HMO: everything you need to know about this alternative health insurance model
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The Federal Health Insurance Act was created to ensure that all Swiss citizens are insured against the risks associated with illness and accidents. This basic compulsory coverage is called LAMal. However, it is possible to choose an alternative to this coverage. Let's take a closer look at one of them: the HMO (Health Maintenance Organization). What is the HMO model? What are the advantages and disadvantages of this health insurance? Answers.
What is the HMO model?
The HMO model is one of the alternative systems to compulsory health insurance. Policyholders who choose this coverage must initially refer only to a network of healthcare professionals adhering to the HMO. They thus have a privileged contact who then directs them to the practitioner best suited to their needs. These professionals are grouped together in HMO centers.
This is not only the least popular health insurance model, but also the least offered by health insurance funds. Yet the trend seems to be changing. More and more people, especially young people, are choosing the HMO model as their health insurance.
It should be noted that to qualify for HMO health insurance, it's best to be domiciled near an HMO center.
Doctors and HMO centers: what you need to know
The HMO model is based on a network of healthcare professionals, in particular doctors and specialists, but also on structures, known as HMO centers.
HMO centers
These are group practices in which family doctors are necessarily to be found, but also often specialists and therapists. Patients therefore have easy access to a wide range of medical services. On the other hand, some cannot be seen in one of these centers. This is particularly the case for:
- Annual gynecological check-ups;
- Ophthalmological check-ups;
- Urgencies.
The centers are divided by catchment area. Unless you live close to the facility, it can be difficult to access HMO care.
HMO doctors
Also known as gatekeepers, HMO doctors coordinate their patients' treatment when they can't handle their own care. They are therefore the ones who prescribe that patients visit a specialist or receive specific care such as outpatient services.
They receive a monthly lump sum for each patient who has chosen the HMO model health insurance and attends the center. This lump sum covers the cost of all services, whatever they may be. The aim is to foster efficient, quality medicine.
Health insurance HMO model: advantages and disadvantages
Like all alternative health insurance models, the HMO has a number of advantages and disadvantages.
Why choose the HMO model?
Policyholders who choose the HMO:
- Benefit from reductions on the basic health insurance premium, which can, depending on the case, reach 25%;
- Can benefit from a significant range of quality healthcare (many centers include a medical analysis laboratory, radiology center, etc.).);
- Are assured of receiving care, even in the absence of their regular doctor, thanks to the presence of numerous practitioners.
What are the limits of the HMO as Health Insurance?
In return:
- Patients must imperatively go to their HMO center whatever their health problem and the quality of primary care they wish to receive;
- Some policyholders do not have an HMO center near their home, effectively excluding them from this alternative health insurance ;
- Not all health insurers offer the HMO model, so some are forced to change companies in order to access it;
- People wishing to obtain a second opinion, from a healthcare professional not adhering to the HMO model will not be able to benefit from coverage of the consultation, which they will therefore have to pay for in full.
Other alternative health insurance models
The HMO model is not the only alternative health insurance to LAMal. Policyholders can also turn to Telmed or the family doctor. It should be noted that all alternative models offer premium reductions on the basic package.
Telmed
The Telmed principle is relatively close to the HMO model, since patients who choose it must contact a telemedicine center before consulting a healthcare professional. It is the advisors who indicate the course of treatment to be followed. Here too, failure to follow this procedure means that the insured cannot benefit from coverage of his or her healthcare expenses. The big advantage of this system is that it provides access to a health advisor 24/7.
Family doctor
As the name suggests, when choosing this model, the policyholder's first contact is his or her family doctor. To benefit from this model, the healthcare professional must be part of the "Family Doctor" network. Unlike other models, the insured may choose to consult a specialist other than the one indicated by his or her family doctor.
Updated on: 01.02.2024Written by Alexis MilonHead of health insurance department at Comparea.To learn more about our team click here.
Frequently Asked Questions
With the HMO model, you benefit from a premium reduction of up to 25% compared with the standard model.
In the case of the HMO model, an appointment with a specialist requires the consultation of a doctor before any prescription.
