• Title/Summary/Keyword: Insurance coverage

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Underwriting Method of Worksite Marketing Product (Worksite Marketing 상품과 언더라이팅 기법)

  • Kim, Cheong-Nyun;Chung, Sung-Wan
    • The Journal of the Korean life insurance medical association
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    • v.24
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    • pp.97-117
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    • 2005
  • Internally Korean insurance market is that whole life products' growth are becoming slowdown that's why new insurance products have appeared on the market in consideration of consumer's needs recently. Externally domestic insurance market competitions has drifted from insurance industry to whole financial industry since bankasurance started. Life insurance companies should open up a new market to survive from severe competitions. Worksite marketing can be an alternative. An insurer make arrangements with an employer about an insurance terms which an insurer offers in Worksite marketing. Then eligible individuals enroll in the plans at their own discretion and pay 100 percent of the premium for coverage through payroll deductions. An employer doesn't need to pay extra money for additional benefit but can raise employee's loyalty and satisfaction of company through worksite marketing. An employee can be covered at discounted premium rate and less strict underwriting guidelines to an insurer compared to individual insurance. In developed countries specially U.S insurance market, Worksite marketing is getting very popular and growing rapidly due to the advantages. Worksite marketing has both individual insurance characters and group insurance characters. Individual insurance characters are that employees enroll in the plans at their own discretion and pay 100 percent of the premium for coverage. Group insurance characters are that actively at work and participation etc. An insurer have to reflect these two characters on Worksite marketing when an insurance company work out a plan for developing products and underwriting guidelines. When an insurer devise worksite products, one should consider participation level which means percentage of eligible employees participating. Participation is related to anti-selection. As we know underwriting is essential for every kind of insurance, especially underwriting plays major role in worksite marketing. We can see that in the below. Firstly, it has a function in calculation of premium rate. When calculate premium rate for worksite products underwriters have to estimate expected participation level and risk factors. So underwriters and acturies keep in close contact with each other. Secondly, underwriting methods are important. When an insurer underwrite worksite products, there are three kinds of underwriting methods. These are Simplified issue underwriting, Full underwriting and Guaranteed issue underwriting. Simplified issue underwriting typically requires no medical examination, but usually requires supplying satisfactory answers to one or several health and/or lifestyle questions. Full underwriting requires a complete medical history questionnaire that may further require an exam. Guaranteed issue underwriting means that coverage is issued without the employee having to provide evidence of insurability. When insurer set the GI limit are usually based on the type of industry, number of eligible employees, the average amount of coverage and participation level. In addition to insurer should have a clear definition of eligible employee on the insurance provision and application form. It will minimize possibility of trouble claims and anti-selection. An insurer also establish preexisting condition exclusion and special guidelines for late entrants. When an insurer introduce Worksite marketing to Korean insurance market, an insurer has to examine market research to analyze potential market and strategy of sales most of all. Also an insurer should review real situation of the U.S, England and Japanese market etc. There are a lot of new technologies about worksite marketing process that an insurer should learn. When an insurer consider many things which we explained it can be a real alternative.

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The Paradox of the Ugandan Health Insurance System: Challenges and Opportunities for Health Reform

  • Emmanuel Otieno;Josephine Namyalo
    • Journal of Preventive Medicine and Public Health
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    • v.57 no.1
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    • pp.91-94
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    • 2024
  • For nearly four decades, Ugandans have experienced a period marked by hope, conflict, and resilience across various aspects of healthcare reform. The health insurance system in Uganda lacks a legal framework and does not extend benefits to the entire population. In Uganda, community-based health insurance is common among those in the informal sector, while private medical insurance is typically provided to employees by their workplaces and agencies. The National Health Insurance Scheme Bill, introduced in 2019, was passed in 2021. If the President of Uganda gives his assent to the National Health Insurance Bill, it will become a significant policy driving health and universal health coverage. However, this bill is not without its shortcomings. In this perspective, we aim to explore the complex interplay of challenges and opportunities facing Uganda's health sector.

A case study on benefit coverage of complementary medicine in public health insurance by the referendum in Switzerland (스위스에서의 국민투표에 의한 보완의학 건강보험 급여화 사례 연구)

  • Kim, Dongsu;Lim, Byungmook;Park, Inhyo;Lee, Yoon Jae
    • Journal of Society of Preventive Korean Medicine
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    • v.21 no.3
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    • pp.29-42
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    • 2017
  • Background : Efforts towards increasing insurance coverage for traditional Korean medicine (TKM) are being continued. However, various difficulties are faced in generating evidence for TKM due to limited financial support and the low quality of research methodology. Objectives : The objectives of this study were to review the Swiss evaluation program for complementary and alternative medicine (CAM) and assess the expansion in public health insurance coverage of complementary medicine as approved by referendum in Switzerland. Methods : The regulations of CAM in the European Union were assessed. Research articles, reports, government publications and websites which deal with the 'Programm Evaluation $Komplement{\ddot{a}}rmedizin$ (PEK)' and the referendum in Switzerland were searched for and analyzed. Results : The PEK was conducted from 1998 to 2005. The PEK evaluated the efficacy, utilization and cost-effectiveness of anthroposophical medicine, homeopathy, neural therapy, phytotherapy and traditional Chinese medicine. However, clear conclusions could not be drawn from the evaluation according to the PEK Report. Later, a referendum was implemented in which 5 therapies would be added to the Switzerland Constitution with the support of the public. The coverage of CAM was approved by Swiss a plebiscite with an approval rate of 67.0%. Conclusions : The reason for the successful referendum is suggested to be public support and the solidarity with CAM experts and politicians. It may be surmised that recognition of the political efforts and scientific aspects required to expand insurance coverage of TKM, and towards obtaining public support, is necessary.

Patients' Satisfaction with Chuna Manual Therapy in the Pilot Coverage Program of National Health Insurance (건강보험 추나요법 급여 시범사업 참여 환자들의 만족도 조사)

  • Kim, Seunghyun;Ryu, Jiseon;Lee, Kyungmin;Kwon, Byungjo;Lim, Byungmook
    • Journal of Society of Preventive Korean Medicine
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    • v.23 no.2
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    • pp.1-10
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    • 2019
  • Backgrounds : In 2017, National Health Insurance implemented the pilot coverage program for Chuna manual therapy(CMT). 65 Korean Medicine(KM) hospitals and clinics were selected in the program to monitor the effectiveness and patients' satisfaction of insured CMT. Objectives : This study aimed to evaluate patients' satisfaction of CMT in the pilot coverage program of National Health Insurance. Methods : Survey participants were recruited among the patients who used CMT at the designated organizations. On-line questionnaire link was sent to the smart phones of patients who agreed to participate in the survey and provide personal contact information. The questionnaire consisted of the basic charactersitics of respondents, imformation on using CMT satisfaction with CMT and willingness to recommend CMT to others. The answers that were automatically coded and saved were statistically analyzed. Results : Of 386 participants who completed the questionnaire, 92.8% satisfied or strongly satisfied with the CMT. Most frequent reason of satisfaction was 'Good effectiveness', and there was no difference in satisfaction between patients of hospital and those of clinics. Patients with the highest and the lowest level of pain satisfied more than those with other pain levels(p=0.003), but the level of copayment and reasons of CMT use did not affect the satisfaction results(p=0.405). The proportions of respondents who had willingness to recommend CMT to others and to revisit for CMT use were 97.8% and 98.8%, respectively. Conclusions : Most patients were satisfied with CMT in the pilot coverage program, and it can provide the rationale for expanding the insurance coverage of CMT to all KM hospitals and clinics.

Considerations in Allowing Voluntary Non-Reimbursable Treatments from a Public Law Perspective - A Commentary on Supreme Court Judgment 2010 Doo 27639, 27646 (ruled on June 8, 2012 by the Grand Bench) - (임의비급여 진료행위의 허용여부에 관한 공법적 고찰 - 대법원 2012. 6. 18. 선고 2010두27639, 27646 전원합의체 판결에 대한 평석 -)

  • Ha, Myeong-Ho
    • The Korean Society of Law and Medicine
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    • v.14 no.2
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    • pp.173-214
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    • 2013
  • Traditionally, the Supreme Court has held that medical treatment agreements covered by national health insurance should be distinguished from other medical treatment agreements which are viewed as a consummation of the autonomous free will between doctor and patient. Namely, the Supreme Court views medical treatment agreements covered by national health insurance to be bound by the National Health Insurance Law with the intent to promote the applicability and comprehensiveness of the national health insurance scheme. Yet, issues of voluntary non-reimbursable treatments are triggered not only by the mistakes or moral hazard of medical care institutions but also by systemic limitations of national health insurance coverage criteria. Thus, there is a need for legislative measures that allow certain medical treatments to be included or reflected in the national health insurance coverage system so that patients may receive prompt and flexible medical treatments. To reflect such concerns, the Supreme Court made an exception for voluntary non-reimbursable treatments and developed a strict test to be applied in such cases in Supreme Court Judgment 2010 Doo 27639, 27646 (ruled on June 8, 2012 by the Grand Bench). Such judgment, however, is not a fundamental overturn of the Supreme Court's prior rulings that voluntary non-reimbursable treatments are not allowed under the law. It is only a slight revision of its previous stance for cases in which there is a lack of legislative measures to make coverage of a new yet valid medical treatment possible under the current national health insurance coverage system.

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A New Healthcare Policy in Korea Part 1: Expanded Reimbursement Coverage of Brain MRI, Brain/Neck MRA, and Head and Neck MRI by National Health Insurance (새로운 건강보험 보장성 강화 대책 1부: 뇌 MRI, 뇌혈관/경부혈관 MRA, 두경부 MRI 급여 확대)

  • Eunhee Kim
    • Journal of the Korean Society of Radiology
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    • v.81 no.5
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    • pp.1053-1068
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    • 2020
  • In accordance with the new healthcare policy of government (Moon Jae-In Care) to strengthen health insurance coverage, the National Health Insurance (NHI) coverage of brain magnetic resonance imaging (MRI), brain/neck MR angiography (MRA), and head and neck MRI have been expanded since 2018 in Korea. This article has been reviewed focusing on the "Detailed matter concerning criteria and method for providing reimbursed services in the NHI. Some revisions" regarding reimbursement for MRI, which was revised from October 2018 to April 2020 and is currently in effect. It included the MRI reimbursement system in Korea, recent adjustment of the reimbursement coverage for patients with headache or dizziness, and reimbursement coverage, standard imaging, and radiologic report of brain MRI, brain/neck MRA and head and neck MRI. This article could help radiologists gain knowledge on health insurance to protect the expertise of the radiologist and to play a leading role in the hospital. As the policy changes, detailed matter concerning criteria and method for providing reimbursed services in the NHI may be revised. Therefore, radiologists should update issues related to insurance reimbursement for MRI continuously.

A Study on Private Health Insurance in Korea (민간의료보험의 현황 및 활성화에 관한 연구)

  • 정기택
    • Health Policy and Management
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    • v.7 no.2
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    • pp.109-146
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    • 1997
  • This study explores the feasibility of activating private health insurance in Korea. The rationale for expanding private supplementary health insurance can be found in many cases of health care reforms in the European countries. Private health insurance can not only relieve the financial distress of the government health insurance programs but also offer the medical institutions incentives to improve the quality of medical care. In Korea there is no supplementary health insurance that reimburses for various kinds of diseases based on a well designed fee schedule. Recently, the cancer insurance is the best seller in the health related insurance market. As observed in the U. S. case, the cancer insurance which pays the predetermined amount (indemnity coverage) regardless of the medical charges incurred to the patient is limited in its coverage for the insured. To provide better protection against catastrophic diseases, the government should give insurance companies incentives to develop health insurance products that cover multiple diseases rather than a single disease. Consumers can hardly understand and compare complex insurance products. To resolve the information asymmetries, the government should publish a consumer report that compare various health insurance products in a user friendly way. In the long run, insurance companies will plan to sell health insurance products that charge risk related premium only when insurers accumulate the underwriting know-hows, the government shares data on various health statistics including claims and demographics, and risk pool for high risk patients is well established and subsidized by the government.

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Impact of Complementary Private Health Insurance on Public Health Spending in Korea (실손형 민간의료보험의 도입이 국민건강보험 재정에 미치는 영향)

  • Huh, Soon-Im;Lee, Sang-Yi
    • Health Policy and Management
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    • v.17 no.2
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    • pp.1-17
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    • 2007
  • Limited coverage for health care services of National Health Insurance(NHI) in Korea has been ongoing policy issue but additional NHI financing through raising contribution or taxes in order to improve coverage faces substantial obstacles. Private health insurance(PHI) is often considered as an alternative financing source to improve coverage. Recent reform that attempted to stretch the role of PHI allowed life insurance companies to provide complementary PHI, indemnity plan which will pay for uncovered services by NHI and out-of-pocket spending for covered services. Although complementary PHI may relieve financial burden of patients, it may significantly raise NHI spending as well as total health expenditure since little out-of-pocket spending may increase utilization of health care. So far, there has not been enough discussion about concerns of potential adverse effect resulting from extended role of PHI. This study investigated potential increase of NHI spending followed by extension of complementary PHI through sensitivity analysis. The amount of NHI spending for services that would be covered by complementary PHI was calculated using 2005 NHI statistics and expected complementary PHI enrollment rate by age and sex. Expected utilization increases were obtained based on price elasticities$(-0.2{\sim}-0.5)$ from previous studies and expected coverage rate$(50{\sim}80%)$ of complementary PHI and then converted to monetary figures. Because coverage rate of complementary PHI has not been determined yet, we employed the sensitivity analysis using coverage rate of $50{\sim}80%$. Findings demonstrate that additional spending for health care services is expected to be $426{\sim}1,702$ billion won, corresponding amount payed by NHI $298{\sim}1,192$ billion won. In conclusion, since complementary PHI may raise NHI spending significantly, there should be an agreement whether this additional cost would be accountable and acceptable in our society. Potential inefficiency resulting from extended role of complementary PHI should be considered since public and private financing do not operate in isolation and there should be more discussion on proper role of PHI in Korea.

Disparities in High-cost Outpatient Imaging Test Utilization between Private Health Insurance Subscribers and Non-subscribers: Changes Following the National Health Insurance Benefit Expansion Policy (민간의료보험 가입자와 미가입자 간 외래 고가영상검사 이용의 격차: 건강보험 보장성 강화 정책에 따른 변화)

  • Yukyung Shin;Young Kyung Do
    • Health Policy and Management
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    • v.33 no.3
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    • pp.325-337
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    • 2023
  • Background: While there are many studies estimating the effects of private health insurance on various types of health care utilization, few have examined how such effects change in conjunction with important policy reforms in national health insurance (NHI). This study examined how the effect of private health insurance (supplemental and fixed cash benefit) on high-cost outpatient imaging test utilization changed following the expansion of magnetic resonance imaging (MRI) coverage in 2018, which is a key example of the NHI benefit expansion policy in recent years. Methods: Data from the 2017 and 2019 Korea Health Panel Survey, which contained information about healthcare utilization before and after the expansion of MRI coverage in 2018, were used. The incremental effect of private health insurance on high-cost outpatient imaging test utilization for each period were quantified and compared, with special attention given to the type of private health insurance. Results: While people with supplemental private health insurance were more likely to use high-cost outpatient imaging tests than those without, both before and after the expansion of MRI coverage, the incremental effect increased from 1.6% points in 2017 to 2.5% points in 2019. Conclusion: Benefit expansion in NHI does not necessarily reduce disparities in the use of health care between private health insurance subscribers and non-subscribers. The results of our study also suggest that the path through which private health insurance affects healthcare utilization may not be limited to the price mechanism alone but can be more complex.

Interaction between Out-of-Pocket Maximum and Indemnity Health Insurance (본인 부담상한제와 민영 실손의료보험의 상호작용)

  • Young-Hee Nam
    • The Journal of the Convergence on Culture Technology
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    • v.10 no.3
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    • pp.667-673
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    • 2024
  • This study aims to diagnose the issues arising from the relationship between the out-of-pocket maximum in health insurance and private indemnity health insurance and propose policy tasks for institutional improvement. Through literature research, the study analyzed the damage to consumers caused by the non-payment of refunds exceeding the out-of-pocket maximum and the changing role of indemnity insurance due to the strengthening of health insurance coverage. The results confirmed that unilateral interpretation of insurance clauses and incomplete sales practices infringe upon consumer rights, and that insurance premiums do not decrease despite the reduction in coverage of indemnity insurance. Therefore, the study emphasized the urgency of institutional improvements such as rationalization of product structure, transparency of risk rate calculation, and reinforcement of consumer information provision, as well as the need for social consensus on the rational division of roles between health insurance and private insurance. This study is significant in that it provides policy implications for the developmental reorganization of the healthcare system.