Financing for Healthcare (Lessons 1 to 12) {Seah Ming En, Eugene}

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Financing for Healthcare (Lessons 1 to 12) {Seah Ming En, Eugene} by Mind Map: Financing for Healthcare (Lessons 1 to 12) {Seah Ming En, Eugene}

1. Government Subsidies (Lesson 2)

1.1. Community Health Assist Scheme (CHAS) (ONLY FOR SINGAPOREANS)

1.1.1. What is CHAS?

1.1.1.1. The Community Health Assist Scheme (CHAS) is a scheme by the Ministry of Health (MOH) that enables Singapore citizens from lower- to middle-income households to receive subsidies for medical and dental care at participating General Practitioner (GP) and dental clinics near their homes.

1.1.2. What are the benefits that I can get from CHAS?

1.1.2.1. Subsidies for 20 chronic conditions under the Chronic Disease Management Programme (AT GENERAL PRACTITIONERS): 1. Diabetes 2. Hypertension (High blood pressure) 3. Lipid Disorders (e.g. High cholesterol) 4. Stroke 5. Asthma 6. Major Depression 7. Chronic Obstructive Pulmonary Disease 8. Schizophrenia 9. Dementia 10. Bipolar Disorder 11. Osteoarthritis 12. Benign Prostatic Hyperplasia 13. Anxiety 14. Parkinson’s Disease 15. Nephritis/Nephrosis 16. Epilepsy 17. Osteoporosis 18. Psoriasis 19. Rheumatoid Arthritis

1.1.2.2. Subsidies available for CHAS Card Holders (from 1 Nov 2019) at Specialist Outpatient Clinics: CHAS Blue Card: (for HHMI below $1,100 and AV of home $13,000 and below) - Common Illness - Up to $18.50 subsidy per visit - Simple Chronic Conditions - Up to $80 subsidy per visit (capped at $320 per year) - Complex Chronic Conditions - Up to $125 subsidy per visit (capped at $500 per year) - Dental Procedures - Up to $11 to $256.50 subsidy per procedure (dependent on procedure) - Subsidy at SOC for services: 70% - Subsidy at SOC for drugs: 75% CHAS Orange Card: (for HHMI between $1,101 to $1,800 and AV of home between $13,001 to $21,000 and below) - Common Illness - Up to $10 subsidy per visit - Simple Chronic Conditions - Up to $50 subsidy per visit (capped at $200 per year) - Complex Chronic Conditions - Up to $80 subsidy per visit (capped at $320 per year) - Dental Procedures - Up to $50 to $170.50 subsidy per procedure (denture, crown and root canal treatment) - Subsidy at SOC for services: 60% - Subsidy at SOC for drugs: 75% CHAS Green Card (for HHMI of more than $1,800 and AV of home more than $21,000) - Common Illness - Not Applicable - Simple Chronic Conditions - Up to $28 subsidy per visit (capped at $112 per year) - Complex Chronic Conditions - Up to $40 subsidy per visit (capped at $160 per year) - Dental Procedures - Not applicable - Subsidy at SOC for services: 50% - Subsidy at SOC for drugs: 50%

1.2. Pioneer Generation Package (ONLY FOR SELECTED SINGAPOREANS)

1.2.1. What is Pioneer Generation Package

1.2.1.1. The Government has introduced the Pioneer Generation Package to honour and thank our Pioneers for their hard work and dedication. They have made Singapore what it is today.

1.2.1.2. Eligibility Criteria for Pioneer Generation Package: - Singaporeans who were 65 years or older in 2014 - Born on or before 31 December 1949 - Became a Singaporean by 31 December 1986

1.2.2. Benefits under the PGP

1.2.2.1. Outpatient Care --> Additional 50% off subsidised services at SOC and Polyclinics on top of Means Test Subsidies --> Additional 50% off subsidised medications at SOC and Polyclinics on top of Means Test Subsidies --> Additional 50% off medication listed under the Standard Drug List (SDL) or the Medication Assistance Fund (MAF) --> Enjoy subsidies at participating GP and dental clinics under the Community Health Assist Scheme (CHAS).

1.3. Merdeka Generation Package (ONLY FOR SELECTED SINGAPOREANS)

1.3.1. What is Merdeka Generation Package

1.3.1.1. Together with the Pioneer Generation, they have contributed greatly to Singapore during a time of struggle, hardship, and sacrifice.

1.3.2. Benefits under the MGP

1.3.2.1. --> Passion Silver Card Top Up: One-off $100 PAssion Silver Card top-up for use on active ageing programmes, public transport and more --> Medisave Top Ups: $200 Medisave Top Ups every year from 2019 to 2023 --> Outpatient Care: Special CHAS subsidies at CHAS GP and dental clinics, which are higher than CHAS Blue subsidies. Additional 25% off subsidised bill at polyclinics and Public Specialist Outpatient Clinics --> Additional Medishield Life Premiums: Additional 5% subsidy for your annual premiums, increasing to 10% after you turn 75 years old

1.4. Subsidies at Restructured Hospitals

1.4.1. Inpatient A Singaporean: NA PR: NA Inpatient B1: Singaporean: 20% PR: 10% Inpatient B2: Singaporean: 65% PR: 40% Inpatient C: Singaporean: 80% PR: 55% Day Surgery: Singaporean: 65% PR: 40% SOC: Singaporean: 50% PR: 25%

2. Financing for Singapore's Healthcare (Lesson 1)

2.1. MOH Healthcare Financing Philosophy

2.1.1. Singapore healthcare financing philosophy - Offer universal healthcare coverage to all citizens - Individual responsibility and affordable healthcare to all citizens (multiple tiers of protection) - Promoting competition and transparency

2.2. Financial Schemes

2.2.1. Medisave

2.2.1.1. Medisave accounts, established in April 1984 is a national scheme that helps individual set aside part of their monthly income in to the Medisave account to meet their future personal or immediate family's medical expenses (More details under Lesson 3 Tab)

2.2.2. Medishield Life

2.2.2.1. Medishield Life is a low cost basic medical insurance scheme introduced in 1990. Premiums for MediShield Life can be paid by Medisave. MediShield Life to help members meet large Class B2 /C hospitalisation bills, which could not be sufficiently covered by their Medisave balances MediShield is operated by the CPF Board. {More details under Lesson 4 Tab)

2.2.3. Medifund

2.2.3.1. In April 1993, Medifund was set up to be a safety net for patients with difficulties paying the subsidised bill charges, despite Medisave and MediShield Life coverage. (More details under Lesson 5 Tab)

2.2.4. Eldershield/Careshield Life

2.2.4.1. Eldershield was set up in September 2002. It offers disability insurance to all 40 year old Singaporeans with Central Provident Fund Board accounts, to risk pool against the financial risks of suffering a severe disability. It provides a monthly cash payout to help pay the out of pocket expenses for the care of a severely disabled person Eldershield will be replaced by Careshield Life from 2020. (More details under Lesson 4 Tab)

2.3. Ministry of Health (MOH) COS Debate 2019

2.3.1. Keeping Healthcare Sustainable and Affordable

2.3.1.1. Supporting aspirations and needs of the Merdeka Generation

2.3.1.2. Enhanced CHAS

2.3.1.3. Extension in Medishield Life coverage

2.3.2. Enhancing Community Care and Caregiving

2.3.2.1. Strengthening our primary care foundation

2.3.2.2. Building communities of care to support ageing in place

2.3.3. Empowering Singaporeans to live healthily

2.3.3.1. Managing Diabetes

2.3.3.2. Encouraging screening

2.3.3.3. Supporting women's health

2.3.3.4. Strengthening Community Mental Health services

2.3.4. Equipping Professionals and Providers

2.3.4.1. A progressive, future ready workforce to meet healthcare demand

2.4. Centralization through Clustering

2.4.1. Centralization creates cost savings through consolidation o Group purchasing office (GPO): Allows for bulk buying of medical consumables and materials. Consolidation of purchases greatly increases leverage of hospitals to demand lower prices. Standardization of cost prices throughout the cluster. o Finance shared services (FSS): an outsourced account payable, account receivable and payroll service provider to various institutions under NHG or SHS group and other related companies. Backend accounting functions are consolidated or shared to reduce the manpower and operating cost o IHIS or integrated health information system was conceived in 2008 by the ministry of health to be the central employer for all public healthcare IT professionals.

2.5. MOH 3 Cluster System (2018)

2.5.1. National University Health System (NUHS)

2.5.2. SIngapore Health Services (SingHealth)

2.5.3. National Healthcare Group (NHG)

3. Subvention (Lesson 2)

3.1. Purpose of Subvention

3.1.1. - Providing public hospitals subvention funds - Block funding for patients using subsidized services (Class B2 & C) - To cover resources such as manpower and consumable supplies

3.2. Types of Subvention

3.2.1. Types of Subvention _________________ 1. Lump sum subvention -Operating funds given to healthcare institution based on budgetary forecast Piece rate subvention -Funds awarded based on total number of patients days and volume of outpatient. -Funding based in usage Casemix subvention -Funds based on DRG -Depends on complexity of treatment Global budget subvention -Funds based on lum sump, piece rate and casemix funding principles

4. Medisave (Lesson 3)

4.1. Who can I Use Medisave For?

4.1.1. You can use Medisave to pay for your own medical expenses. They can be used to pay for self and immediate family members such as spouse, parents, children. (CANNOT USE SIBLINGS MEDISAVE)

4.2. What can I use Medisave for?

4.3. To provide more support to the ageing population, CareShield Life will replace Eldershield in 2020 CareShield Life will feature higher payouts that increase over time with no cap on payout duration, to provide better protection against the uncertainty of long term care costs if you become severely disabled

4.3.1. CareShield Life will provide better protection and assurance in 4 ways: 1. Lifetime cash payouts For as long as you are severely disabled 2. Payouts increase over time Starting at $600 per month in 2020. Payouts increase until age 67, or when you make claims, whichever is earlier 3. Government Subsidies to make it affordable No one will lose coverage if they cannot pay the premiums. 4. Premiums can be fully payable by MediSave

4.4. Medisave Usage for Outpatient Treatment

4.4.1. Medisave Usage has increased to $500 per year per account.

4.5. Charges covered by Medisave Inpatient ward charges ($450 per hospitalisation day) Approved day surgeries (up to $300 for each day surgery episode) For surgery (Claims from $250 to $7550 based on the TOSP) Outpatient charges: Chronic diseases treatment (20 chronic diseases under CDMP) - similar to CHAS CDMP scheme *15% co-payment Cancer treatment Renal dialysis - $450 per month per patient Health screenings (mammograms and screening for new born) Selected vaccinations such as Pneumococcal vaccine for children, Hepatitis B vaccine, HPV vaccines for females (9 to 26 years) Medisave Maternity Package (for pregnant women) - claim up to $3000 for Natural Delivery and $4850 for Caesarean Delivery. $300 per year patient per scans needed to diagnose or treat your medical scans (for CT or MI scans ONLY) For Old Age: $200 per year per patient under Flexi Medisave (aged 60 years and above) -Community hospital and hospice Comm. Hosp. : $250 per day, up to $5000 per year Day Rehab: $25 per day, up to $1,500 per year Inpatient Hospice: $200 per day. Home Palliative Care: $2,500 per lifetime (no limit for terminal cancer or end stage organ failure) You can use Medisave to pay for your Medishield Life and/or ElderShield premiums to have a peace of mind for large medical expenses.

5. Insurance and Employment Medical Benefit (Lesson 4)

5.1. Common Types of Health Insurance

5.1.1. Insurance Insurance can be that company buy the insurance for individual or individual would buy. Two types of health insurance Catastrophic Medical insurance o Cover major illness where the associated medical cost is substantial o Example: Medishield Life Long term care insurance o Fix monthly amount for long term nursing treatment o Cannot do 3 of ADL, can approach insurance company and activate it (ADLs are bathing, dressing, feeding, going to the toilet and moving around) o Example Eldershield

5.1.1.1. Limitations (Co-ordination of Benefits clause) - To prevent clients to make profit from insurance companies - Company would check health bill to check - Claim processing rules requires submission of original bills only. _ System prints only one Original Bill. Further reprints will bear the "Duplicate Bill'' label

5.2. Medishield Life

5.2.1. Provide better protection and higher payouts so that patients pay less Medisave /cash for large hospital bills Protection for all Singapore Citizens and Permanent Residents, including the very old and those who have pre existing conditions Protection for life Cover Singapore Citizens and Permanent Residents who were previously not covered under Medishield

5.2.2. There will be better benefits under Medishield Life: - with higher claim limits - lower co insurance rates - Medishield Life pays more and patients pay less.

5.3. Integrated Shield Plans (IP)

5.3.1. Integrated Shield Plans (IPs) are made of two components – the MediShield component and additional private insurance coverage.

5.3.2. Examples of IPs - AIA HealthShield Gold Max - Aviva MyShield _ AXA Shield - Great Eastern SupremeHealth - NTUC Income IncomeShield - Prudential PruShield

5.3.3. Additional Private Insurance Coverage - Provide higher coverage. Example: To cover cost of private hospital or CLASS B1 or A wards in public hospitals - Manage by a private insurer

5.4. Employer Medical Insurance Benefits

5.4.1. Employed Singaporeans have medical insurance coverage provided by their employers.

5.4.1.1. Disadvantage: Pre existing illness or medical conditions - As employees change job, the company coverage would automatically exclude all pre existing illnesses or medical conditions at inception and typically for the 12 months thereafter Retirement/Unemployment - Employee health insurance does not insure a person after their retirement or unemployment, thus exposing him/her to financial risk when they need it most after their retirement

5.5. Eldershield/Careshield Life

5.5.1. For those who are ill or those who are not able to work because of illness, Eldershield can held reduce the burden of long term care (only applicable if they are insured under Eldershield and meet the requirements to receive payout) Due to raising healthcare cost, some opt to upgrade to Eldershield Supplement

5.5.2. To provide more support to the ageing population, CareShield Life will replace Eldershield in 2020, CareShield Life will feature higher payouts that increase over time with no cap on payout duration, to provide better protection against the uncertainty of long term care costs if you become severely disabled

5.5.2.1. CareShield Life will provide better protection and assurance in 4 ways: 1 Lifetime cash payouts For as long as you are severely disabled 2 Payouts increase over time Starting at $600 per month in 2020 Payouts increase until age 67, or when you make claims, whichever is earlier 3 Government Subsidies to make it affordable No one will lose coverage if they cannot pay the premiums. 4 Premiums can be fully payable by MediSave

5.6. Letter of Guarantee

5.6.1. Letter of Guarantee is an official document issued on an episodic or corporate basis by a business entity to undertake the medical bills of patient(s) A long termed Letter of Guarantee on a corporate basis in the form of a contract is termed the Hospitalization Identity Card (HIC) Scheme

5.7. Civil Service Medical Benefits

5.7.1. There are 3 medical benefit schemes: Comprehensive Co-Payment Scheme (CCS) - For Civil Servants appointed BEFORE 1 Jan 1994 Medisave-cum-Subsidised Outpatient Scheme (MSO) - - For Civil Servants appointed FROM 1 Jan 2994 Co-Payament on Ward Charges Scheme

6. Medifund (Lesson 5)

6.1. Key Principles of Medifund Assistance

6.1.1. 1. Personal Responsibility - Patient expected to co pay according to ability 2. Medical Necessity - Based on necessity, hence exclude non essential choices (e.g. Class A ward, cosmetic surgery…) 3. Family Responsibility - Use immediate family member’s Medisave where possible 4. Many Helping Hands - Medifund to complement, not replace charity funds - Encourage philanthropy to provide additional assistance

6.2. Medifund Eligibility Criteria

6.2.1. Medifund eligibility criteria Medifund general scheme: - Medifund assistance: - Is a Singapore citizen; - Is a subsidised patient; - Has received treatment from a Medifund-approved institution - Patient and family have financial difficulties paying for his healthcare bills despite receiving government subsidies and drawing on other means of payments including MediShield Life/Integrated Plans, Medisave and cash.

6.2.1.1. Needy patients who have problems paying their medical bills can approach the Medical Social Workers of Medifund approved restructured hospitals and institutions for assistance. Local Medifund committees at the approved hospitals and institutions will decide on the appropriate level of assistance for the applications

6.2.1.2. Medifund Approval Levels 1. Medifund Level 1: Pre Qualified Case (Auto) --> Public Assistance Card --> Medical Fee Exemption Card --> Medical Fee Assistance Card --> IMH / MOH Permanent Waiver List Exemption from Approval. 2. Medifund Level 2: Straight Forward Application (SF) --> Recommended % based on Household income are the same or lower than Eligible % Approval at Medical Social Worker (MSW) level 3. Medifund Level 3: Non Straight Forward Applications (NSF) --> Recommended % is GREATER than Eligible % based on Household income Approval by Medifund Committee

6.3. To provide more targeted assistance for the needy elderly and the young, Medifund Silver and Medifund Junior was introduced in 2007 and 2013 respectively.

6.3.1. Medifund Junior

6.3.1.1. - From 1 March 2013 the Ministry of Health (MOH) set aside 8 million annually under a new Medifund Junior scheme for needy Singaporean children aged below 18 to tap on to defray their healthcare cost - Needy families with children will be able to draw on Medifund Junior for assistance with their healthcare bills at the public hospitals By creating Medifund Junior, MOH can target more financial assistance for sick children from needy families.

6.3.2. Medifund Silver (65 yrars and above)

6.3.2.1. - Medifund Silver, with a set up capital sum of 500 million, was launched in November 2007 in restructured hospitals and institutions - In April 2008 Medifund Silver was rolled out to the rest of the Medifund approved institutions in the Intermediate and Long Term Care sector to benefit more elderly patients - With an ageing population, the Ministry of Health had decided to carve out a portion of Medifund as Medifund Silver to deliver assistance to needy elderly patients in a more targeted manner

6.4. Calculation of Household Income

6.4.1. Household income is calculated by summing up the income (including all allowances and bonuses, but after deducting CPF contributions) for (a) the patient himself; (b) all immediate family members (defined as parents, spouse and children regardless of whether they are living together or apart; and (c) all other non immediate family members staying in the same household. Note: Household Income (HI) = Monthly Per Capita Household Income (gross income net of CPF For both Medifund and Medifund Silver, if the household income falls between the minimum and ceiling income, the level of Medifund assistance provided will vary along a straight line between the two figures given

6.5. Medication Assistance Fund & Medication Assistance Fund (Plus)

6.5.1. Medication Assistance Fund (MAF) -To help lower income patient on medication (drugs) -Max subsidy 75% -Per capita income $1,500 and below -Drugs must be listed under the MAF form by MOH

6.5.2. Medication Assistance Fund Plus -To cover non standard and non formulary drugs - Increase maximum subsidy level from 50% to 75% upon assessment by Medical Social Service. - Expanding MAF to include NSDL Drugs (MAF +)

7. Financial Counselling (Lesson 6)

7.1. Rationale for Financing Counselling

7.1.1. Rationale for Financial Counselling

7.1.1.1. It is mandatory under the Private Hospitals and Medical Clinics (PHMC) Regulations for all hospitals to provide financial counseling to their patients prior to or upon admission

7.1.1.2. The estimated bill size of their forthcoming treatment must be communicated. Patient must be informed, to enable them to make the following decision: - Choice of class, primarily Private or Subsidized - To proceed or not to proceed with treatment - Seek alternative options at other institutions - Standard or non standard options

7.1.2. General Rules & Regulations

7.1.2.1. Upgrading - Should you request for upgrading to a higher ward class, all charges (except patient daily standard ward fee) incurred at the lower ward class up till the upgrading will be recomputed and charged at the higher class rate. Downgrading - Patients can be downgraded from private to subsidized ward class if they pass the downgrading procedure (means testing). Downgrading/Upgrading is subjected to availability of beds and takes effect when the patient physically occupies the lower/higher class bed. Follow-up at Specialist Outpatient Clinic after discharge - Class A/B1 patients will be charged at private rate. - Class B2/C patients will be charged at subsidized rate (only for Singapore citizens and PRs) All other citizenship will be charged at private rate. Patients classified under Industrial Accident would be charged at private rate. Social Overstayer (Patients who wish to stay more than 7 days after certified to be discharge) Class B1 Ward Charge: $235 Daily Treatment Fee: $90 Class B2 Ward Charge: $200 Daily Treatment Fee: $90 Class C Ward Charge: $170 Daily Treatment Fee: $90

7.2. When is financial counselling performed?

7.2.1. Financial Counselling should be done when: there are subsequent changes to the estimated hospitalisation bill sizes (due to complications, longer length of stay, more drugs/treatment required etc). For patients admitted through the Emergency Department: - a second FC should be done within 48 hours of admission. Rationale being the diagnosis and/or treatment that the patient may require at the point of admission may still be uncertain.

7.2.2. Financial Counselling Process (from lesson activity) Process: 1. Consent Form (Government Subsidy for Class B2 and C Wards) 2. Payslip/Bank statement 3. Means- Test declaration form (Patient Income or Annual Value of Residence) 4. Consent to release Medisave/ Medishield Information 5. Acknowledgement that FC is performed by patient signing 6. Show estimated Blll 7. Medisave authorization form (to authorise PSA or Financial Counsellor to gain access to patient's medisave/medishield life details)

7.3. Application of Means Test

7.3.1. --> Individual means testing o Inpatient admission For employed: average monthly income for past 12 months For self-employed: monthly income within last two years For unemployed or no income, received full subsidy (65% Class B 80% Class C) BUT for property with an annual value more than $11,000 they are given subsidies of 50% and 65% respectively for B2 and C wards. -Household means testing o Inpatient downgrading o SOC enhanced subsidy o ILTC subsidy o Medifund application o Community health assist scheme (CHAS) applications - Gross income (no deduction of CPF) of person needing care all spouse and immediate family members. - Annual value of place residence for household with no income Calculation of HHMT : Total monthly gross earnings of family (21 years to 65 years) including patient/Number of Family Members Family members are defined as all related family members (i.e. related by blood, marriage or legal adoption) staying at the same residential address with the patient, as indicated in the NRICs.

7.4. Key Steps in Financial Counselling

7.4.1. - Patients/NOK to be introduced to different class of wards and their charges - Subsidized charges on chart is based on 100% subsidies - Subsidies may varies due to MT - Allow time for Patient /NOK to decide - Check if previous valid means test result available - Obtain authorisation from patient before means testing - Use of paper Means Test Declaration Form - Conduct Online Means Test - Patient signs Admission/eFinancial Counselling Form

8. Documentation & Inflight Management (Lesson 7)

8.1. Information Required during registration of patients

8.1.1. 1. Patient details: - Patient unique identification number - Name - Date of birth - Address 2. Other necessary information: - Contact number - 3rd party payers - Next Of Kin (NOK) information - Allergy information - Referral source

8.2. Medical Claims Proration System

8.2.1. MCPS is a secure web based medical benefits and claims processing/ proration system that helps Singapore Civil Service to centrally manage and process employee healthcare benefits. • The system, which is integrated with healthcare providers, insurance companies and various government agencies, has significantly streamlined medical claims processes, ultimately enabling public service employees to enjoy medical benefits at clinics and hospitals.

8.3. Payment vs Deposit

8.3.1. - Payment is treated as money paid for services rendered. - Deposit is deemed to be monies that may be refunded.

8.4. Credit Assessment