Health insurance models in Switzerland compared
When it comes to basic insurance in Switzerland, you can choose between different health insurance models. Comparis gives you an overview of the various health insurance models, along with their advantages and disadvantages.
14.08.2023
iStock/Stígur Már Karlsson/Heimsmyndir
1. What are alternative insurance models?
When it comes to basic insurance, in addition to the standard model, you can also choose from other health insurance models. The models offered and their names may differ depending on the health insurance company. Basically, the following are available:
Mixed models
Your chosen health insurance model determines the first point of contact for medical questions (e.g. family doctor or GP, health centre, medical helpline or pharmacy). For mixed models, you can choose between different contact points.
All alternative insurance models have one thing in common: the choice of care providers (doctors, hospitals, pharmacies, etc.) is limited. In return, you’ll receive a premium discount.
Granting of the premium discount
In order for the premium discount to be approved by the Swiss Federal Office of Public Health (FOPH), the insurance company must prove how much policyholders save with an alternative health insurance model. However, the insured benefits are the same for every model and are regulated in accordance with the Health Insurance Act (KVG).
2. Alternative health insurance models: what should I consider?
With an alternative insurance model, you must follow the guidelines for the point of contact if you have a new health problem. This means you can’t go directly to specialists. You must obtain advice and a referral from a contact person beforehand. In technical jargon, this is known as “gatekeeping”.
Exceptions to the restricted choice of doctor
The following are exempt from this obligation:
Emergencies
Annual gynaecological preventive check-ups
Check-ups by ophthalmologists and dentists
Examinations by paediatricians
The requirements vary depending on the health insurance company and are set out in the general conditions of insurance.
If you don’t follow the rules, health insurance companies will act in accordance with the general conditions of insurance. The consequences range from the health insurer refusing to cover costs to downgrading your policy to the standard model. Downgrading means that you lose your premium discount and will have to pay the premiums of the standard model.
Further restrictions of alternative insurance models
Other conditions may be linked to the insurance model. Examples include:
You may only buy medicines from an approved partner pharmacy
Only generic drugs are covered
You may only choose a hospital from a specified list
3. Which benefits are included in alternative health insurance models?
Health insurance benefits are regulated by the Health Insurance Act (KVG) (in German, French and Italian only). This act also applies to alternative insurance models. This means that the services offered are the same for the standard model and for alternative health insurance models.
4. What are the different health insurance models?
Standard basic insurance is the mandatory health insurance offered by all health insurance companies. The benefits are identical regardless of health insurer. Policyholders are free to choose any doctor.
Free choice of doctor means that you can decide for yourself who will treat you. You can go directly to specialists.
The first point of contact for insured persons in the family doctor model is their chosen family doctor (GP). Depending on medical need, they will refer the insured person to a specialist.
Pros
You can usually keep your family doctor
Premium discount of up to 25%
Cons
You need a referral for specialists
Your family doctor must be on the family doctor list of the health insurance company, depending on the insurance and model type
The first point of contact for HMO insured persons is their chosen health centre. The health centre then plans and coordinates the further course of treatment.
Pros
Easy access for people without a family doctor or GP
A replacement doctor is always available
Medical devices (e.g. ultrasound, X-ray, etc.) are available
Specialists are available
Premium discount of up to 25%
Cons
You need a referral for specialists
Your health insurance company may not have a HMO practice nearby
The first point of contact for emerging health problems for Telmed insured persons is the helpline. Medical professionals will advise you on the next treatment steps over the phone. The call may or may not include video.
Pros
Free medical advice around the clock (24-hour hotline)
Premium discount of up to 25%
Cons
You must always first call the medical helpline before you can get an appointment with a doctor
Hybrid or mixed models have been available since 2020. There are two to three different first points of contact:
Family doctor/GP
Health centre
Helpline
Pharmacy
Depending on the model, there is one of two options for choosing the initial point of contact:
You must choose one of the possible initial contact points for the entire duration of the contract.
You can select the initial point of contact on a case by case basis.
These medical services often support each other. In the pharmacy model, for example, the first consultation takes place at a partner pharmacy. If a doctor is needed, you can consult them via telephone or an app from a telemedicine provider. If necessary, you will receive a referral to a specialist or hospital.
Watch out for additional costs
In some cases, consultations over the phone or at a pharmacy are also subject to a fee. In the pharmacy model, you must purchase medicines from a partner pharmacy.
Therefore, you should read the rules governing exemptions in the general insurance conditions of your model.
Pros
Great flexibility due to multiple initial contact points
Premium discount of up to 25%
Cons
Comparability difficult due to special conditions
5. What is the best insurance model for me?
The best insurance model depends on your personal needs and wishes. You have to decide for yourself what you value in your health insurance. It’s important that you are aware of the conditions for the selected model.
Many people still do not choose an alternative model out of fear of restrictions or worse benefits. However, the benefits are the same under every model and are regulated by law. Freedom and flexibility remain high even with an alternative model.
This article was first published on 14.08.2023
