MR Microinsurance_2012_03_29.indd - International Labour ...

Th ird-party payment mechanisms in health microinsurance
ance policy (see Figure 6.2). Th e premiums collected in advance by healthcare
providers are expected to cover the cost of the services. In this situation, patients
do not have to submit claims. As with a TPP mechanism, in the integrated claim
model insured patients have access to care without paying out of pocket or only
paying a moderate portion when cost-sharing is in place.
Figure 6.2 Integrated care and fi nancing model
HMI
Healthcare
providers
3) Reimbursement model: With the reimbursement claims model, the insured
member pays for healthcare services at the time of use and then submits claim
documents and receipts from healthcare providers to the HMI scheme to request
reimbursement (see Figure 6.3).
Figure 6.3 Reimbursement model
Healthcare
providers
Premium payment
Provide health care services
with cashless access
(may include some cost-sharing)
HMI
Claims
reimbursement
Provide healthcare services
Pay for healthcare services
Submit
claims
Insured patient
Insured patient
Premium payment
Insured
Insured
Practitioners often mix the diff erent models depending on contracts with
providers and services covered (see Box 6.2).
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