Specialist

What is a specialist?

A specialist is a physician who, after medical school, has completed several years of postgraduate training in a particular field. Examples are cardiology for the heart, dermatology for the skin, gynaecology, orthopaedics, psychiatry or ophthalmology. Strictly speaking, your GP is also a specialist, usually in general internal medicine; in everyday language, however, “specialist” means the physician you go to with a particular question.

For health insurance, specialists are service providers like all physicians. They need a licence from the canton in which they work. To get it, they must have worked for at least three years in the field applied for at a recognised Swiss postgraduate training institution, prove that they speak the language of their region and join a community for the electronic patient record. Without a licence, basic health insurance does not pay for their services.

The cantons also limit the number of physicians working on an outpatient basis at the expense of basic health insurance in one or more fields or regions. Once the maximum number in a field has been reached, no further physicians are licensed there. This can explain why you have to wait a long time for an appointment in some regions.

How it works

How you get to a specialist depends on your insurance model.

Model	First step	What the insurer pays
Standard model	directly to the specialist of your choice	Mandatory benefits from any licensed, suitable specialist
GP model	first to your chosen GP practice	Services the practice provides or arranges with a referral
HMO model	first to the health centre	Services of the centre or with a referral
Telemedicine model	first a telephone consultation	Services as recommended by the advice centre

In the models, the referral is key. It shows the insurer that your first point of contact arranged the treatment by the specialist. Many insurers have exceptions, for example for emergencies, gynaecology or ophthalmology. These exceptions are not set out in the law, but in the insurer’s terms and conditions, and they are not the same everywhere.

The specialist bills according to the tariff. Since 01.01.2026, the TARDOC fee-for-service tariff and outpatient flat rates have applied to outpatient medical services. For mandatory benefits, the specialist may not charge anything beyond the tariff. As with any benefit, you pay the deductible and a 10 % retention fee up to the annual maximum of CHF 700.

If a specialist operates on you or treats you as an inpatient in hospital, the rules for hospital stays apply. Free choice of physician in hospital is then not a benefit of basic health insurance, but a matter for supplementary hospital insurance.

Legal basis

For outpatient treatment, Art. 41 para. 1 of the Federal Health Insurance Act (KVG) gives you free choice among the licensed service providers who are suitable for your illness; the insurer pays according to the tariff of the physician you chose. Under Art. 41 para. 4 KVG, you can agree with your insurer to limit this choice to selected service providers. The insurer then only has to cover services that these providers provide or arrange; the mandatory benefits remain insured. The details of these models are set out in Art. 99–101 KVV.

Licensing is governed by Art. 36 and 37 KVG: cantonal licence, three years of work in the field applied for at a recognised Swiss postgraduate training institution, proof of language skills and joining the electronic patient record. Art. 55a KVG requires the cantons to limit the number of physicians working on an outpatient basis in one or more fields or regions.

Example: free access or referral

Sandro is 45, lives in Bern and sees an orthopaedic specialist several times a year because of back problems. He has a CHF 300 deductible and wonders whether he needs direct access in the standard model. The table shows the median monthly premiums for 2026 in the municipality of Bern (region 1), adults with accident cover. Source: FOPH, health insurance premiums 2026.

Model	Median per month	per year
Standard model (direct access)	CHF 680.00	CHF 8,160.00
Telemedicine and other models	CHF 607.70	CHF 7,292.40
GP and HMO models	CHF 593.10	CHF 7,117.20

You will find the premiums for your municipality, your age and all models in the premium calculator.

What this means for you

Before choosing a model, think about how often you need specialists and how important direct access is to you:

1. Do you have a specialist you see regularly? This remains possible in a model, but with a referral. Ask your insurer how long a referral is valid.
2. Do you want to decide yourself which specialist you see? Then the standard model suits you, but it costs a higher premium.
3. Are there exceptions for fields that matter to you? Check the terms and conditions, for example for gynaecology or ophthalmology.

You can switch to a model at any time, but you can only switch back to the standard model at the end of the year, with notice by 30 November. The dates are under deadlines, and the models of the individual insurers under health insurers. If you are unsure about an important diagnosis, a second opinion can help.

Common mistakes

• Going straight to a specialist in a model. Without a referral, the insurer can refuse to pay, unless an exception in the terms and conditions applies.
• Seeing a specialist without a licence. At new practices, ask whether they bill basic health insurance.
• Not renewing the referral. Referrals can be time-limited. Ask about this for longer treatments.
• Thinking specialists are not covered in a model. The mandatory benefits are the same; only access goes through your first point of contact.

We explain how we analyse premiums under how we calculate.