Confused about health insurance models

Banks, Insurances & Third Pillar
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I am about to get my first health insurance as a newcomer in Switzerland and I am confused about the different models. I like the idea of having an app or a hotline where I can give my symptoms and then I can be referred to a doctor. Even better those models are one of the cheapest. But there is something strange. I will give ÖKK’s models as an example. But I saw the same with other companies.

They have the ÖKK Casamed Select which they state that the initial contact should be via telmed, app or pharmacy. They also have ÖKK Casamed 24 which is the same, but the initial contact can only be made via telmed or app. No option for pharmacy.

What I don’t understand is why is the model with less options (no pharmacy, only app and telmed) more expensive? More options should result in higher price not the other way around. What am I missing?

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Sometimes it doesn’t make sense, it’s just market segmentation. (Was the same a few years ago with kpt win.win being cheaper than a more restrictive model)

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Yes, I even asked a KPT employee on the phone about this because it made 0 sense. She also didn’t really know the answer, apart from that KPT wanted to push this win.win model this year.

@Tualatin, something to check is whether your choice of doctors (after consulting app/phone) is more limited in the cheaper one.

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Theoretically, the pharmacy model can work out cheaper for insurers because, for smaller issues, many people will be content with a pharmacist’s diagnosis. At this point at least, people aren’t likely to accept an app’s diagnosis, or even a diagnosis via video call. Most people will still want to see a doctor. So I would argue that a pharmacy would do a better job at weeding out the cases that do not require a doctor. Since pharmacies have an incentive (sell a salve for the allergic reaction or a syrup for that cough), they are likely to make a favorable deal with the insurance company which costs the insurance very little.

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Have you wrapped your head around excess (“Franchise”) and deductible (“Selbstbehalt”) yet? What about supplementary insurances? This federal info might help.

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Your translations look wrong to me. “Franchise” is “deductible”, and “Selbstbehalt” I would straightforwardly translate as “own contribution”.

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I received an official response from ÖKK:

The only difference between ÖKK CASAMED SELECT and ÖKK CASAMED 24 is, that the ÖKK CASAMED SELECT model gives you the option for a pharmacy consultation and this is the reason why we recommend ÖKK CASAMED SELECT.

So I guess all of you were right. Thanks for all the inputs!

As for Franchise and Selbstbehalt, I think I already made my mind.

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I now have a health insurance but I do not know how to use it :sweat_smile: I will reuse this thread to ask some questions and would appreciate any inputs.

If I want a consultation in person with a doctor what is my best course of action?

I can call the Medgate phone number. I read some users saying they just call and say they want to visit a particular doctor and Medgate just needs to approve but I am not sure this is possible.
Or I can state my symptoms and probably they will refer me to a doctor?

Another option is to use the app and start a chat. But I am worried that they will just prescribe something and I will not be able to visit a doctor in person.

And finally if I am allowed to visit a doctor, will they give me coordinates to a specific one or do I have to find one on my own? And how do I book an appointment, do I just call the doctor/write an email or maybe I should use a platform like OneDoc?

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Well, have you read its conditions?

Yes, I think this is what is going to happen.

I don’t think Medgate will find you a doctor. Like all professionals, they are in high demand.

Yes, that is good. There are also big medical centers like Medbase, totally worth checking in my opinion.

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Sounds like you have the MedGate model where you have to call or chat first. MedGate then has to record in its system which doctor you want to see. The procees is as follows:

  1. Describe in the chat what your symptoms are, how long you had them, etc
  2. They will either want to talk to you on the phone OR they will suggest that you see a doctor
  3. Then you suggest a doctor, MedGate then enters this doctor and a timeframe (~2 Months or something like this) in there systems and you can then make an appointment with the doctor you have chosen yourself

The people behind the chat and phone are also just people. Just be friendly and open about what you want. So far, I’ve always been allowed to see a doctor when I wanted to. However, as Dr. Pi already said, it depends on the conditions of your health insurance - you may have something slightly different. For example, there are models where you can’t just choose any doctor, but have to go to a health centers. If you call your health insurance company (not MedGate), they will be able to tell you how it works in your case and what are allowed. Or you can read the documents you have signed. Please note that basic insurance does not pay for preventive medical check-ups unless they are necessary for health reasons.

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