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% |