmacy/pharmacy group specified by the health insurance.

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Please note the following for alternative insurance models

  • If insured persons claim direct outpatient or inpatient treatment outside of an emergency situation without previous instruction by their HMO doctor or family doctor, they have to cover the costs themselves with some health insurance providers.
  • If the insured persons select an original medical product instead of a generic medical product from the list, the costs are not always completely covered.

These regulations are not standardised, but they are stated in the general terms of contract (AVB) of the health insurance companies.

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