Health Insurance Models

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Introduction & Principles - Coverage Kickstart

  • Health Insurance: Mechanism pooling funds to finance healthcare costs, protecting against catastrophic health expenditure (CHE).
  • Need: Reduce Out-of-Pocket Expenditure (OOPE), improve healthcare access & financial security.
  • Core Principles:
    • Risk Pooling: Spreading financial risks.
    • Law of Large Numbers: Predictable losses for large groups.
    • Premium: Periodic payment for coverage.
    • Cost-sharing: Deductibles, co-payments, co-insurance.
  • Key Challenges:
    • Adverse Selection.
    • Moral Hazard (e.g., overutilization of services).

⭐ Adverse selection is a major challenge where individuals with higher health risks are more likely to purchase insurance. oka

Government Schemes - Govt. Guardian Schemes

  • Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY):
    • Targets >10.74 crore poor, vulnerable families (approx. 50 crore beneficiaries).
    • Coverage: ₹5 lakh/family/year for secondary & tertiary care hospitalization.
    • Cashless access to services; portable across the country.
    • Eligibility based on Socio-Economic Caste Census (SECC) 2011 data.

    ⭐ PM-JAY is the world's largest government-funded health assurance scheme.

  • Central Government Health Scheme (CGHS):
    • Beneficiaries: Central Govt. employees (serving & pensioners) & their dependents.
    • Comprehensive healthcare: Allopathy & AYUSH systems.
    • Services: OPD, IPD, investigations, medicines from wellness centres/polyclinics & empanelled hospitals.
  • Employees' State Insurance Scheme (ESIS):
    • For employees in factories/establishments with wages ≤ ₹21,000/month (₹25,000 for persons with disabilities).
    • Benefits: Medical care, sickness, maternity, disablement, dependent's benefits.
    • Contribution: Employee share 0.75%, Employer share 3.25% of wages.
  • Ex-Servicemen Contributory Health Scheme (ECHS):
    • For Armed Forces veterans & their dependents.
    • Comprehensive medical care through a network of ECHS polyclinics, service hospitals, and empanelled private hospitals.

Private & Community Insurance - Market & Mates Models

  • Private Health Insurance (Market Model):

    • Voluntary, individual-based, often profit-driven.
    • Premiums typically risk-rated (higher risk → higher premium).
    • Primarily serves the formal sector & higher-income groups.
    • Potential issues: Adverse selection, moral hazard, cream-skimming.
  • Community-Based Health Insurance (CBHI) (Mates/Mutual Model):

    • Collective, non-profit, emphasizes community participation & solidarity.
    • Risk pooling within a defined community (often informal sector, rural).
    • Premiums often community-rated or subsidized; prepayment mechanism.
    • Aims to improve financial access & reduce out-of-pocket expenditure for underserved populations.
    • Challenges: Small risk pool size, financial sustainability, quality assurance.

    ⭐ CBHI schemes often target the informal sector, which constitutes a large part of the Indian workforce, by leveraging social capital.

  • Micro-insurance:

    • Low premium, low coverage products for low-income populations, often linked with microfinance institutions (MFIs).

Key Terminology & Challenges - Jargon & Jolts

  • Premium: Regular payment to maintain insurance coverage.
  • Deductible: Amount insured pays before policy benefits begin.
  • Co-payment: Fixed sum paid by insured for a specific service.
  • TPA (Third-Party Administrator): Manages claims, network hospitals.
  • Risk Pooling: Spreading financial losses of few over many.
  • Moral Hazard: Insured's tendency for ↑ service use or riskier behavior.
  • Adverse Selection: Disproportionate enrollment of high-risk individuals.
  • Key Challenges (India):
    • Low insurance penetration & awareness.
    • High Out-Of-Pocket Expenditure (OOPE).
    • Operational issues: fraud, claim delays, information asymmetry.

Ayushman Bharat PM-JAY provides health coverage of ₹5 lakh per family per year for secondary and tertiary hospitalization.

High‑Yield Points - ⚡ Biggest Takeaways

  • PM-JAY (Ayushman Bharat): World's largest government-funded health assurance; ₹5 lakh/family/year for secondary/tertiary care.
  • RSBY: Key precursor to PM-JAY, targeted BPL families.
  • CGHS: Comprehensive care for Central Govt. employees & pensioners; contributory scheme.
  • ESIC Scheme: Social insurance for organized sector workers; tripartite contributions (employee, employer, govt.).
  • Social Insurance: Compulsory participation, statutory backing, risk pooling (e.g., ESIC).
  • Voluntary Private Insurance: Market-driven, risk-rated premiums, based on individual choice.
  • CBHI: Community-managed risk pooling, often for informal sector, voluntary membership.

Practice Questions: Health Insurance Models

Test your understanding with these related questions

Which ministry covers ESI (Employees' State Insurance)?

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Flashcards: Health Insurance Models

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Extended sickness benefit is payable for _____ years under ESI act.

TAP TO REVEAL ANSWER

Extended sickness benefit is payable for _____ years under ESI act.

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