HMO is short for Health Maintenance Organisation. It is an alternative insurance model for mandatory health insurance, under which the policyholder agrees to always first consult a specific HMO centre in the event of illness. Policyholders benefit from a premium reduction of up to 25 per cent compared to the standard model due to the limited choice of doctors.
Emergencies as well as the annual gynaecological check-up and regular eye examinations are exempt from this obligation. The exceptions vary from one health insurance company to another and are laid out in the General Insurance Conditions of each provider.
An HMO practice is a group practice including not only GPs but usually also specialists and therapists from various areas of medical specialisation. This allows for a broad range of medical services to be offered, depending on the size of the practice. HMO centres have their own catchment areas. This means that every centre has its own geographical area of activity.
The HMO doctor is referred to as a gatekeeper. He receives a lump sum every month for the treatment of his registered policyholders. This covers all services claimed by policyholders either from the HMO doctor, from external specialists or in the context of a hospital stay. The gatekeeper principle allows the HMO doctor to coordinate treatment of his patients. This lump sum payment is an incentive for the HMO doctor to only administer treatment that the patient actually needs. Therefore, premiums for HMO insurance are up to 25 per cent lower than those for standard basic insurance, while offering the same benefits.