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Table 3 Breadth, scope and depth of coverage of state funded health programs and health insurance (2010)

From: Promoting universal financial protection: health insurance for the poor in Georgia – a case study

State vertical programs covering personal health services and State funded or subsidized Insurance programs Population coverage Service coverage Cost coverage (covered by the state program)
Urgent care (population over 60) 830,000 – approx. 19% of the total population Defined inpatient urgent conditions First 6 days of ICU care, 75% of actual cost for predefined conditions
Urgent and hospital care for children under 3 years of age 220,000 – 5% Defined urgent and inpatient conditions Full cost in case of critical conditions and population residing in high mountainous areas; 80% of actual cost for predefined inpatient conditions
General outpatient care Little over 1 million – approx. 22% (children under-6, elderly over 60, oncologic and diabetes patients) Visits to Primary Health Care (PHC) physician/nurse, 4 home visits, immunization, limited list of express lab tests, management of the chronic diseases Fully covered/no co-payment
Rural outpatient care “rural physician” Little over 2 million – approx. 47% Visits to PHC physician/nurse, 4 home visits, immunization, limited list of express lab tests, management of the chronic diseases Fully covered/no co-payment
Maternal child health Women of reproductive age and children Four prenatal visits for all. Defined list of tests, extended care for high risk pregnancies and complicated delivery Upper limit from 833 to 3,000 GEL for complicated pregnancy and delivery
Emergency care (ambulance) Entire population Ambulance service, medical transportation Fully covered/no co-payment
Referral program Entire population Medical needs during emergency situations, MIP eligible beneficiaries not yet insured; individual cases Fully covered/no co-payment
Cardiac surgery Entire population Defined conditions; waiting list for planned interventions Fully covered for children less than 18 years of age; from 50 to 75% of the predefined price for each type of surgery
Management of oncologic diseases Entire population Defined conditions; outpatient and inpatient care Fully covered for children less than 18 years of age; 70% of the predefined price of defined interventions with upper limits (e.g., chemotherapy)
Dialysis and renal transplantation Entire population Defined conditions Fully covered/no co-payment
TB control Entire population DOTS, outpatient and inpatient care Fully covered/no co-payment
Mental health Entire population Defined outpatient and inpatient care Fully covered/no co-payment
Other programs (war veterans, draftees, etc.) Small groups Defined list of outpatient and inpatient care Fully covered/no co-payment
MIP insurance About 885,000 poor below eligibility threshold 70,000, about 55,000 between 70,000 and 100,000 scores; about 65,000 other groups (teachers, IDPs, orphans, etc.) – total about 1 million, or 22% of population Comprehensive defined list of urgent care, critical care and inpatient services; defined list of outpatient services, outpatient drug benefit from essential drug list Annual limits: planned inpatient services – 15,000 GEL; chemotherapy and radiation therapy – 12,000 GEL; delivery – 400 GEL; outpatient drugs – 50 GEL, with 50% co-payment
Affordable insurance* 125,000 – 2% Urgent outpatient and inpatient care and critical conditions; outpatient services included in general outpatient care program Fully covered PHC. Annual limits: Urgent outpatient care – 300 GEL; critical care from 1,000 to 5,000 GEL, with co-payment from 0–50%
  1. *2010 data.
  2. Source: compiled by authors.