Recently, following a number of representations made by various stakeholders (including Insurers) on a multitude of issues as well as to update the existing framework, the IRDAI, by way of a notification of 18th July 2016, issued the IRDAI (Health Insurance) Regulations 2016 (Health Regulations 2016) replacing the Health Regulations 2013. The IRDAI also replaced the Standardization Guidelines 2013 with the Guidelines on Standardization in Health Insurance of 29th July 2016 (Standardization Guidelines 2016) and the Guidelines on Product Filing in Health Insurance Business of 29th July 2016 (Product Filing Guidelines). Health Insurance Regulations 2016, Registration and Scope of Health Insurance Business : As per Section 3 of the Health Insurance Regulations 2016: Health Insurance products may be offered only by entities with a valid registration granted to carry on Life Insurance or General Insurance or Health Insurance Business under the Insurance Regulatory and Development Authority (Registration of Indian Insurance Companies) Regulations 2000 as amended from time to time.Life Insurers may offer long term Individual Health Insurance products i.e., for term of 5 years or more, but the premium for such products shall remain unchanged for at least a period of every block of three years, thereafter the premium may be reviewed and modified as necessary. Provided that a life insurer may not offer indemnity based products either Individual or Group. All existing indemnity based products offered by life insurers shall be withdrawn as specified under these Regulations. Provided also that no single premium health insurance product shall be offered under Unit Linked platform.General Insurers and Health Insurers may offer individual health products with a minimum tenure of one year and a maximum tenure of three years, provided that the premium remains unchanged for the tenure.Group Health Policies may be offered by any insurer for a term of one year except credit linked products where the term can be extended up to the loan period not exceeding five years Provided General Insurers and Health Insurers may also offer Credit Linked Group Personal Accident policies for a term extended up to the loan period not exceeding five years.Provided further, notwithstanding the provisions of Regulation 4 (b) of these Regulations, Life Insurers may offer Group Health Insurance Policies as specified in Regulation (3) (d).Group Personal Accident Policies may be offered by General Insurers and Health insurers with term less than one year also to provide coverage to specific events. Other Insurance Products offering Travel Cover and Individual Personal Accident Cover may also be offered for a period less than one year.Overseas or Domestic Travel Insurance policies may only be offered by General Insurers and Health Insurers , either as a standalone product or as an add-on cover to a health or personal accident policy.Health Insurance, Restrictions on Life Insurers offering Health Insurance Policies : Life Insurers are prohibited from offering indemnity based health insurance products either as individual or group policies. Consequently, all such existing indemnity based products offered by Life Insurers are now required to be withdrawn in accordance with the prescribed procedure.
Insurance Encyclopedia
Health Insurance Services
The benefits covered under a health contract.
health insuring organization (HIO)
Entity that provides for or arranges for the provision of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services. This may involve state or federal programs such as Medicaid or Medicare beneficiaries. HIOs contract with providers on a discounted fee-for-service or a capitated basis to provide medical services.
Health IT Certification
Provides professional training and certification for those responsible for planning, selecting, implementing, and managing electronic health records (EHRs) and other health information technology (HIT). See Certified Professional in Electronic Health Records (CPEHR) and Certified Professional in Health Information Technology (CPHIT) . Website: www.HealthITCertification.com
Health Level Seven (HL7)
Standard protocols and encoding rules published for developers to apply in the health industry. These were created by the Accredited Standards Committee X12 (ASC X12), a committee formed by American National Standards Institute (ANSI). HL7 sets some of the electronic standards for exchange of clinical and administrative information in health care applications (see Box H-1 ).Box H-1HEALTH LEVEL SEVEN FORMAT OF DATE AND TIME OF BIRTHTo determine the date and time of a patient’s birth date (e.g., for a neonate, for whom the age in hours might be relevant), the time of the birth, using military time, can be recorded with the birth date. From this, the age can be generated from the date of birth (DOB). Baby Jane was born on March 24, 2007, at 8:26 am .When the required HL7 format is YYYY MMDDHHMM, Baby Jane’s date and time of birth will be entered for transmission as: 200703240826YYYYMMDDHHMM200703240826YearMonthDayHourMinute
Health Level Seven, Inc. (HL7)
Founded in 1987, a nonprofit, American National Standards Institute (ANSI)-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services.
Health literacy
Ability to obtain, interpret, and understand basic medical information and health services and the capability to use the data and services to improve health.
Health Maintenance Act of 1990
Act developed by the National Association of Insurance Commissioners (NAIC) and used by most states as a model for legislation of health maintenance organizations (HMOs). This act mandates that HMOs have a certificate of authority to carry out their business in the state and they must provide the state with detailed financial and qualifying data.
Health maintenance organization (Health Insurance)
A prepaid plan that provides medical services to members. Health care providers contract with this type of plan to provide services to members. The plan members must then seek services from these providers. Employers who have more than 25 employees are obligated to offer them an HMO plan, except if the cost exceeds that of the currently offered benefit plans.
Health Maintenance Organization (HMO)
An alternative system to the one traditionally used to provide health care, an HMO is a group of doctors and other health care providers that offers a full range of health care services on a prepaid basis.
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US: An organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment. The HMO can be sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies, and hospital medical plans.
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MEDICAL,USA: Oldest of all prepaid health plans. A comprehensive health care financing and delivery organization that provides a wide range of health care services with an emphasis on preventive medicine to enrollees within a geographical area through a panel of contracted providers and hospital facilities. Members are required to use those participating in the plan. Primary care physicians called “gatekeepers” are usually reimbursed via capitation. One method is when enrollees pay a monthly premium and a small copayment for using medical services. Another method is when capitated rates are paid by payers for each member based on a projection of patients’ costs. Payers may include employers, insurance companies, or government programs. There are four types of HMOs: group, staff, independent practice association, and network. HMOs can either be for profit or nonprofit. There are also specialized HMOs that provide vision, dental, or mental health care.
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Prepaid group health insurance plan that entitled members to services of participating physicians, hospitals and clinics. Emphasis is on preventative medicine, and members must use contracted health-care providers. Health plus Life Combi Products” : As per Sec. 2. J Health Plus Life Combi Products mean products which offer the combination of a Life Insurance cover offered by a life insurer and a Health Insurance cover offered by General Insurer or Health Insurer. Under the ‘Combi Product’, underwriting of respective portion of risk shall be carried out by respective insurance companies, that is; Life Insurance risk shall be underwritten by Life Insurer and the Health Insurance portion of risk shall be underwritten by General or Health Insurer. Commission and Claim pay-outs in respect of ‘Combi Products’ shall be by respective insurers only.