MR Microinsurance_2012_03_29.indd - International Labour ...

136 Health insurance
Box 6.2 Claims models in HMI schemes
An online survey conducted by the ILO’s Microinsurance Innovation Facility in
2009 confi rmed that the majority of HMI schemes use TPP mechanisms.
Among the 65 respondents:
– 52 per cent use a TPP mechanism
– 22 per cent use reimbursement models (mostly in Asia)
– 18 per cent use a mix of TPP mechanism and claims reimbursement, depend- depend-
ing on services covered or type of healthcare provider
– 8 per cent use an integrated care and claim-fi nancing model
Among the HMI schemes with pure TPP mechanisms, one out of four had
not implemented any cost-sharing (e.g. co-payment, deductibles) or benefi t limits.
Some regional patterns emerge. In Central and West Africa, TPP mecha- mecha- mecha-
nisms appear to be a standard feature of health mutuals, for which the UMSGF
is a representative example.
In India, Devadesan et al. (2004) reported that only two out 12 schemes studied
were using TPP mechanisms, including Yeshasvini. Five other schemes were inte-
grated into healthcare providers, and off ered cashless access to services. In Pakistan,
the National Rural Support Programme started with a reimbursement model and
is evolving towards a TPP mechanism based on client feedback. All schemes devel-
oped by First Microinsurance Agency (FMiA) use TPP mechanisms.
In Cambodia, Lao PDR and Viet Nam, TPP mechanisms were a common
feature amongst HMI schemes since they tend to rely less on the integrated care
and fi nancing model and since national health-fi nancing systems are oriented
toward social health insurance with TPP. In Lao PDR, only one communitybased
health insurance (CBHI) network has developed so far, under the super-
vision of the Ministry of Health, with a TPP mechanism. In Cambodia, all fi ve
existing CBHI schemes use TPP mechanisms. Th e Ministry of Health has issued
guidelines regarding key design features allowing TPP mechanisms with capita-
tion to be negotiated with public health facilities for both primary and hospital
care at district level. At provincial level, HMI schemes typically pay hospitals on
a fee-for-service basis according to a fee schedule.
Responses to the survey from Latin America were were too limited to paint a fair
picture of claims models in that region. Five schemes from Bolivia, Colombia
and Mexico responded to the survey. Th ree of these have adopted TPP mecha-
nisms, including Sol Salud healthcare insurance services from Zurich Bolivia and
BancoSol.
Source: Authors.