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InsuranceHealth insuranceGlossary

Alternative insurance models

What is meant by an alternative insurance model?

Examples of alternative insurance models are HMO, family doctor / GP and Telmed. These alternative health insurance models offer premium discounts of up to 25% compared to the standard basic insurance model.

In basic insurance, you can choose from a range of insurance models (family doctor, HMO, Telmed and mixed models). However, each provides the same level of cover, in accordance with the Health Insurance Act (KVG/LAMal). The difference between them is the first point of contact for medical questions (e.g. family doctor, health centre, medical call centre or pharmacy). Policyholders choosing an alternative health insurance model will receive a discount on their premiums.

What should I watch out for with alternative insurance models?

If you choose an alternative insurance model, you must follow the specified first-point-of-contact procedure for each new health problem (e.g “always consult the family doctor first”). This requirement does not usually apply to emergencies, annual gynaecological check-ups and regular eye tests. The procedure differs from insurer to insurer and is stated in the general conditions of insurance. If you do not follow the procedure, you may receive a warning, have to pay for the treatment yourself or be transferred to the standard model.

Other conditions may also be attached to the insurance model:
  • Purchase of medicines from a partner pharmacy only
  • Purchase of generic medicine only
  • Choice of hospital from a specified list only

What are the different health insurance models?


Standard basic insurance

Standard basic insurance is the compulsory health insurance offered by all health insurance companies. The cover is identical irrespective of insurer. Policyholders are free to choose any doctor.


Family doctor models

The first point of contact for policyholders opting for the family doctor model is their chosen family doctor. This family doctor must be included in the health insurer's family doctor model. If you would like a specific family doctor, you should check first whether your health insurer has included this doctor in its family doctor model.

The family doctor is responsible for providing and coordinating medical treatment for the policyholder. If medically necessary, this doctor will refer the policyholder to a specialist. The policyholder may choose a different specialist than the one recommended, depending on the health insurance company and family doctor model.

Advantages:
  • You can stay with the same long-standing family doctor.
  • You have free choice of gynaecologist.
  • Premium discount of up to 15-20%
Disadvantages:
  • You need a referral if you want to see a specialist.
  • Your family doctor must be on the health insurance company’s list of approved doctors.

HMO / health centre models

HMO stands for Health Maintenance Organization. The first point of contact for HMO policyholders is the chosen health centre. This should be located close to the policyholders home or place of work. The health centre plans and coordinates the course of treatment.

Advantages:
  • Easy access for those without a family doctor
  • An alternative doctor is always available
  • More extensive range of medical devices (e.g. ultrasound, x-ray)
  • Wider range of specialists
  • Premium discount of up to 25%
Disadvantages:
  • You need a referral if you want to see a specialist.

Medical helplines (Telmed, Callmed)

For Telmed policyholders, the first point of contact for each new health problem is the medical helpline. Medical experts are available via telephone or video consultation to give advice, recommend a course of action, prescribe medicines, provide a doctor's note or refer patients to a doctor, hospital or therapist. The medical helpline is free of charge and is available 24 hours a day.

In the traditional Telmed model, the customer has free choice of doctor following the telephone consultation. However, other models stipulate the doctor and the subsequent course of treatment (hybrid or mixed models). These models are combined with a family doctor, health centre or pharmacy, for example.

Advantages:
  • Free medical advice available round the clock (24-hour helpline)
  • Free choice of doctor after that in most cases
  • Premium discount of around 15-20%
Disadvantages:
  • You must always call the medical helpline before arranging a doctor's appointment.

Other models / mixed models / hybrid models

Hybrid or mixed models became available in 2020. These models have two or three different first points of contact: family doctor, health centre, medical helpline or pharmacy. In some models, policyholders must decide on one of the possible first points of contact, which will then apply for the entire policy period, while in others they are free to choose the first point of contact on a case-by-case basis.

The different medical services often support each other. For example, a patient may first consult a pharmacist. Then, if necessary, a doctor can be consulted via telephone or the app of a telemedicine provider.

Sometimes, there may also be a charge for telephone or pharmacy consultations. If a pharmacy is the first point of contact, the policyholder must purchase any required medicine from a partner pharmacy. It's therefore a good idea to check the general conditions of insurance for the terms of the model in question and details of how exceptions are handled.

Advantages:
  • Multiple possible first points of contact provide greater flexibility.
  • Premium discount of up to 15-20%
Disadvantages:
  • Special conditions make comparisons difficult.

Which insurance model is the best?

Which insurance model is best depends on your personal needs and preferences. You must therefore decide for yourself what your priorities are: freedom of choice, flexibility, price etc. What is important is to understand the conditions applying to your chosen model and to find out when it is possible to switch. Many people still decide against an alternative model for fear of receiving an inferior service or having limited choice. However, each model offers the same cover, which is regulated by law. In addition, the alternative models still offer a considerable degree of freedom and flexibility.

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