cmfas hi own notes

7/23/2019 CMFAS HI Own Notes

1/30

CMFAS Health Insurance

Chapter 1: Overview of Healthcare Environment in SG

Healthcare

Philosophy

5 Fundamental o!ectives:

1" Nurture a healthy nation#" Promote personal responsibility$" Promote good and afordable basic medical services:

%$&' framewor() uni*ue to Sin+apore) &edisave) &ediShield)

ElderShield) &ediFund"," Rely on competition and promote transparency5" Government intervention

$ -evels of

Healthcare

Primary Healthcare

Provided y networ( of outpatient polyclinics) General

Practitioners and dental clinics) Specialist Outpatient Clinics

Provision of asic medical treatment) preventive healthcare

and health education" &OH started Primary Care Partnership Scheme .PCPS/ for

a0ordale healthcare for needy elderly and disaled"

hen renamed as Community Health 2ssist Scheme .CHAS/

for middle low income

Students3 Healthcare

Student Health Services .SHS/ : annual health screenin+)

immuni4ation) education) promotion pro+rammes

School ental Service .SS/

6nstitutional Healthcare

Provided y pulic sector hospitals) private hospitals andnursin+ homes

Complementary &edicine .e"+" C&/

Overseen y C& Practitioners 7oard

Healthcare

Services for

the Elderly

8oluntary 9elfare Or+ani4ation .89Os/

8oluntary set up and +overned y elected volunteer oard

on;pro


2/30

testin+ to ensure that susidy +oes to those who need it"Healthcare

Financin+

Fundamental principle: 6ndividual savin+s ; Medisave

Supplementary roles: Government susidies and

Catastrophic insurance > Medishield,

Mediund, !lderShield

&ultiple layers of protection:1" a=;ased susidies

a" Government susidies across primary) acute)

rehailitative and nursin+" ?niversal access ut no 1@@A susidy to avoid over

consumption#" Compulsory healthcare savin+s

a" 6ndividual medical savin+s account for employees

.&edisave/$" Bis(;poolin+ via insurance schemes

a" State;run) low cost catastrophic health insurance

scheme > &ediShield" Private health insurance for additional covera+e >

&edisave approved inte+rated shield plansc" Severe disaility insurance > ElderShield

," ?ltimate safety net for needya" Endowment fund set up > &edifund" 6nterest income +enerated +oes towards assistin+

most needy

Governmen

t

Suvention

&eans testin+: method to calculate susidies that a patient will

receive from +overnment focus limited resources for needy

Sin+aporeans

1" &eans testin+ in Pulic Hospitalsa" 9ard classes .7#) C classes/" ot applicale for services such as day sur+ery) 2DE)

Specialist outpatient) polyclinic visits) unless it is a

follow;up after 7# or C hospitali4ationc" 7ased on monthly income over last availale 1#

months .for employed/ or annual value of residence

.for unemployed/

d" PB pays hi+her medical ills with lesser susidyversus Sin+aporeans

e" Hospital e=tract income info from CPF oard system

within last # years) or via 6B2S#" &eans testin+ for other puliccommunity services

a" Polyclinics provide 5@A susidies for services" ru+s

are also hi+hly susidied" For 89Os which provide healthcare services such as

renal dialysis) methal reha) nursin+ homes) &OH

funds 5@A of operatin+ e=penditure and @A of

capital e=penditure"

Casemi= Casemi=: +eneric term that descries mi= of patients treated in a

#


3/30

hospital"

?sed y +overnment

1" o mana+e input and output of healthcare resources in

e0ective way

#" 2s a costin+ mechanism to determine amount ofsusidies to e +iven to pulic hospitals for acute

patient care and day sur+ery"$" Government pays all pulic hospitals same rate for

each ia+nosis Belated Group .BG/) i"e" fundin+ is on

a per BG asis and is proportional to resources

needed to treat the patient

hree common features:

1" Clinical meanin+ .patients same class) similar clinical

conditions/#" Similar resource use .patients same class) cost same

to treat/$" Optimal numer of classes

Compariso

n etween

&eans

estin+ and

Casemi=

&eans estin+ Casemi=

Financin+ mechanism

6nvesti+ative process to

determine if eli+ile to

receive hospital e=pense

susidy from +overn O!ective to +ive more

assistance and divert

resources to lower socio;

economic se+ments

?se +ross income or

ownership of assets to

evaluate eli+iility

2ppropriate

fundin+susidies will e

allocated to patientsaccordin+ly

Cost allocation mechanism

escries a mi= of patients

within a healthcare settin+

Befers to a set of inter;

related patient attriute)

includin+ severity of illness)

ris( of death) treatment

variety) sta+e of disease

2dministration usually uses

concept of di0erent patients

treated re*uire di0erent

resources which result in

di0erences in the rationale

of providin+ healthcare

2ppropriatefundin+susidies will e

allocated to hospitals and

healthcare centres

Governmen

t

Healthcare

7odies and

Professional 7oards

1" &OH:

plans) formulates health policies .wor( with Sin+apore

&edical 2ssociation) Sin+apore &edical Council)

Specialists 2ccreditation 7oard) SG ursin+ 7oard) SG

ental Council) SG Pharmacy 7oard) C& 7oard) H2S/ promotes healthy livin+ and preventive health

$


4/30

pro+rammes

lon+;term plannin+ of healthcare manpower)

infrastructure and services .with &OH/

wor(s closely with &E9B in maintenance of environment

hy+iene

#" Sin+apore &edical Council Statutory oard under &edical Be+istration 2ct 2dminister compulsory continuin+ medical education

.C&E/ Pro+ramme$" Specialists 2ccreditation 7oard

Estalished under &edical Be+istration 2ct

Only accredited doctors can enter names into Be+istrar of

Specialists maintained y S&C," Sin+apore ursin+ 7oard

Empowered y urses and &idwives 2ct

5" Sin+apore ental Council

Self;re+ulatory ody under ental Be+istration 2ct" Sin+apore Pharmacy 7oard

&aintains re+ister of pharmacists

" C& Practitioners 7oard

Statutory oard under &OH) under C& Practitioners 2ct

2pprove) re!ect applications for re+istration) accredit

courses and re+ulate re+istered persons"

,


5/30

Chapter #: &edical E=pense 6nsurance

$

Cate+ories

of Health

6nsurance

1" Beimursement for cost of medical treatment or nursin+ care#" Periodic income upon disaility or hospitali4ation$" Fi=ed cash amount upon disaility or su0erin+ from a ma!or

illness&edical

E=pense

6nsurance )

a(a

Hospital

and

Sur+ical

.HDS/

6nsurance

1" Provides inpatient and some outpatient ene


6/30

within same year"ii" Co;insurance: Pay a speci


7/30

?nderwritin

+

&ain sources:

1" 6ndividual: proposal form

#" Group: Group Fact;Find form .for small +roups of L1@) may

re*uire employees to complete health declaration form/

HealthcareSusidy

level

2ppendi= #C

ermination

of Cover

Covera+e terminates when

1" death of insured person#" date enters into full;time ational Service .e=clude reservist)

trainin+/$" end of policy period which insured person attains ma= a+e

covered," date policy terminates5" date of e=piry of last premium payment" total amount of claims made reaches lifetime limit" date of cessation of the insured person as employee .not

applicale to individual policies/

Chapter $: Group &edical E=pense 6nsurance

Characteris

tics of

Group

insurance

1" &aster Contract .(ept y employer > policy owner)

employees are insured persons/#" &inimal ?nderwritin+ Be*uirements .complete health

declaration foam and rely on re;e=istin+ condition e=clusion/$" E=perience;ratin+ .ased on past claims e=periences of the

+roup/," Cost;e0ectiveness .Premium is unit related .unli(e individual

which is a+e related/5" Plan Continuation .renewale yearly/" Eli+iility Be*uirement .e"+" full;time employees) a+e specs)

SGPB) proation period/"

&edical

6nsurance

Be*uirement for

Forei+n

9or(er

1" &O& re*uires employer purchase minimum medical

insurance covera+e for forei+n wor(ers and domestic

wor(ers durin+ their stay in SG .inpatient care and daysur+ery for S Pass) 9P/#" &inimum ene


8/30

" 2dvanta+es of 8oluntary plansi" o Employer: employees assume part of the

cost) +eerates interest and appreciation from

participatin+ employeesii" o Employee: +ives employees come control

over the plan) otain cover at lower premiumrate than uyin+ individually

#" 2reas of di0erences etween individual and +roupa" Eli+iility" Contract ownerc" Choice of pland" ?nderwritin+e" ermination of Coverf" Premium

Portale

andransferal

e &edical

7ene


9/30

i=" 2dditional premium to employers) which is

partially o0set y additional ta= deductionc" Provision of 6nte+rated Shield Plan .i"e" &ediShield or

&edisave;approved private inte+rated plan/"i" Similar to P&7S) Employer en!oy #A ta=

deduction up to #A of total employees3remuneration) .if scheme covers N#@A of local

employees) pay Shield plan premiums on ehalf

of employees directly to insurer or reimurse

premiums into respective employees3

&edisave/

2dditional ta= deduction e=cludes %Biders on Shield plans' that

cover deductiles and copayments) as Government does not want

to incentivi4e employers to ta(e up riders resultin+ in over;

consumption of healthcare services"


10/30

Chapter ,: isaility 6ncome 6nsurance

isaility

6ncome

6nsurance

2lso (nown as 6ncome Protection 6nsurance or 6ncome Beplacement

6nsurance

Policy continues to pay out until he returns to wor() dies or policy

ends"

i0erent from otal and Permanent isaility .P/ 7ene


11/30

aily -ivin+ .2-s/ > washin+) dressin+) feedin+)

toiletin+) moility) and transferrin+"

Partial

disaility

Becover from total disaility to certain e=tent) inaility to perform

all duties of his own occupation) ut aility to wor( in another other

occupation which pays a salary 5A or less of his Pre;disailityEarnin+s

Becurrent

disaility

.-in(ed

Claims/

Su0ers relapse within speci


12/30

of isaility

7ene


13/30

Batin+ structure: Class 6 .indoor) des(ound/

Class 66 .oRce ased with si+ni


14/30

claims days/" Claim form) claimant3s statement) clinical astract

form) doctor3s statement) B6C) evidences of earnin+s)

letter from company) copies of &C) -a est results)

policy report) and incident report"

#" Forei+n Besidency urin+ Claims Perioda" 6nsurer noti


15/30

Premium ar level ased on entry a+e level

E=pires or terminates if premiums remain unpaid after +race

period

6f insured recovers from disaility) payments stop"

E=clusions Pre;e=istin+ conditions

Self;inKicted

&ental disorders

2lcoholism and dru+ ause

26s

9ar) participation in riot

?nderwritin

+

considerati

ons

Proposal form

&edical info

Claimant Claimant re*uired to inform insurer as soon as practicale

Produce satisfactory proof of insured3s inaility to perform2-s

Chapter : Other ypes of Health 6nsurance

Critical

6llness

6nsurance

1" esi+ned to provide a lump sum ene


16/30

i" Can e issued stand;alone!" Critical illness rider does not ac*uire any cash value(" Provides #, hrs a day) worldwide covera+e unless

otherwise statedl" 2ssi+nment may or may not e allowed

m" &a= .e"+" 55 years/ and min .1 year/ restrictionn" &in .e"+" M1@)@@@/ and ma= .e"+" M1million/ sum

assured restrictiono" Cover may e=pire ma= a+e of 5 years or whole life

cover" ypes of Critical 6llness Covers:

a" 2cceleration 7ene


17/30

a" Only standard and su;standard ris(s with up to

medium ratin+ can e considered for critical illness

insurance

omination

of7ene


18/30

e=ceeded per lifetime limit/d" E=piry 2+e .insured not reach e=piry a+e/e" Cause .in!ury or illness not fall under one of the

e=clusions/$" Features of Hospital Cash insurance:

a" Can e stand;alone or as rider" Per day hospitali4ation ene


19/30

" ermination of cover:a" Premium not paid at end of +race period" 6nsured reaches e=piry a+ec" Per life;time limit eachedd" 7asic policy lapses or matures

e" 6nsured dies" Claims:a" Claim form" Hospital dischar+e summary ills

&edical

E=pense

7ene


20/30

2llowances" Hospital char+esc" Caused y war) revolutiond" &edicine +ivene" Purely cosmetic treatment

f" Self;inKicted+" Beplacement of ro(en) lost) stolen dentures," -imitation Clause

a" 9or( 6n!ury Compensation 6nsurance policy" Government pulic pro+ramme of dental ene


21/30

procedures and services

Besult in smaller reimursement fees for

physicians who char+e hi+her than

avera+e feesc" uality of care

i" Ensure *uality of care not compromised withcost;containment e0ort) &HCO only contracts

with those that possess re*uisite s(ills) trainin+

and licensesCommon

ypes of

&HC

Plans

1" 2hreecommon types of &HC plansa" Health &aintenance Or+anisation .H&O/

i" &ost restrictive as memer has least choice in

selectin+ his healthcare providerii" 'our asic types of H&O:

Sta0 &odel H&O

a" PCP refer patients to contracted

specialist Group &odel H&O

a" H&O ne+otiates services with +roup

practice" Group practice responsile for

otainin+ physicians) compensatin+

physicians) providin+ facilities)

arran+in+ to provide hospital

servicesc" Same cost mana+ement potential as

Sta0 &odel etwor( &odel H&O

a" Contracts medical care services

instead of employin+ physicians" oes not have ti+ht control over

utilisation mana+ement as Sta0 and

Group &odel"

6ndependent Practitioners 2ssociation .6P2/

&odela" -i(e etwor( model) 6P2 model may

elon+ to one or more PPO

networ(s) or may contract with moreone H&O

" 6P2 physicians actively continue to

develop their private practicesc" oes not have ti+ht control over

utilisation mana+ement as Sta0 and

Group &odel"" Preferred Provider Or+anisation .PPO/

i" Similar to H&Os %provider networ('ii" ?nli(e H&Os) memers do not have a PCP

%+ate(eeper' and not restricted to use only

provider networ( for their care"iii" o encoura+e) PPO o0ers ene


22/30

such as lower or no deductile) lower or no co;

paymentc" Point of Service .POS/

i" Comination of H&O and PPOii" Similar to H&Os %provider networ('

iii" 2llows memer to use provider not in thenetwor() ut !ust pay hi+her co;payments or

deductiles

Choice of

Providers

versus

Cost

Control

1" 6n order of decreasin+ cost control ut increases de+ree of

choice of providersa" Sta0 model" Group modelc" etwor( modeld" 6PCe" POS PPO

f" raditional &edical E=pense 6nsurance&ana+ed

Healthcar

e

6nsurance

1" 7ene


23/30

i" Si+n &edisave 2uthorisation Form to authorise

CPF 7oardii" 9ith medical insurance) produce %letter of

+uarantee' or %hospitalisation identity card' to

admission sta0

iii" &edisave Payment: receive two statements .CPF)and hospital after dischar+e/

f" Bestrictions on use of &edisave:i" Ceilin+ not suRcient to cover medical e=penses

from ma!or illnesses such as cancerii" &a= withdrawal limits imposed not suRcient to

cover full hospital illiii" Covers limited outpatient treatmentsiv" Pays only if person is hospitalised for more than

hrsv" Covers only a ma=imum of $ sur+ical operations

#" &ediShielda" -ow cost .Critical 6llness/ &edical E=pense 6nsurance

schemei" Beimursement asis) su!ect to limits)

deductile) co;insurance) pro;ration factors" Government put in place measures to ma=imi4e

population covera+ei" Facilitate automatic covera+e wherever possileii" 2uto;cover arran+ement encoura+es

participation) lowers admin and enforcement

costs of runnin+ compulsory scheme

iii" Be+ular pulic messa+in+ to raise awareness ofene


24/30

insurance where lar+e ills were covered

ade*uately

one y increasin+ in claim limits and

deductilesii" Bemove cherry pic(in+ and (eep premiums

a0ordale while retainin+ competitive mar(et one y enlar+in+ pool of policyholders to

ma= economies of scale

2nd restructurin+ private medical

insurance scheme .P&6S/ as 6nte+rated

Shield plans .6Ps/ for e=tensive industry

consultation etween insurers and

re+ulator) maintain min

deductilescoinsurance for 6Ps so as ein+

focused on catastrophic e=penses

ElderShield

1" Severe disaility insurance scheme paid from CPF &edisave#" Provide lon+;term care protection to elderly to defray out;of;

poc(et e=penses$" Currently run y $ insurers) 2viva) Great Eastern -ife

2ssurance) ?C," 2utomatically covered once ,@years old unless opt out5" Eli+iility criteria:

a" &eets waitin+ period .e"+" @days/ from policy

commencement date .not applicale if due to accident/" ?nale to perform at least $ 2-sc" &eets deferment period .e"+" @ days/ startin+ from

claim date" How to claimT

a" Claim form" 2ppointment with insurer3s assessor

" How Eldershield ene


25/30

d" ate which written notice from insured to cancel policy

is received y insurer6nterim

isaility

2ssistanc

ePro+ramm

e for the

Elderly

.62PE/

1" Social scheme to help +roup of people not eli+ile to !oin

ElderShield scheme due to a+e or health reasons"#" 2dministered y ?C 6ncome

$" hose ma(in+ claims are su!ect to means testin+administered y Citi4ens3 consultative committees and

recipient of payment need to pay nominal fee of M1@ .or M,@ if

done at home/ for each assessment in the event of a claim," Pay;out limited to only # months .same as ElderShield/

&edifund 1" Endowment fund#" Government uses interest earned from fund to help poor pay

medical ills$" 2pplied throu+h &edical Social 9or(ers .&S9s/ at &edifund

approved institutions or any Community evelopment

Councils .CCs/," Cases will e sumitted to respective Hospital &edifund

Committee .H&C/5" E=tended to help H68 treatment

Eldercare

Fund

1" Endowment fund#" ?sin+ ud+et surplus to sustain


26/30

o 2ny One isaility

o Covered Char+es

o ay of Hospital Con


27/30

conditions Sumission of Claim

Physical E=amination Provision

&ediation2ritration and -e+al 2ctions provisions

"

Endorseme

nts

Separate document that modi


28/30

?nderwritin

+

" Group stailityc" Group si4ed" 6nsured company3s nature of usinesse" Employee classesf" -evel of participation

+" 2+e and +ender within the +rouph" E=pected persistencyi" Past claims e=perience

!" &edical inKation(" &edical utili4ation rate and trend

Sources of

?nderwritin

+

6nformation

1" Primary source: Proposal form#" 2+ent3s Statement$" &edical E=aminationsests," 2ttendin+ Physician Statements .2PS/5" Supplementary uestionnaires

How an

6nsurance

Bep help in

?nderwritin

+ ProcessT

1" Estalish client3s motivation and needs to purchase policy#" Go throu+h *uestions in the proposal form .truthfully and

est (nowled+e/$" Gather as much info as possile," ecide on ehalf of underwriter if whether there is a need of

2ttendin+ Physician3s StatementFinal

?nderwritin

+ ecision

1" Standard Bis(s > policy issued ased on premium stated in

rate oo(#" Su;standard ris(s > policy cover has to e modi


29/30

sellin+ Service Orientation

ot Pressurin+ to 7uy

-on+;erm Belationships

Fact Findin+ 1" 7asic Sections of Fact;Find Form:a" 6mportant otice to Prospective Client

i" Enales prospective client to (now whichinsurance intermediary that you are

representin+ii" Hi+hli+hts to prospective client the

importance of completin+ the Fact;Find form" 2pplication ypec" Personal 6nformationd" Employment etailse" etails of Spouse and ependantsf" E=istin+ health insurance policies+" Personal priorities

h" Health conditioni" Beplacement of policy

!" Bepresentative3s eclaration6dentifyin+

and

*uantifyin+

needs

1" 6dentifyin+ eedsa" Emer+ency fund: +uard a+ainst readwinner3s loss

of !oincome" Employment Status and Occupationc" -ife sta+e: married) with children) pre;retirement)

retirementd" ependantse" E=istin+ insurance policies

i" &edical e=pense insuranceii" Critical illness insuranceiii" Personal accident insuranceiv" -on+ erm Care 6nsurancev" &ana+ed healthcare insurance

vi" Hospital Cash insurancevii" -ife 6nsurance Policy and 9or( 6n!ury

Compensation 6nsurancef" Financial Position+" Prospective Client3s Prioritiesh" eed for Health 6nsurance

#" uantifyin+ eeds

a" isaility 6ncome Protection eeds .&aintenancecosts/

i" hree methods to *uantify1" A of &onthly income > e=istin+ ene


30/30

i" otal monthly e=penses > e=istin+ ene

cmfas hi own notes

Documents