Rules of managed care models: how to avoid benefit cuts

Why the rules decide about your money

GP, HMO, telemedicine and pharmacy models are the norm in Switzerland: according to the Office of the health insurance ombudsperson, around 80 % of all insured persons were in a model with a restricted choice of service provider in 2025. You pay a lower premium and in return commit to contacting the agreed point of contact first whenever you have a health problem. This principle is called gatekeeping.

The law allows insurers in these models to pay only for services provided or arranged by the agreed service providers. The statutory benefits remain insured (Art. 41 para. 4 of the Federal Health Insurance Act, KVG). So you do not lose any benefit, but the route to it is prescribed. If you do not follow the route, you risk your insurer not covering the bill.

Each health insurer sets out the details in its own regulations, sometimes also called general insurance conditions. The ombudsperson notes that these rules are becoming “ever more complex” in certain models and can become a cost trap for insured persons who do not read them in detail. In 2025 the office received 4,906 cases, 2,251 of them (45.9 %) about insurance benefits.

The typical rules of the money-saving models

The following rules appear in many regulations. Which of them apply in your tariff, and with which deadlines, is only set out in its conditions.

First point of contact before any treatment

In the GP model this is the practice you chose, in the HMO model the health centre, in the telemedicine model the telemedicine centre, and in the pharmacy model the partner pharmacy. The contact must take place before the treatment, not afterwards. This applies to every new health issue.

Referral to a specialist

You go to a specialist, to physiotherapy or to hospital with a referral from your first point of contact. The law does not set a period of validity; the regulations determine whether it applies to one treatment, a number of consultations or a certain period. What exactly happens if you go directly without a referral is explained in the article GP model and specialists.

Emergency: go straight there, report afterwards

In an emergency you go straight to hospital or call 144. The regulations provide exceptions for this, but often require you to inform your first point of contact afterwards within a certain deadline. An emergency is a treatment that cannot be postponed; what counts as one is often disputed in the individual case.

Exceptions and additional contact points

Many regulations exempt certain specialist fields or preventive check-ups from the referral requirement. Conversely, there are models with additional obligations: for 2025 the ombudsperson describes a model in which, for specialist fields such as cardiology, urology or orthopaedics, insured persons must contact an additional advice service after their GP, which then suggests three specialists. The insurer can adjust the list of specialist fields at any time and informs insured persons about it in writing.

Rules on medicines and changing practice

According to the FOPH, the models can also contain rules on the choice of certain service providers or on the dispensing of medicines. If you want to change your GP practice, you notify your insurer beforehand; some tariffs only allow a change on certain dates.

What happens if you break the rules

The consequences are set out in the regulations. The ombudsperson summarises practice as follows:

The ombudsperson repeatedly sees cases in which insured persons ignored the warning letters and are then surprised that the insurer no longer pays, or no longer pays in full. So read every letter from your insurer about your model.

In the case from the 2025 annual report, the insurer refused to pay the costs because insured persons had gone straight to the specialist after the GP’s referral without first calling the additional advice service. Under its regulations, the insurer offered a switch to the standard model retroactively to 1 January, with the higher premium; it then covered the refused treatment costs. Whether your tariff has such an option is set out in its regulations.

The disadvantages of the GP model and the other money-saving models

The premium is lower, the benefits are the same. The disadvantages show up in everyday life:

• Less freedom. You no longer go directly to any doctor, but first to your point of contact. As a rule, you also get a second opinion through them.
• More organisation. You have to keep track of referrals, deadlines for reporting afterwards and any additional advice services yourself. According to the ombudsperson, GPs are generally not familiar with the conditions of the individual models in detail.
• You can only leave once a year. You can switch into a model at any time, but back to the standard model only at the end of the year, with receipt by 30 November (Art. 100 para. 2 and 3 of the Health Insurance Ordinance, KVV, FOPH).
• Rules can change. The insurer adjusts lists of practices or specialist fields; it informs you in writing.
• Not available everywhere. A model is only open to insured persons who live in the area where the insurer operates it (Art. 100 para. 1 KVV).

The premiums show how large the discount is compared with these disadvantages: municipality of Bern (region 1), adults (born 1970), deductible CHF 300, with accident cover; source FOPH. In 2026 the median premium was CHF 680.00 per month in the standard model and CHF 593.10 in the GP and HMO tariffs. That is CHF 86.90 a month or CHF 1,042.80 a year.

Sample calculation: what three visits without a referral cost

Example with fictitious people. Thomas is 56, lives in Bern, has a CHF 300 deductible and is insured in a GP model. Because of regular physiotherapy, he had already used up his deductible in spring. In autumn he goes directly to a specialist three times without a referral. Assume each consultation costs CHF 250 and his retention fee has not yet reached the annual maximum.

The calculation does not show that a model is not worthwhile, but where the costs of a model lie: in discipline, not in the premium. Whether a model suits your everyday life is clarified by the model finder.

Step by step: how to keep to the rules

1. Read the regulations before switching. Look for three points: when do you need a referral, which exceptions are there, and what happens if you break the rules? The page Insurance models summarises the rules of the common models.
2. Save your point of contact. The telephone number of the practice or telemedicine centre and your insurer’s app belong on your phone, also for children you insure with you.
3. Before every appointment, ask: do I have a valid referral? For longer treatments, ask your point of contact whether the referral is still valid or needs to be renewed.
4. Report emergencies afterwards. After an emergency, you inform your point of contact within the deadline in your regulations, preferably in writing.
5. Read your insurer’s mail. Notices of breaches and changes to the model arrive by letter or in the customer portal. Respond to them.
6. Check once a year. Does the model still suit you? If you often need to see specialists, check before 30 November whether another model or the standard model suits you better. The article GP, HMO, Telmed, pharmacy compares the models.

If your insurer won’t pay: your rights

If your insurer refuses a bill because of a breach of the rules and you disagree, there is a set procedure:

1. Ask for the reasons. Ask in writing which rule in the regulations the insurer is relying on.
2. Ask for a written decision. For benefits you disagree with, the insurer must issue a written, reasoned decision with information on legal remedies (Art. 49 para. 1 and 3 of the Federal Act on the General Part of Social Insurance Law, ATSG).
3. Lodge an objection. You can lodge an objection against the decision with the insurer within 30 days; the objection procedure is free of charge (Art. 52 para. 1 and 3 ATSG).
4. Contact the ombudsperson. The Office of the health insurance ombudsperson gives neutral advice free of charge and can mediate with the insurer.

The article Benefit refused describes the whole procedure. Whether there was an emergency or the referral was valid depends on the individual case and the regulations; we cannot assess this for you.

Common mistakes

• Only reading the regulations once a bill has been refused. The rules apply from your first day in the model.
• Assuming your GP knows the rules of your tariff. According to the ombudsperson, GPs are generally not familiar in detail with the conditions of the individual models. The responsibility lies with you.
• Ignoring warning letters from your insurer. After the first breach there is often only a warning, after the next one a refusal.
• Not reporting the emergency afterwards. Direct treatment is allowed, but the reporting deadline afterwards is still in the regulations.
• Leaving the model too late. If you realise the rules do not suit your everyday life, you must notify the switch to the standard model by 30 November.

You compare the premiums of the models in your municipality in the premium calculator; the profiles under Health insurers show which models an insurer offers. You will find all money-saving topics in the Saving money section.