Overview of insurance products

Insurance models within the compulsory basic health insurance

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General practitioner model/HMO model BeneFit PLUS

With the general practitioner model, you always contact your selected GP or HMO group practice for any health problems. Your physician works with you to determine the next steps in terms of treatment and, if necessary, refers you to a specialist or hospital.

As a result, you benefit from the optimal coordination of your medical treatment and can save at least 12% on your health insurance premiums. The medical benefits are the same as with standard basic insurance.

With the general practitioner model, all treatment is coordinated by your GP/group practice – this prevents unnecessary duplicate examinations.

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How the general practitioner model/HMO model works

With the general practitioner model, you benefit from the advantages of a central point of contact for all your health problems, and you receive a generous discount on your basic insurance premium. In exchange, you agree to receive coordinated treatment from your selected doctor's practice under this health insurance.

When taking out this insurance, you select a physician or HMO group practice from the Helsana list of physicians as your point of contact for any medical needs.

Krankheit und Unfall

In the event of illness or accident

If you experience any health problems, you go to your selected GP or HMO group practice.

Notfall

In the event of an emergency

In an emergency, go directly to an emergency physician or hospital.

Insurance benefits

You receive the following insurance benefits after deduction of the statutory co-payment (deductible/excess/hospital cost contribution) with the general practitioner model / HMO model.

Details about the co-payment >

Hospital stays in Switzerland General - canton of residence

Hospital stays

If you have opted for another insurance model, you will receive benefits only subject to the following conditions:

  • BeneFit PLUS Family Doctor option: The stay in hospital is prescribed by your GP or group practice.

You receive the costs of a stay in a general ward (multi-bed room) and medical treatment in accordance with the standard rate in your canton of residence.

Choice of hospital

You are free to choose among all the hospitals in Switzerland that are included on the cantonal hospital lists (“listed hospitals”), but receive no more than the costs specified by the tariff of your canton of residence.

Further information

Abroad EU/EFTA Member States: respective social rate / Other countries: double amount of the insured costs in Switzerland

Emergency treatment abroad (outpatient)

By virtue of the Swiss-EU Bilateral Agreement on the Free Movement of Persons, you have the same access to public healthcare (doctors, pharmacies, hospitals or ambulances) in EU/EFTA countries as the residents of the country you are in at that moment. In the event of a medical emergency you will therefore receive costs in accordance with the basic rate of the country in question.

In all other countries outside Switzerland you will receive the costs for outpatient emergency treatment up to double the amount that the same treatment would cost in Switzerland (rate of your canton of residence).

Emergency treatment abroad (inpatient)

By virtue of the Swiss-EU Bilateral Agreement on the Free Movement of Persons, you have the same access to public healthcare (doctors, pharmacies, hospitals or ambulances) in EU/EFTA countries as the residents of the country you are in at that moment. In the event of a medical emergency you will therefore receive costs in accordance with the basic rate of the country in question.

In all other countries outside Switzerland you will receive the costs for inpatient emergency treatment up to double the amount that the same treatment would cost in Switzerland (rate of your canton of residence).

Transport and rescue 50% up to CHF 500.–

Transport at home

You receive overall 50% of the costs, up to CHF 500 per calendar year, of scheduled transportation to a medical facility for medically necessary treatment at home and abroad.

This is on condition that you choose a recognised mode of transport, e.g. a vehicle operated by Spitex, a wheelchair-accessible taxi, a Red Cross vehicle or an ambulance.

Rescue at home

You can claim 50% of the costs up to CHF 5,000 per calendar year for rescue operations in Switzerland.

Medicines Medications on the specialities list

You receive the costs of medications prescribed by a doctor which are included on the specialities list.

Special case for points limitation:

Certain medications are divided into therapeutic groups. You receive the costs for a predetermined quantity from this group within 90 days. The doctor or pharmacist is required to inform you of this.

Further information

Outpatient treatment – conventional medicine According to the tariff in the canton of residence

Outpatient treatment

You receive the costs according to the tariff in your canton of residence for treatment by Federally certified doctors, chiropractors and medical support staff such as physiotherapists, occupational therapists, nurses, midwives, speech therapists, etc.

This is subject to the condition that the treatment has been prescribed by a doctor and is listed in the benefits catalogue of the basic insurance.

Further information

Outpatient treatment – complementary medicine Defined methods

Complementary (alternative medicine)

You receive contributions towards the costs of the following types of complementary medicine:

  • Anthroposophic medicine
  • Classical homoeopathy
  • Phytotherapy
  • Pharmacotherapy within traditional Chinese medicine (TCM)
  • Acupuncture

Please ensure that your doctor holds a recognised certificate of competence awarded by the Swiss Medical Association (FMH) for these methods.

Prevention (preventive medical care) Costs for certain preventive measures

Check-ups

You receive the costs for specific examinations for the early detection of illnesses and for preventive measures (e.g. vaccinations) that are performed or prescribed by a doctor.

The costs of a gynaecological check-up are covered for women every three years. The costs of mammograms are covered subject to certain conditions. We would be happy to give you information on this by phone.

Medical aids and equipment According to list

You receive the costs of medically prescribed aids and apparatus, such as crutches, blood-sugar measuring devices, inhalation/respiration therapy equipment and compression stockings, up to the maximum amount specified by law.

This is on condition that the medical aids are listed in the aids and equipment list and that you obtain them from an authorised provider.

Further information

Maternity Examinations and consultations

Pregnancy

Check-ups and ultrasound examinations
  • For a regular pregnancy, you are entitled to seven check-ups carried out by a doctor or six examinations by a midwife.
  • We will also reimburse you for two ultrasound examinations carried out by a doctor.
  • For a high-risk pregnancy, you will receive the costs of all necessary check-ups and ultrasound examinations.
Breastfeeding guidance
  • You receive 3 sessions of breastfeeding guidance from a midwife or specially trained nursing staff. In case of multiple births, you receive up to 2 additional guidance sessions.
  • Breastfeeding guidance replaces the breastfeeding allowance. This was abolished with the 1996 revision of the Health Insurance Act.

Birth preparation

You can claim CHF 150 per calendar year for ante-natal courses provided by an accredited midwife.

Home birth

For a home birth you can claim costs in accordance with the applicable rate or contract with the midwife.

Hospital stays

If you have opted for another insurance model, you will receive benefits only subject to the following conditions:

  • BeneFit PLUS Family Doctor option: The stay in hospital is prescribed by your GP or group practice.

You receive the costs of a stay in a general ward (multi-bed room) and medical treatment in accordance with the standard rate in your canton of residence.

Nursing care Cost contribution

Spitex

With home care, the care specialist determines your expected need for care with the direct time requirement. The specialist completes a relevant statement of requirements. We pay for the duration of care required based on the corresponding amount in francs specified by law.

You receive a contribution to the costs for Spitex at home (home nursing care), if prescribed by a doctor.

This is subject to the condition that the chosen Spitex organisation or healthcare professional is qualified and recognised.

Further information

Nursing home

You receive the costs according to the applicable tariff for inpatient care services in a nursing home. The tariff is based on the level of care needed, as determined on your admission.

We cannot assume boarding costs (room and board at the nursing home) from basic insurance.

Spa treatment CHF 10 per day

You receive CHF 10 per day for up to 21 days per calendar year for spa therapies at recognised therapeutic spas in Switzerland.

Conditions:

  • The spa treatment is medically certified as necessary.
  • The spa treatment has been prescribed by a doctor.
  • The spa treatment is carried out at a recognised therapeutic spa.

FAQs

Answers to frequently asked questions regarding the BeneFit PLUS General Practitioner/HMO model:

What are the advantages of the general practitioner model?
  • Your GP or HMO group practice knows your medical history in detail and coordinates your medical treatment as closely as possible with your particular conditions and medications.
  • You have only one contact person who is your trusted practitioner.
  • You are referred as and when needed, so avoiding unnecessary multiple examinations.
  • You receive a discount of at least 12% on your basic insurance premium. Please see our list of physicians for your actual premium discount.
  • The doctors involved in your treatment discuss your treatment in detail. This increases certainty and saves time and costs.
Can I stay with my current GP?

When taking out this insurance, you have to select a physician or HMO group practice from the Helsana list of physicians as your central contact for medical issues. If your current GP is on our list of physicians, you can continue to be treated by him or her.

What happens if I go directly to a specialist?

By choosing the BeneFit Plus General Practitioner/HMO model, you agree to always go to your selected GP or HMO group practice in the event of health problems. If you need to see a specialist, your GP or HMO group practice will refer you to one.

If you consult a specialist directly, without having been referred by your GP or HMO group practice, you are breaching your obligations under the general practitioner/HMO model. As a result, Helsana may switch you to the standard model of basic insurance. This will result in you losing the discount on your basic insurance premium associated with the general practitioner model.

What do I do if I have a chronic illness?

When suffering from a chronic illness, your first point of contact should still be your GP. He or she will determine your individual course of treatment and refer you to a specialist, if necessary.

What do I need to do when I'm abroad?

You generally have the same obligations when you are abroad:

  • if you anticipate that you will need treatment, consult with your GP or HMO group practice beforehand.
  • If you experience an emergency while abroad, contact your GP or HMO group practice after you have received initial emergency treatment and inform them of any further treatment you may need.
Who can take out the general practitioner model/HMO model?

Everyone who lives within the service area of the selected doctor network. Use our general practitioner search function to find out if the general practitioner model or HMO model is available where you live.

Can I switch from standard basic insurance to the general practitioner model or the HMO model?

If you have taken out the mandatory BASIS standard variant with us, you can switch to this alternative insurance model on the first of any month and take advantage of its benefits.

Contact us if you would like to switch your current insurance.

How and when can I terminate this health insurance?

You can terminate the insurance on 31 December of each year and switch to another health insurance company in Switzerland, provided that you have no overdue premiums. There is a one-month notice period from notification of the premium for the following year.

Details about termination >

What deductibles are available?

Adults age 19 and over can either select the statutory minimum deductible of CHF 300 or one of five optional deductibles between CHF 500 and CHF 2,500. The higher your deductible, the lower your basic insurance premium.

There is no minimum deductible for children; however, by choosing the optional CHF 500 deductible for them, you can save on their premium too.

Details about the annual deductible >

Still not sure which deductible makes the most sense in your case? Our advisor will be happy to help you. Call us on 0844 80 81 82.

How and when can I change my deductible?

You can increase or decrease your deductible on 1 January of the following year.

We must receive your notification regarding the change in deductible by no later than 31 December.

Change deductible >

Do I receive a premium reduction?

Those whose income and assets justify financial support are entitled to a premium reduction (PR). The premium reduction varies from canton to canton and often does not take effect until the policyholder has asked about it. So it is worth asking the competent office of the canton in which you live whether you are entitled to financial support for your health insurance.

Details about the premium reduction >

Is there a discount? How can I save on premiums?

There are several ways of saving on your premium for basic insurance.

Tips for saving on basic insurance premiums >

Why do I need basic insurance?

Under the Swiss Health Insurance Act (KVG), healthcare insurance is compulsory for anyone living in Switzerland. It provides basic medical care in the event of illness, accidents and maternity, and is therefore known as basic health insurance.

The scope of benefits it covers is regulated by law. This means you receive exactly the same benefits from every health insurer in Switzerland.

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Popular supplements to basic insurance cover

Supplement your basic insurance cover with one or more supplementary insurance policies to close any gaps in coverage based on your needs.

Supplementary insurance at a glance >