Facilitation for Health Schemes

health

Ayushman Bharat is National Health Protection Scheme, which will cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage upto 5 lakh rupees per family per year for secondary and tertiary care hospitalization. Ayushman Bharat – National Health Protection Mission will subsume the on-going centrally sponsored schemes – Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).

Salient Features
  • Ayushman Bharat – National Health Protection Mission will have a defined benefit cover of Rs. 5 lakh per family per year.
  • Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.
  • Ayushman Bharat – National Health Protection Mission will be an entitlement based scheme with entitlement decided on the basis of deprivation criteria in the SECC database.
  • The beneficiaries can avail benefits in both public and empanelled private facilities.
  • To control costs, the payments for treatment will be done on package rate (to be defined by the Government in advance) basis.
  • One of the core principles of Ayushman Bharat – National Health Protection Mission is to co-operative federalism and flexibility to states.
  • For giving policy directions and fostering coordination between Centre and States, it is proposed to set up Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) at apex level Chaired by Union Health and Family Welfare Minister.
  • States would need to have State Health Agency (SHA) to implement the scheme.
  • To ensure that the funds reach SHA on time, the transfer of funds from Central Government through Ayushman Bharat – National Health Protection Mission to State Health Agencies may be done through an escrow account directly.
  • In partnership with NITI Aayog, a robust, modular, scalable and interoperable IT platform will be made operational which will entail a paperless, cashless transaction.

 

IMPLEMENTATION STRATEGY

  • At the national level to manage, an Ayushman Bharat National Health Protection Mission Agency (AB-NHPMA) would be put in place. States/ UTs would be advised to implement the scheme by a dedicated entity called State Health Agency (SHA). They can either use an existing Trust/ Society/ Not for Profit Company/ State Nodal Agency (SNA) or set up a new entity to implement the scheme.
  • States/ UTs can decide to implement the scheme through an insurance company or directly through the Trust/ Society or use an integrated model.
Major Impact

Ayushman Bharat – National Health Protection Mission will have major impact on reduction of Out of Pocket (OOP) expenditure on ground of:

  • Increased benefit cover to nearly 40% of the population, (the poorest & the vulnerable)
  • Covering almost all secondary and many tertiary hospitalizations. (except a negative list)
  • Coverage of 5 lakh for each family, (no restriction of family size)

This will lead to increased access to quality health and medication. In addition, the unmet needs of the population which remained hidden due to lack of financial resources will be catered to. This will lead to timely treatments, improvements in health outcomes, patient satisfaction, improvement in productivity and efficiency, job creation thus leading to improvement in quality of life.

 

EXPENDITURE INVOLVED

The expenditure incurred in premium payment will be shared between Central and State Governments in specified ratio as per Ministry of Finance guidelines in vogue. The total expenditure will depend on actual market determined premium paid in States/ UTs where Ayushman Bharat – National Health Protection Mission will be implemented through insurance companies. In States/ UTs where the scheme will be implemented in Trust/ Society mode, the central share of funds will be provided based on actual expenditure or premium ceiling (whichever is lower) in the pre-determined ratio.

NUMBER OF BENEFICIARIES

Ayushman Bharat – National Health Protection Mission will target about 10.74 crore poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data covering both rural and urban. The scheme is designed to be dynamic and aspirational and it would take into account any future changes in the exclusion/ inclusion/ deprivation/ occupational criteria in the SECC data.

STATES/DISTRICTS COVERED

Ayushman Bharat – National Health Protection Mission will be rolled out across all States/UTs in all districts with an objective to cover all the targeted beneficiaries.

National Health Insurance Schemes

  1. Rashtiya Swasthiya Bima Yojana (RSBY)
  2. Employment State Insurance Scheme (ESIS)
  3. Central Government Health Scheme (CGHS)
  4. Aam Aadmi Bima Yojana (AABY)
  5. Janashree Bima Yojana (JBY)
  6. Universal Health Insurance Scheme (UHIS)

 

1. Rashtiya Swasthiya Bima Yojana (RSBY)

RSBY ( Rashtriya Swasthiya Bima Yojana)  has been launched by Ministry of Labour and Employment, Government of India to provide health insurance coverage for Below Poverty Line (BPL) families. The objective of RSBY is to provide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization. Beneficiaries under RSBY are entitled to hospitalization coverage up to Rs. 30,000/- for most of the diseases that require hospitalization. Government has even fixed the package rates for the hospitals for a large number of interventions. Pre-existing conditions are covered from day one and there is no age limit. Coverage extends to five members of the family which includes the head of household, spouse and up to three dependents. Beneficiaries need to pay only Rs. 30/- as registration fee while Central and State Government pays the premium to the insurer selected by the State Government on the basis of a competitive bidding.

Unique Features of RSBY

The RSBY scheme is not the first attempt to provide health insurance to low income workers by the Government in India. The RSBY scheme, however, differs from these schemes in several important ways.

  • Empowering the beneficiary– RSBY provides the participating BPL household with freedom of choice between public and private hospitals and makes him a potential client worth attracting on account of the significant revenues that hospitals stand to earn through the scheme.
  • Business Model for all Stakeholders– The scheme has been designed as a business model for a social sector scheme with incentives built for each stakeholder. This business model design is conducive both in terms of expansion of the scheme as well as for its long run sustainability
  • Insurers– The insurer is paid premium for each household enrolled for RSBY. Therefore, the insurer has the motivation to enroll as many households as possible from the BPL list. This will result in better coverage of targeted beneficiaries.
  • Hospitals– A hospital has the incentive to provide treatment to large number of beneficiaries as it is paid per beneficiary treated. Even public hospitals have the incentive to treat beneficiaries under RSBY as the money from the insurer will flow directly to the concerned public hospital which they can use for their own purposes. Insurers, in contrast, will monitor participating hospitals in order to prevent unnecessary procedures or fraud resulting in excessive claims.
  • Intermediaries– The inclusion of intermediaries such as NGOs and MFIs which have a greater stake in assisting BPL households. The intermediaries will be paid for the services they render in reaching out to the beneficiaries.
  • Government– By paying only a maximum sum up to Rs. 750/- per family per year, the Government is able to provide access to quality health care to the below poverty line population. It will also lead to a healthy competition between public and private providers which in turn will improve the functioning of the public health care provider
  • Information Technology (IT) Intensive – For the first time IT applications are being used for social sector scheme on such a large scale. Every beneficiary family is issued a biometric enabled smart card containing their fingerprints and photographs. All the hospitals empanelled under RSBY are IT enabled and connected to the server at the district level. This will ensure a smooth data flow regarding service utilization periodically.
  • Safe and foolproof– The use of biometric enabled smart card and a key management system makes this scheme safe and foolproof. The key management system of RSBY ensures that the card reaches the correct beneficiary and there remains accountability in terms of issuance of the smart card and its usage. The biometric enabled smart card ensures that only the real beneficiary can use the smart card.
  • Portability– The key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to use his/ her smart card in any RSBY empanelled hospital across India. This makes the scheme truly unique and beneficial to the poor families that migrate from one place to the other. Cards can also be split for migrant workers to carry a share of the coverage with them separately.
  • Cash less and Paperless transactions– A beneficiary of RSBY gets cashless benefit in any of the empanelled hospitals. He/ she only needs to carry his/ her smart card and provide verification through his/ her finger print. For participating providers it is a paperless scheme as they do not need to send all the papers related to treatment to the insurer. They send online claims to the insurer and get paid electronically.

Read more:- http://www.rsby.gov.in/

2. Employment State Insurance Scheme (ESIS)

Employees’ State Insurance Scheme of India, is a multidimensional social security system tailored to provide socio-economic protection to worker population and their dependants covered under the scheme. Besides full medical care for self and dependants, that is admissible from day one of insurable employment, the insured persons are also entitled to a variety of cash benefits in times of physical distress due to sickness, temporary or permanent disablement etc. resulting in loss of earning capacity, the confinement in respect of insured women, dependants of insured persons who die in industrial accidents or because of employment injury or occupational hazard are entitled to a monthly pension called the dependants benefit.

Coverage

Applicability

  • The Act is applicable to non-seasonal factories employing 10 or more persons.
  • The Scheme has been extended to shops, hotels, restaurants, cinemas including preview theatres, road-motor transport undertakings and newspaper establishments employing 20* or more persons.
  • The Scheme has been extended to Private Medical and Educational institutions employing 20 or more persons in certain States/UTs.

*Note: 14 State Govts. / UTs have reduced the threshold limit for coverage of shops and ther establishments from 20 to 10 or more persons. Remaining State Governments/UTs are in the process of reducing the same. The existing wage limit for coverage under the Act is Rs. 15,000/- per month ( w.e.f. 01/05/2010)

Areas covered

The ESI Scheme is being implemented area-wise by stages. The Scheme has already been implemented in different areas in the following States/Union Territories of Indian Union.

States :- All the States except Manipur, Sikkim, Arunachal Pradesh and Mizoram.

Union territories :- Delhi and Chandigarh

Read more :- http://www.esic.nic.in/index.php

3. Central Government Health Scheme (CGHS)

The “Central Government Health Scheme” (CGHS) provides comprehensive health care facilities for the Central Govt. employees and pensioners and their dependents residing in CGHS covered cities. Started in New Delhi in 1954, Central Govt. Health Scheme is now  in operation in Allahabad, Ahemdabad ,Bangalore ,Bhubhaneshwar ,Bhopal ,Chandigarh , Chennai ,Delhi , Dehradun ,Guwahati ,Hyderabad, Jaipur , Jabalpur , Kanpur , Kolkatta , Lucknow , Meerut , Mumbai , Nagpur , Patna , Pune , Ranchi , Shillong , Trivandrum and Jammu. The Central Govt. Health Scheme provides  comprehensive healthcare to the CGHS Beneficiaries in India.  The medical facilities are provided through Wellness Centres (previously  referred to as  CGHS Dispensaries) /polyclinics under  Allopathic, AyurvedaYoga,UnaniSidha and  Homeopathic systems of medicines.

The main components of the Scheme are:

  • The dispensary services including domiciliary care
  • F. W. & M.C.H. Services
  • Specialists consultation facilities both at dispensary, polyclinic and hospital
  • level including X-Ray, ECG and Laboratory Examinations.
  • Hospitalization
  • Organization for the purchase, storage, distribution and supply of medicines and other requirements
  • Health Education to beneficiaries

Read more :- http://msotransparent.nic.in/cghsnew/index.asp

4. Aam Aadmi Bima Yojana(AABY)

Aam admi bima yojana, a Social Security Scheme for rural landless household was launched on 2nd October, 2007. The head of the family or one earning member in the family of such a household is covered under the scheme. The premium of Rs.200/- per person per annum is shared equally by the Central Government and the State Government. The member to be covered should be aged between 18 and 59 years. On natural death Rs 30,000. On death due to accident / on permanent disability due to accident ( loss of 2 eyes or 2 limbs ) Rs 75,000. On partial permanent disability due to accident( loss of one eye or one limb ) Rs 37,500

Benefits

A separate fund called “Aam Admi Bima Yojana Premium Fund” has been set up by Central Govt. to pay the Govt. contribution. Fund is maintained by LIC. A free add-on benefit in the form of scholarship to children is also available under the Scheme.

Read more:- http://financialservices.gov.in/insurance/gssois/aaby.as

5. Janashree Bima Yojana

Janashree Bima Yojana (JBY) was launched on 10th August 2000. The Scheme replaced Social Security Group Insurance Scheme (SSGIS) and Rural Group Life Insurance Scheme (RGLIS). 45 occupational groups have been covered under this scheme

Note: Aam Admi Bima Yojana and Janashree Bima Yojana have been merged into one scheme. It is renamed as “Aam Admi Bima Yojana” , effective from 01.01.2013.

Reference: www.licindia.in

6. Universal Health Insurance Scheme (UHIS)

The four public sector general insurance companies have been implementing Universal Health Insurance Scheme for improving the access of health care to poor families. The scheme provides for reimbursement of medical expenses upto Rs.30,000/- towards hospitalization floated amongst the entire family, death cover due to an accident @ Rs.25,000/- to the earning head of the family and compensation due to loss of earning of the earning member @ Rs.50/- per day upto maximum of 15 days. The Universal Health Insurance Scheme (UHIS) has been redesigned targeting only the BPL families. The premium subsidy has been enhanced from Rs.100 to Rs.200 for an individual, Rs.300 for a family of five and Rs.400 for a family of seven, without any reduction in benefits.

Read more:- http://financialservices.gov.in/insurance/gssois/uhis.asp