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InsuranceHealth insuranceGlossary

HMO – a brief description

  • What is the HMO model?
  • Advantages of the HMO model
  • Disadvantages of the HMO model
  • HMO practice
  • HMO doctor

What is the HMO model?

HMO stands for Health Maintenance Organization and is an alternative insurance model for basic health insurance. Under the HMO model, policyholders are required to consult a particular HMO practice first in the event of illness. Because the choice of doctors is limited, policyholders choosing this model benefit from a premium reduction of up to 25% compared to the standard model.

The requirement to first consult an HMO practice does not apply to the following:

  • Emergencies
  • Annual gynaecological preventive check-ups
  • Eye tests by an ophthalmologist

These exceptions vary depending on the health insurer and are defined in the insurer's general conditions of insurance.

Advantages of the HMO model

  • Discounted premiums: you pay up to 25% less compared to the standard model.
  • Range of services and specialist fields under one roof: individual doctors cannot always afford expensive equipment such as x-ray and ultrasound machines. HMO doctors, however, share the infrastructure and therefore have access to more facilities. And because they work closely with specialists, referrals are usually more straightforward.
  • Availability: with multiple doctors working together in the same practice, there is always another doctor available in the absence of your own.

Disadvantages of the HMO model

  • Referrals: you always need a referral to see a specialist.

HMO practice

An HMO practice is a group practice employing not only family doctors but also specialists and therapists from various medical fields. 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 geographical area.

HMO doctor

The HMO doctor is referred to as a “gatekeeper”. These doctors are paid a lump sum every month to treat their registered policyholders. This covers the cost of all the services provided for policyholders, whether by the HMO doctor, external specialists or in the context of a hospital stay.

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). The lump sum payment to cover all statutory benefits is an incentive for the HMO to prioritize efficiency and quality rather than prescribing unnecessary medical treatment to increase revenues. Therefore, premiums for HMO insurance products are up to 25% cheaper than those for the standard basic insurance model, although the level of cover is the same.

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