HMO model

What is the HMO model?

The HMO model is a form of basic health insurance with a restricted choice of doctor. HMO stands for “Health Maintenance Organization”, a term from the USA. In Switzerland, however, it means something different from a US HMO plan: a health centre or group practice in which several doctors, often together with other health professionals, provide primary care. If you choose the HMO model, you commit to going to this centre first whenever you have a health issue.

The HMO model is one of the special types of insurance, called “insurance with a restricted choice of service provider” in the law. These also include the GP model, in which your own general practitioner (GP) is the first point of contact, and the Telmed model with an initial consultation by phone or online. The umbrella term for this way of steering care is managed care.

Important: the HMO model is not supplementary insurance and not a different level of benefits. The benefits are the same as in the standard model, laid down by law and identical at all insurers. Only the route to these benefits is restricted.

HMO, GP, PRAXIS

The line between the HMO and GP models has become blurred in recent years, because many insurers mix models with group practices, doctors’ networks and individual practices. That is why the Federal Office of Public Health (FOPH, in German BAG) reclassifies the models in its premium data from 2027: HMO and GP models are grouped under the label “PRAXIS”, because the difference is no longer considered significant. The first point of contact there is always a designated medical practice, for example your GP or a health centre. Models with an initial consultation by phone or online are now called “TEL_DIG”.

How it works

Gatekeeping

The centre takes on the role of “gatekeeper”. This is called gatekeeping: when you have symptoms, you contact the centre first. The doctors there treat you themselves or refer you to a specialist, a hospital or a therapist. Referrals usually go to partners the centre works with. The insurer only covers benefits that the centre has provided or arranged.

Each insurer sets out the exceptions in its insurance conditions. Common ones are:

• Emergencies: in a genuine emergency, you go straight to hospital or to the nearest doctor. You usually have to inform the centre afterwards.
• Direct access to certain specialties: many insurers allow, for example, check-ups with a gynaecologist or an ophthalmologist without a referral.
• Stays outside the catchment area: for example when you are on holiday.

Exactly what applies is stated in the conditions of the product in question. Read them before you switch.

Who can choose the model

The HMO model is open to everyone who lives in the area in which the insurer offers it. The insurer defines the catchment area at the level of municipalities (Gemeinden); the FOPH publishes it together with the premium data. If you live too far from a centre, you will not be offered the model. The premium calculator shows which insurers offer a model with a health centre in your municipality, and the health insurers page gives an overview of the insurers.

Premium and co-payment

In return for restricted access, the insurer gives you a premium discount. It may only be based on cost differences linked to the restricted choice or to the special remuneration of service providers, not on a healthier pool of insured persons. The insurer must back the discount with claims data from at least five years; without such data, the premium may be at most 20% below standard insurance. In addition, the premium for all special types of insurance combined must be at least 50% of the premium for standard insurance with accident cover.

The deductible (Franchise) and the retention fee (Selbstbehalt) apply as in the standard model; you can combine the model with any deductible from CHF 300 to CHF 2,500. The ordinance allows insurers to waive the deductible and the retention fee fully or partly in the model (Art. 99 para. 2 KVV); whether an insurer does so is stated in its conditions.

Legal basis

The Federal Health Insurance Act (KVG) allows a restricted choice of doctor in Art. 41 para. 4 KVG: in agreement with the insurer, insured persons can limit their choice to service providers that the insurer selects with a view to more cost-effective care. The insurer then only has to cover the cost of benefits that these service providers provide or arrange. The benefits required by law are covered in every case. Under Art. 62 para. 1 KVG, the insurer may reduce premiums for this kind of insurance.

The details are set out in the Health Insurance Ordinance (KVV):

• Art. 99 KVV: Insurers may operate models with a restricted choice alongside standard insurance and may fully or partly waive the deductible and the retention fee.
• Art. 100 KVV: The models are open to all insured persons resident in the area in which the insurer operates them (para. 1). Switching into such a model is possible at any time (para. 2); switching to another type of insurance or another insurer only at the end of the calendar year with the notice periods under Art. 7 KVG (para. 3).
• Art. 101 KVV: Premium reductions only for cost differences resulting from the restricted choice and the special remuneration, backed by claims data from at least five accounting years; without such data, at most 20% below the standard premium.
• Art. 90c KVV: The premium for special types of insurance is at least 50% of the premium for standard insurance with accident cover in the same region and age group.

The insurer sets out the details of the referral requirement, the exceptions and the consequences of breaches in the insurance conditions of the model.

Example: standard versus HMO at the same insurer

Nadia is 34 and lives in the city of Zurich. At one insurer, Atupri, she compares the standard model with free choice of doctor and the HMO model, both with accident cover (premiums 2026, municipality of Zurich, region 1, adults; source FOPH).

Deductible	Standard model	HMO model	Difference per month	Difference per year
CHF 300	CHF 623.70	CHF 517.70	CHF 106.00	CHF 1,272.00
CHF 2,500	CHF 495.40	CHF 389.40	CHF 106.00	CHF 1,272.00

The example shows a single insurer and is not a recommendation. At other insurers, the discount is larger or smaller. The model finder and the premium calculator show which models are available in your municipality and which one suits your daily life.

What this means for you

Check these questions before switching to an HMO model:

1. Is there a centre near you? You will need it for every cold and every referral. Short distances and suitable opening hours matter more than a few francs.
2. Do you want to keep your current doctor? If they do not work at the centre, you lose them as your first point of contact. A GP model in which your doctor is on the list may then be a better fit.
3. Do you regularly need specialists? If you are in ongoing treatment, check beforehand whether the centre will keep referring you to your current specialist.
4. Do you know the exceptions? Emergency, gynaecologist, ophthalmologist, holidays: read the conditions and save the centre’s phone number.

You can join at any time, even in the middle of the year. You can only return to the standard model on 1 January, with notice by 30 November. All dates are listed under deadlines.

Common mistakes

• Going straight to a specialist. Without a referral, the insurer does not have to pay, except in an emergency or where the contract provides an exception.
• Misunderstanding what an emergency is. An emergency is a situation that requires immediate action. A complaint you have had for weeks does not usually become one at the weekend. If in doubt, call the centre or your insurer’s emergency number.
• Choosing the model on premium alone. A centre you never go to will cost you benefits when it matters.
• Forgetting about a move. If you move out of the catchment area, you must tell your insurer; the model cannot continue there.
• Confusing the HMO with supplementary insurance. The HMO model only concerns basic insurance. Your supplementary insurance continues independently.