791 - TRANSACTING PRIVATE MEDICAL INSURNACE SYLLABUS 2006

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1 791 - TRANSACTING PRIVATE MEDICAL INSURNACE SYLLABUS 2006 Objective : To provide a knowledge and understanding of the principles and practices of transacting private medical insurance business and the provision and operation of PMI within the healthcare sector. Method of assessment : A 3-hour examination that involves : 8 compulsory short-answer questions carrying 6 marks each 1 compulsory essay-style question carrying 50 marks and a choice of 3 from 5 essay-style questions each carrying 34 marks Notes: The syllabus will be based on Irish law and practice. The April session will test the legal position as of 31 st August of the preceding year. The October session will test the legal position as of 28 th February of the same year.

Method of assessment : A 3-hour examination that involves : 8 compulsory short-answer questions carrying 6 marks each 1 compulsory essay-style question carrying 50 marks and a choice

2 1 The Irish Healthcare Market 1.1 The Irish Healthcare System Discuss the elements of the Irish Healthcare system Describe the legislative framework supporting the Irish Healthcare system (public and private) 1.2 Healthcare Professionals Describe the roles of the main professionals involved in the delivery of healthcare services, including : General Practitioners Consultants Other Healthcare Practitioners 1.3 Private Medical Insurance Providers Explain the demand for Private Medical Insurance (PMI) products, Critical Illness and Healthcare Cash Plans Describe the relationship between PMI insurers and the public system Describe the organisation, function and regulation of the private healthcare market in Ireland including : provident insurers commercial insurers 3 rd party administrators other providers of healthcare insurance health cash plans and, dental insurance Describe the status of the health insurance market in Ireland Explain the different regulations and how they effect each insurer

2 Healthcare Professionals Describe the roles of the main professionals involved in the delivery of healthcare services, including : General Practitioners Consultants Other Healthcare Practitioners 1.

3 2 Private Medical Insurance Market and products 2.1 Regulatory Principles Discuss the development of the operation and philosophy of community rating Explain the concept of age-adjusted community rating Discuss the concept of risk equalisation Discuss the concepts and philosophy of Open Enrolment and Lifetime Cover Describe the methods of funding large and small schemes, including company funding Explain the rules for scheme membership 2.2 Benefit Design and PMI Products Discuss the core benefits of private medical insurance policies Explain the limitations that apply Describe the optional benefits and ancillary services, including those other than for medical treatment Explain the scope of overseas cover and how it differs from Ireland-specific policies Outline the types of private medical insurance policy available within the individual market, the corporate/company market and the voluntary group market sectors Explain the conditions in PMI policies and their impact upon enrolment, renewal and midterm alterations Explain the core differences between a risk rated market and community rating e.g. USA and UK models 2.3 Risk assessment and management Discuss the principles of actuarial assessment and financial management of private medical insurance and group risks Explain the principles of pricing including: Reviews and their timing Permissible risk discrimination factors

Discuss the concepts and philosophy of Open Enrolment and Lifetime Cover Describe the methods of funding large and small schemes, including company funding Explain the rules for scheme membership 2.

4 Banding of prices Projection factors used in setting premium levels Discuss the main methods of cost containment, including : The operation of no and low claim discount schemes Loyalty discounts Payment method discounts The use of excesses Benefit limits Exclusions The use of provider networks 2.4 Medical underwriting Discuss the considerations relating to pre-existing and chronic medical conditions Explain the application of medical underwriting in private medical insurance business Describe the types and uses of moratoria and excesses in private medical insurance policies Discuss the use of standard exclusions from cover in private medical insurance policies Understand The Association of British Insurers Code of practice for genetic testing 2.5 Alternative Healthcare provision Explain the nature, benefits and application of: Health Cash Plans Fixed price surgery Major Medical Expenses (MME) Critical Illness Dental Insurance Occupational Health

4 Medical underwriting Discuss the considerations relating to pre-existing and chronic medical conditions Explain the application of medical underwriting in private medical insurance business

5 3 Claims Principles Explain the relationships between product providers and hospitals / consultants and outline the impact on claims Discuss the principles of managed care within the PMI industry Outline the principles and practice of dealing with claims arising under PMI policies Discuss the impact of the pre-authorisation of claims Describe the principles for dealing with incurable conditions Explain the impact of contribution and 3 rd party recoveries on PMI claims management Discuss the role of the Financial Services Ombudsman Bureau Explain Information technology and its relevance to administration Discuss the use and benefits of outsourcing in the PMI market in Ireland 4 Taxation Describe the current rules that apply to the treatment of PMI premiums for taxation purposes Discuss the scope of allowable expenses Discuss the tax implications for company/employer paid schemes Describe the application and effect of Tax Relief at Source (TRS) 5 Marketing and sales Explain the role of the Health Insurance Authority (HIA) Explain the role of the Financial Regulator Describe the buyers of private medical insurance and evaluate their needs : the individual market voluntary deduction group market corporate/company sponsored market affinity schemes market Discuss the techniques employed in marketing private medical insurance business

conditions Explain the impact of contribution and 3 rd party recoveries on PMI claims management Discuss the role of the Financial Services Ombudsman Bureau Explain Information technology and its

6 Outline the distribution channels used for private medical insurance, including: direct sales force telesales internet broker network employee benefit consultants Discuss the role of insurer / provider relations and the link with product marketing KNOWLEDGE RATINGS : Each sub-topic has been designated a numerical knowledge rating as follows: 1. General background awareness necessary. 2. Requires a knowledge of the major elements of procedures or concepts and their uses. 3. Requires the ability to evaluate concepts, issues, policies and procedures, together with an understanding of associated aspects of these items and their application to various situations. The Private Medical Insurance Market and Products Types of private medical insurance policy available within the individual market, the corporate / company market and the voluntary group market sectors 3 Elements of the Irish Healthcare System 2 Roles of the professionals involved in the delivery of healthcare 2 The development of the operation and philosophy of community rating, open enrolment and lifetime cover 3 Age-adjusted community rating 3 The concept of risk equalisation 2 Methods of funding large and small schemes, including company funding 2

Requires a knowledge of the major elements of procedures or concepts and their uses. 3.

7 Rules for scheme membership 2 The demand for Permanent Health Insurance (PHI) products, Critical Illness and Healthcare cash plans 2 The status of the health insurance market in Ireland 2 The legislative framework supporting the Irish Healthcare system and the regulation of the PMI market 2 PMI providers and the way in which they are structured 2 Conditions in PMI policies and their impact upon enrolment, renewal and mid-term alterations 2 Benefit design The relationship between PMI insurers and the public system 3 Core benefits of private medical insurance policies 3 Limitations that apply 3 Optional benefits, including those other than for medical treatment 3 Differences in risk-rated and community rated markets 2 Risk assessment and management Principles of actuarial assessment and financial management of private medical insurance and group risks 3 Principles of pricing including: Reviews and their timing 2 Permissible risk discrimination factors 2 Banding of prices 2 Projection factors used insetting premium levels 3 Cost containment 3

impact upon enrolment, renewal and mid-term alterations 2 Benefit design The relationship between PMI insurers and the public system 3 Core benefits of private medical insurance policies 3

8 Medical underwriting Consideration of pre-existing and chronic medical conditions 3 Application of medical underwriting in private medical insurance business 3 Types and uses of moratoria in private medical insurance policies 3 Use of standard exclusions from cover in private medical insurance policies 3 The Association of British Insurers Code of practice for genetic testing 1 Claims Relationships between product providers and hospitals/consultants 2 Principles of Managed Care with the PMI industry 2 Principles and practice of dealing with claims arising under PMI policies 3 Pre-authorisation of claims 3 Principles for dealing with incurable conditions 3 Insurer/provider relations and the link to claims management 2 Contribution, third party recoveries 2 The role of the Financial Services Ombudsman 3 Information technology and its relevance to administration 2 Use and benefits of outsourcing in the PMI market in Ireland 1 Alternative Healthcare provision The nature, benefits and application of : Health Cash Plans 2 Fixed price surgery 2 Major Medical Expenses (MME) 2 Critical Illness 3 Dental Insurance and Occupational Health 2

Relationships between product providers and hospitals/consultants 2 Principles of Managed Care with the PMI industry 2 Principles and practice of dealing with claims arising under PMI policies 3

9 Taxation The current rules that apply to the treatment of PMI premiums for taxation purposes 3 The scope of allowable expenses 3 The tax implications for company / employer paid schemes 2 The application and effect of Tax Relief at Source (TRS) 3 Marketing and sales The role of the Health Insurance Authority (HIA) / Financial Regulator 2 Buyers of private medical insurance: the individual market 2 voluntary deduction group market 2 corporate / company sponsored market 2 affinity schemes market 2 Techniques employed in marketing private medical insurance business 2 Distribution channels used for private medical insurance, including: direct sales force 3 telesales 3 internet 3 employee benefit consultants / broker channel 3 Role of insurer / provider relations and the link with product marketing 2

market 2 voluntary deduction group market 2 corporate / company sponsored market 2 affinity schemes market 2 Techniques employed in marketing private medical insurance business 2 Distribution

The Malaysian Insurance Institute

The Malaysian Insurance Institute (35445-H) 103 Private Medical Insurance Objectives: To develop in the candidate: A knowledge and understanding of the principles and practices of transacting private medical