Managed care

What is managed care?

Managed care means “coordinated care”. It refers to insurance models in basic health insurance in which you do not go directly to any doctor you like but first to a designated point of contact. This point of contact coordinates your treatment: it treats you itself, refers you to specialists or to hospital and keeps an overview. The technical term for this role is gatekeeping.

In Switzerland, managed care is not a product of its own but the umbrella term for several models that insurers offer alongside the standard model:

• GP model: The first point of contact is a GP you choose from the insurer’s list.
• HMO model: The first point of contact is an HMO practice, a health centre with employed doctors. A Swiss HMO is not the same as a US HMO plan.
• Telemedicine model: The first point of contact is a medical advice service by phone or online.
• Doctors’ network: The first point of contact is a practice from a doctors’ network that works with the insurer.

In the law, these models are called “insurance with a restricted choice of service providers”. The idea behind them is that coordinated treatment should save costs. The insurer may lower the premium, but only to the extent of the cost differences that the model actually brings about.

Important: managed care only concerns basic health insurance under the Federal Health Insurance Act (KVG). The benefits are laid down by law and are the same in every model. What differs is the route to treatment.

How it works

1. Choose a model. You choose a model with your insurer and, depending on the model, a GP, an HMO practice or the insurer’s telemedicine service.
2. Point of contact first. If you have a health problem, you contact this point of contact first. It decides whether to treat you itself or refer you.
3. Referral. If you need a specialist, you receive a referral. Many models require the referral to be in place before the appointment.
4. Exceptions. Emergencies are always possible without a referral. Which other exceptions apply is set out in the conditions of your model.
5. Consequences of breaches. The insurer only has to cover the costs of services provided or ordered by the model’s service providers. What exactly happens in the event of a breach is governed by the insurer’s model conditions.

You can switch to a model with restricted choice at any time. Going back to the standard model or to another insurer is only possible at the end of the year, with the normal notice periods. In such models, insurers can also waive the deductible and retention fee in full or in part.

Legal basis

Art. 41 para. 4 KVG allows you, in agreement with your insurer, to limit your choice to service providers that the insurer selects with a view to more cost-effective care. The insurer then only has to cover the costs of services provided or ordered by these service providers. The article expressly states that the statutory compulsory benefits are insured in all cases. Under Art. 62 para. 1 KVG, the insurer can reduce the premium for such insurance.

The details are governed by the Health Insurance Ordinance (KVV). Art. 99 KVV allows these forms of insurance alongside ordinary insurance; under para. 2 the insurer can waive the deductible and retention fee in full or in part. Art. 100 KVV governs joining and leaving: the models are open to all insured persons in the area, switching in is possible at any time and switching out only at the end of a calendar year. Art. 101 KVV governs premiums: discounts are only allowed for cost differences resulting from the restricted choice and the way service providers are remunerated, and must be supported by at least 5 years of empirical data. Without such data, the premium may be at most 20% below that of the same insurer’s standard model.

Example: standard or managed care in Zurich

Lukas, 34, lives in the city of Zurich, has a deductible of CHF 2,500 and is insured with accident cover. The table shows the median monthly premium of all offers per model group. Premiums 2026, municipality of Zurich (region 1), adults, with accident cover; source FOPH.

What this means for you

Managed care is worthwhile above all if you are prepared to contact a fixed point of contact first. Ask yourself these questions:

1. Do you have a GP who is on the insurer’s list? Then the GP model is often possible without any change.
2. Do you regularly need specialists? Then you regularly need referrals. Clarify with your point of contact how this works.
3. Are you often on the move or do you want advice quickly? Then a telemedicine model may suit you.
4. Do you stick to rules? If you go to a specialist without a referral, you risk paying the bill yourself.

The model finder helps you choose. The premium calculator shows the premiums of all models for your municipality, and you can find the individual insurers under health insurers. If you want to switch insurer for next year, the switching page explains the deadlines and the process.

Common mistakes

• Looking only at the discount. A model whose rules you do not follow becomes expensive if the insurer rejects bills.
• Forgetting the referral. Without the required referral, the insurer does not have to pay for appointments with specialists.
• Believing the benefits are lower. The statutory benefits are the same in every model.
• Underestimating the way back. You can only return to the standard model at the end of the year.

We explain how we evaluate premiums under How we calculate.