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   See: health risk

    Domain: microinsurance

One of the principal functions of a health micro-insurance scheme. It includes:
- technical management, which deals with insurance-related activities: enrolment, collection of premiums and membership fees, claims settlement. It also deals with preventing the occurrence of insurance-related risks or limiting their effects: adverse selection, moral hazard, etc. Another of its functions is to establish relations with certain external actors, in particular with health care providers;
- internal control, which consists of verifying whether decisions have been implemented and whether the scheme's operating procedures and obligations, as defined in the statutes, internal rules, contracts, etc., have been properly respected;
- monitoring, which consists of monitoring the progress of the scheme's activities, and making adjustments if necessary;
- evaluation, which consists of assessing the scheme's operations, and determining whether its initial objectives have been met;
- internal organization, human resources management, accounting and financial management. [ILO-STEP, 144]

   Context: coverage from a health insurance scheme
See: flat-rate benefit

   A condition placed on a benefit in which coverage is limited to a maximum number of days, cases or sessions per person and per year.
Example: A "Prenatal consultation" benefit covers 100 per cent of expenses incurred, up to a maximum limit of three prenatal consultations per pregnant woman per year. If the patient undergoes two prenatal consultations, the scheme covers 100 per cent of the expense and the patient pays nothing. However, if the patient undergoes four prenatal consultations, the scheme covers 100 per cent of the expenses corresponding to the first three consultations and the patient pays for the fourth. [ILO-STEP, 144]

   People's response to illness in terms of reliance on health services.

   Benefits that are granted only upon proof of need. Different types of income or assets, such as capital, earnings, benefits and other payments may be taken into account in the aggregate for the purpose of determining whether the applicants are eligible for benefit at all and the amount of benefit which will be granted. [ILO,694]

   A physician who works for the health micro-insurance scheme and provides advice to the scheme, as well as to its partner health providers and to patients. He or she advises the scheme concerning the conclusion of agreements with health providers, analyses requests for prior agreement and issues authorizations or refusals for coverage. The medical adviser monitors the appropriateness of the health services provided and the validity of and compliance with the rules of reimbursement. He or she may also play a role in activities relating to health education. [ILO-STEP, 144]

    Domain: microinsurance

A document authenticating a person's membership in a health micro-insurance scheme. The membership card may contain the first and last names, dates of birth and, in some cases, photographs of the member and his or her dependents. By presenting the membership card, the person protected may benefit from fee agreements or third-party payment arrangements with the scheme's partner health providers. [ILO-STEP, 144]

   A sum of money paid to a health micro-insurance scheme by a new member upon enrolment. The membership fee covers administrative expenses and is not refundable in the event of withdrawal. The membership fee is also referred to as the enrolment, registration or initiation fee. [ILO-STEP, 144]

   Synonym: membership monitoring report (Philippines)

   Synonym: registry of members (Philippines)

   Synonym: member's information sheet (Philippines)

   The various methods used by the health micro-insurance scheme and/or patients, who are members of the scheme, to purchase medical services from health care providers. The main methods of payment are fee-for-service, payment per cluster of health services, payment per hospital day or per episode of illness and capitation payment (payment of an annual global fee for each covered person). Other methods involving mixed forms of payment (fee-for-service plus capitation payment) may also be used. [ILO-STEP, 144]
See also: fee-for-service, global payment

    An insurance scheme – often set up by a civil society organization – whose purpose is to provide health insurance coverage to persons excluded from formal systems of social protection – mainly informal economy workers and their families. The term "micro" does not refer so much to the size of these schemes as to their social moorings. Even if such schemes are usually small in size, there are some, notably in Asia, that extend coverage to more than 100,000 persons. Others participate in networks or unions in which numerous schemes are linked together to form vast organizations. The term "insurance" refers to the financial mechanism utilized, which consists of pooling the risks and resources of an entire group in order to guarantee protection to all members against the financial consequences of health risks determined on a mutual basis. [ILO-STEP, ISSA, 1770].
Synonym: HMIS

   Minimum benefit granted to beneficiaries whose benefit entitlement would otherwise not reach a specified minimum level. [ILO,694]

   See: health risk

   Synonym: embezzlement

   A benefit in which 100 per cent of health expenses are covered, minus a fixed sum, expressed in monetary units, which is always borne by the member and is not proportional to the expenses actually incurred. The deductible may be applied to each health service utilized or totalled on an annual basis.
Example of monetary deductible applied to each health service utilized: A "Surgery" benefit covers 100 per cent of expenses incurred, minus a deductible of 2,000 Monetary Units (MUs). If surgery expenses are 1,500 MUs (<2,000 MUs), the scheme pays nothing and the member pays 1,500 MUs. If surgery expenses are 3,000 MUs, the scheme pays 1,000 MUs (3,000 − 2,000 MUs), while the amount of the deductible (2,000 MUs) is borne by the member.
Example of an annual monetary deductible: A "Consultations and treatment" benefit covers 100 per cent of expenses incurred, minus an annual deductible of 3,000 MUs. So long as the expenses accumulated over the year by the person protected are less than 3,000 MUs, the scheme pays nothing. However, the scheme covers 100 per cent of the patient's accumulated annual expenses in excess of 3,000 MUs. [ILO-STEP, 144]

   A phenomenon according to which insured persons take undue advantage of the health services covered by the scheme because they know they are insured against the cost of such services. Their utilization of health care exceeds the standard used as an input for determining premiums. Some authors consider moral hazard also to include prescription abuse by health care providers, or the risk of over-prescription. [ILO-STEP, 144]
Synonym: risk of over-consumption

   A health micro-insurance scheme characterized by the broad participation of members in the scheme's management. Mutual health organizations are democratic institutions founded on the principles of mutual assistance and solidarity. They are set up and managed by and for their members. The members of mutual health organizations participate in management through general assemblies and the election of officers. Mutual health organizations are the collective property of their members; the latter are at once the insurers and the insured. For this reason, no contract is concluded to formalize relations between mutual health organizations and their members (since one cannot conclude a contract with oneself). Rather, they are governed by the rights and obligations set forth in the statutes and internal rules of the organization. Mutual health organizations pursue objectives aimed at the promotion of social and individual well-being. They seek to reconcile the achievement of these objectives with the financial viability and competitiveness of the scheme as compared to other forms of health care financing, such as prepayment schemes, health micro-insurance schemes set up and managed by health providers, commercial insurance companies, etc. [ILO-STEP, 144]