Simplified “family doctor” models

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Simplified “family doctor” models

All insured persons with a basic health insurance model that requires they see their family doctor first. These alternative models are:

  • PrimaCare and SUPRAcare (free choice of family doctor), both of which will become “PrimaCare” as from 1 January 2022
  • Health Network, Optimed and BasicPlus (choice of family doctor from a list), all three of which will become “OptiMed” as of 1 January 2022

No further action is required on your part. You will automatically enjoy the benefits set out in your new terms and conditions of insurance, effective 1 January 2022.

It’s an alternative model to the standard basic health insurance model. You receive the same benefits as with a standard basic health insurance model but pay a lower premium. In return, you agree to first see the family doctor you have chosen.

Your family doctor, also known as “general practitioner (GP)”, examines you and refers you to a specialist if necessary. This avoids unnecessary consultations and helps to reduce health care costs.

If your family doctor or another doctor refers you to a specialist, you must ask your GP to draw up a short certificate, i.e. a "referral voucher". Some doctors send it to us electronically. If this is not the case, you can ask your doctor for the referral voucher (a simple signed note is sufficient, mentioning the specialist recommended and the period of validity of the certificate). You can send it to us by post or via your online customer area.

You are not required to consult your general practitioner beforehand in certain specific cases (e.g. for consultations with a gynaecologist, eye specialist, etc.).
You will find all the necessary information in your special terms and conditions of insurance.

We are simplifying our basic health insurance models with family doctor in order to better meet our insured persons’ expectations:

  • We care about our insured persons
    We want to spare our policyholders unnecessary administrative procedures and relax certain rules that are too strict and lead to discontent (e.g. we will no longer refuse to refund a treatment if policyholders have not complied with the rules of their insurance model).
  • Terms and conditions of insurance that are easy to understand
    We wish to simplify the wording of our terms and conditions of insurance to make them more reader-friendly.
  • More widely available in Switzerland
    We want our insurance models to be available in more cantons so that our insured persons do not have to switch models when they move.

The rules of the basic health insurance models affected by the simplification, as well as the related benefits, will not change:

  • The rules of your insurance model will remain the same next year. In case of a medical necessity, you simply continue to go to your chosen family doctor and send us a certificate (referral voucher) if the doctor refers you to a specialist for further treatment.
  • Compared to the standard model, you will continue to benefit from the same attractive terms and conditions (premium reduction) as now. As with every year, the exact amount of the 2022 premiums can go up or down, depending on healthcare cost trends. Your insurance certificate, which will be sent to you in October, will indicate your 2022 premium. (Premiums for the following year cannot be communicated until the Swiss Federal Council officially announces them in September.)
  • The medical benefits covered by your insurance will remain the same. The benefits of basic health insurance are defined by the Swiss Law on Health Insurance (LAMal/KVG) and are therefore identical, regardless of the insurance company and the basic health insurance model chosen.
  • If your canton of residence pays part of your health insurance premium, the subsidies to which you are entitled will not be affected by this simplification.
  • Your deductible amount will remain the same next year. If you wish to change your deductible, you can inform us by 30 November 2021 for a reduction in deductible or by 31 December 2021 for an increase in deductible.
  • Health data shared with your family doctor will remain the same as currently. It must be processed in a secure manner for the proper functioning of your insurance model, in accordance with the Federal Law on Data Protection(LPD/DSG).

  • Your family doctor will remain the same next year. However, you are of course entitled to change your family doctor if you wish. Just let us know as soon as possible through one of the following channels:
    - contact form
    - letter
    - telephone
    - online customer area
  • Your supplemental insurance policies will not be affected by this simplification, which only concerns basic health insurance.

The terms and conditions of insurance have been reviewed in order to make them more straightforward and user-friendly. These changes will apply from 2022 onwards:

  • We will no longer refuse to refund a treatment when insured persons have not complied with the rules of their "family doctor" insurance model. However, these insureds will receive a letter reminding them of the rules of their insurance model. In case of repeated non-compliance, insured persons will automatically be transferred to the standard model with free choice of doctor.
  • We will no longer require that insured persons return to see their family doctor when several doctors are involved in a same treatment. If a doctor other than your family doctor considers that it necessary for you to see a specialist, we will also accept referral vouchers signed by this other doctor.
  • All lists of recognised doctors under the current BasicPlus, Health Network and Optimed models will be combined into a single OptiMed list. Insured persons will be able to keep their family doctor and new OptiMed policyholders will therefore have more choice. Children insured under this model will be free to choose their family doctor, even if the doctor is not on a list.

You can download your new terms and conditions of insurance for 2022 below:

The new terms and conditions of insurance were sent out personally between July and September 2021. They are also available on our PrimaCare and OptiMed product pages, under the tab "Documents for download".

If you have any further questions about this simplification, please do not hesitate to contact us:

Groupe Mutuel

Rue des Cèdres 5 Case postale, 1919 Martigny    |    +41 0848.803.111