A patient talks with a boy on a bed inside the Indian Railways Divisional Railway Hospital in Mughalsarai, Uttar Pradesh, India, on Wednesday, Sept. 30, 2015. (Photographer: Dhiraj Singh/Bloomberg)

ModiCare’s Implementation Guidelines And Timelines Decoded

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August 15, India’s Independence Day. That’s the deadline Prime Minister Narendra Modi has set for officials to launch the state-sponsored health insurance scheme that will cover over 10 crore families.

A model tender document for the Pradhan Mantri Rashtriya Swasthya Suraksha Mission, which BloombergQuint has reviewed, will be shared this week with state governments for comments. It will also be circulated among the bidding insurers by the states, a government official privy to the development told BloombergQuint on condition of anonymity.

The scheme, reviewed by Modi on May 7, will cover poor families for Rs 5 lakh each worth of hospital expenses related to more than 1,300 diseases.

States with similar plans will be asked to increase their sum assured to the central level so that they can be co-branded, the official said. By May, all states will be brought on board starting with those in the north and northeast, the official quoted above said. The IT platform, to be launchedby July, will be modelled on the existing health insurance portal for Telangana.

Here’s all you need to know about the scheme:

The Scheme

It’s a Rs 5 lakh family floater plan covering all members of a family for one year. New members can be added after the government’s approval.

Who Is Covered?

About 10.74 crore poor families that fall under the seven deprivation criteria listed by Socio-Economic Caste Census, 2011, along with the existing Rashtriya Swasthya Bima Yojana beneficiaries. These include deprived rural families, households without shelter, the destitute, manual scavenger families, primitive tribal groups and legally-released bonded labourers. They can be admitted for treatment at empanelled hospitals on verifying identity using Aadhaar, ration card and other such specified document.

What Is Covered?

The scheme will cover 1,354 medical and surgical packages categorised under 25 specialties such as cardiology, neurosurgery, oncology (chemotherapy for 50 types of cancers), mental disorders, burns, reconstructive surgeries, among others. Patients can’t avail surgical and medical packages at the same time.Treatment for nearly half the packages will require pre-authorisation from the insurer, which must respond within 12 hours to the empanelled healthcare provider.

Benefits under the basic risk cover:

  • Hospitalisation expenses such as registration, nursing and boarding charges in general ward
  • Consultation fees, surgical equipment and procedure charges and cost of implants, medicines, diagnostic tests and food to patient
  • Follow-up care along with pre- and post-hospitalisation expenses

In case of multiple surgeries, the highest package rate will be waived for the first treatment, and 50 percent and 25 percent of the package rate will be provided for the second and third treatment. The rest will be borne by the policyholder.

Who Will Fix The Rates?

The pricing will be decided by the state health agency in consultation with the selected insurer and empanelled hospitals for three years. But the third year will be contingent to the performance of the insurer in the first two. Any surgical procedure not included under the listed package can also be availed for a sum of up to Rs 1 lakh for each family, after pre-authorisation by the insurer.

How Will The Scheme Be Implemented?

The scheme will be implemented jointly by the central and state governments.

Central level: National Health Agency, which comes under the Ministry of Health and Family Welfare, will implement the scheme and run the web portal.

State level: State health agencies will sign contracts with insurers and empanelled hospitals. They will be responsible for auditing and monitoring the scheme through spot checks. They will also ensure that empanelled hospitals have the required IT and allied infrastructure to identify beneficiaries, print e-cards and provide services.

•District level: The insurer will set up an office within 15 days of signing the insurance contract with the state. Hospitals will be empanelled after approval and audit through district and state empanelment committees. A contract will then be signed between the insurer, the state government and the hospital within seven days.

Criteria for selecting hospitals

While all public hospitals will be empanelled from day one, private hospitals can register through the scheme portal https://pmrssm.gov.in/.

All the network hospitals must have:

  • At least 10 inpatient beds with adequate spacing and supporting staff.
  • In case of hospitals providing surgical packages, a minimum of 15 beds is prescribed.
  • Quality certification from National Accreditation Board for Hospitals & Healthcare Providers will be mandatory for all the selected hospitals within a year of approval.
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