Principles and operations of health insurance
1, Subject Code: H12, examination subjects: health insurance principles and operations of the three examination time: 90 minutes 4, examination forms: 100 multiple-choice questions first chapter an overview of health insurance exam Objective: To grasp the basic concept of health insurance and classification the main characteristics and social roles, as well as operational profile Examination Content: The concept of health insurance, health insurance, the classification (health insurance, disability insurance, care insurance), health insurance characteristics and specificity, health insurance, the role of micro-and macro. Chapter II of the emergence and development of health insurance exam Objective: To understand the historical evolution of foreign health insurance, and development trends, are familiar with the development of national health insurance status and trends of test content: knowledge of foreign origin and development of health insurance trends in the development of China's health insurance course, familiar with the basic medical insurance system for urban workers, to learn about our health insurance market conditions and trends. Chapter III of the health insurance products Examination Objective: To grasp the common health insurance, the type and morphology, classification, and product characteristics and basic elements. Exam Content: master critical-illness insurance, medical insurance, care insurance in time to the basic contents insurance, product characteristics, types and classifications. Chapter IV Health insurance product pricing Examination Objective: To understand the basis of health insurance product pricing theory, grasp the principle of product pricing and basic principles, actuarial assumptions and pricing process. Exam Content: Understanding Health Insurance in the risk-sharing mechanisms, pricing Shuolijichu, pricing needs of statistics; familiar with the pricing principles and the basic principles; to master all kinds of product pricing and actuarial assumptions, all kinds of health insurance products, pricing process; understanding Product pricing regulation. Chapter V of commercial health insurance market and sales Examination Objective: To grasp the concept of the health insurance market, characteristics and functions, sales channels and strategies and sales processes; familiar with the health insurance market factors. Examination content: control the health insurance market in features and functions; familiar with the health insurance market demand and supply factors; to master a variety of health insurance, sales strategy (target market strategy, marketing mix strategy, competitive strategy), marketing channels (the insurance company direct sales channel, personal channel agent, agents and brokers, institutional channels), and the sales process. Chapter VI of the Health Insurance Contract Examination Objective: To understand the concept of insurance contracts, classification and characteristics of the constituent elements; familiar with health insurance, part of the contract, the contract terms and effectiveness, performance, change and termination. Exam Content: Understanding the concept of insurance contracts, classification and characteristics of elements (subject, object, content); familiar with the components of the health insurance contract, insurance contract terms, validity (the establishment of effective, ineffective, revocable); Health Insurance performance of the contract, change and termination. Chapter VII of the health insurance underwriting examination Objective: To grasp the concept of health insurance underwriting and processes, as well as individual and group health insurance underwriting. Examination content: control health insurance underwriting concept, purpose and meaning and the principle, and the distinction between life insurance underwriting; familiar with the health insurance underwriting process (individual health insurance and group health insurance underwriting process); Chapter VIII of the Health Insurance Examination of the claims Objective: To grasp the concept of health insurance claims and the role of the claims process considerations; familiar with the principles of health insurance claims and the legal basis and with the distinction between life insurance claims, claims process; understand the main points of health insurance claims management. Exam Content: The concept of health insurance claims, role and claims management as well as the legal basis for the principles; commercial health insurance, life insurance claims and comparative claims, and claims process and claims process considerations. Chapter IX operational risk control health insurance exam Objective: To understand the health insurance business risks and control health care costs are familiar with the main factors; master health insurance, business risk control methods and progress. Examination content: the concept of health insurance, and its main source of operational risk, risk control strategies and tools; medical costs of the factors (factors that affect health service utilization, the factors affecting the cost of medical services and also affects both factors); Health the control of business risk insurance, the traditional methods (terms of design, nuclear security, the claims when the risk control); health insurance risk control methods, new progress (for medical services, process control is conducive to cost control of medical services, compensation mode, non - NCD and other profit-sharing measures, preventive health care and health education, managed care), co-management in hospitals. Chapter health insurance clients Service Examinations Objective: To grasp the definition and importance of customer service, the main service content, service mode, ways and characteristics; familiar with a customer service requirements and operations; understanding of value-added services and customer relationship management an important role. Examination content: to master customer service role, purpose and content (policy service, policy maintenance, premium collection, consulting services, value-added services, customer relationship management), customer service, ways and means and service characteristics. Chapter XI managed care Exam Objective: To understand the organizational forms of managed care, marketing and monitoring, medical treatment rates to develop methodologies, familiar with managed care to control costs and quality of medical services and acquire the means of the concept of managed care and characteristics. Examination content: master of managed care concepts (definitions, characteristics, and the difference between traditional health care, resulting in the background); regulatory bodies and information systems, cost and quality control; understanding of the organizational form of managed care, marketing and regulation, contract, rates and to use.