Alternative Insurance Models (Family Doctor, HMO, Telmed)

Concept and Legal Basis

Swiss basic insurance in principle guarantees free choice among licensed providers (Art. 41 para. 1 KVG). Art. 41 para. 4 KVG, however, allows insured persons, by agreement with the insurer, to restrict this choice to providers selected by the insurer with a view to more cost-effective care. Art. 62 KVG authorises the Federal Council to regulate such special forms of insurance, which Art. 99 et seq. KVV specify. Three variants dominate: the family doctor model, in which a chosen general practitioner acts as first point of contact and gatekeeper; the HMO model, with treatment in a group practice whose physicians often share budget responsibility; and the Telmed model, in which a telemedicine advice centre must be contacted before every doctor’s visit. Pharmacy and combined models also exist. Emergencies as well as gynaecological and ophthalmological check-ups are usually exempt from gatekeeping.

Premium Discount and Limits

Under Art. 101 KVV the discount may reflect the cost difference to the ordinary model; the FOPH caps the combined discount from model and elective deductible at 50 % of the ordinary premium with a CHF 300 deductible including accident cover. Members who disregard the model rules risk, depending on the insurer’s terms, a warning, a benefit reduction or transfer back to the ordinary model. For insurers the models are an instrument of care management; for insured persons they are today the most important legal saving option alongside the deductible and are now chosen by the majority of the insured population.

Country Comparison

In Germany, GP-centred care under § 73b SGB V corresponds to the family doctor model; optional tariffs under § 53 SGB V offer contribution advantages but are far less widespread. Austria’s ÖGK has no comparable optional models with contribution discounts. In international private medical insurance (IPMI), provider networks and pre-authorisation perform a similar steering function.