Abstract

Introduction: The importance of health insurance coverage can be considered from two viewpoints: protecting people against the costs of providing health; and providing universal coverage of health services so that people have access to affordable and adequate health services. Overview of insurance organizations' performance in Iran indicates that they are faced with various problems such as increasing costs, the lack of comprehensiveness and adequacy of services, the lack of clear boundaries between basic and supplementary health insurance packages, as well as, the problems on determining the scientific and fact-based tariffs. This research aimed to study the problems of health insurance coverage in a large insurance organization from the perspective of its managers. Methods: This study is an applied and qualitative research conducted in Iran in 2011. The participants in this study were 11 senior managers of one of the largest health insurance organizations selected using purposive method. Data was collected using structured interviews. Framework analysis using Atlas-Ti software was used to analyze the collected data. Results: Available challenges were categorized into 4 themes including structure and organization, policy making, the management of providing services, and culture and public education which were identified as the effective factors in health insurance coverage, and 69 sub-themes. Conclusion: Stated challenges can be largely met through making comprehensive and integrated policies by insurance organization, developing an updated and health-oriented structure, purposeful outsourcing of services, the application of modern and mechanized systems in providing services, as well as, providing the insured with information by electronic systems.