A man purchases medicines at a pharmacy in Lajpat Nagar, New Delhi. (Photographer: Kuni Takahashi/Bloomberg)

Jan Arogya Abhiyan: All You Need To Know About Modi’s Health Insurance Scheme

A pilot programme of India’s largest health insurance scheme was announced by Prime Minister Narendra Modi in his Independence Day address on Wednesday.

The states and union territories selected for the pilot run of the Pradhan Mantri Jan Arogya Abhiyan National Health Protection Mission are: Chhattisgarh, Uttarakhand, West Bengal, Chandigarh, Himachal Pradesh, Daman and Diu, Nagaland, Manipur, Haryana and Andhra Pradesh.

The insurance cover scheme is under the government’s Ayushman Bharat healthcare policy umbrella.

So far, 29 out of 36 states and union territories have agreed to join the scheme. Another six are expected to sign up in the coming months while Odisha has opted out.

“Private hospitals may not be enrolled in some states as the purpose of launching the scheme on pilot basis is to test our systems in real time,” said Indu Bhushan, chief executive officer, National Health Agency—the implementing agency. Private hospitals will be included later, he said.

Here’s a lowdown on the scheme:

The Scheme

It’s a Rs 5-lakh cashless family floater insurance covering all members of the household for one year. Members can be added after the government’s approval.

Who Is Covered?

The Prime Minister said the mission will cover 10 crore families when it is launched nationwide on September 25, 2018. They include existing Rashtriya Swasthya Bima Yojana beneficiaries and those part of similar schemes in the participating states.

Why Is It Needed?

Indians pay over three-fourths of all healthcare costs out of pocket, according to a study by the Public Health Foundation of India published in May. Nearly 5.5 crore people were pushed below the poverty line because of healthcare expenses, of which 3.8 crore became poor only because they had to bear medicine costs, it said. The scheme is targeted at such families.

What Is Covered?

It covers 1,354 medical and surgical packages categorised under 25 specialties such as cardiology, neurosurgery, oncology (chemotherapy for 50 types of cancers), burns, among others. Patients can’t avail surgical and medical packages at the same time.

Benefits:

  • 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 for patients.
  • 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 costs will be provided for the second and third treatment, respectively.

Jan Arogya Abhiyan: All You Need To Know About Modi’s Health Insurance Scheme

Who Will Fix The Rates?

The state health agency in consultation with the selected insurer and empanelled hospitals for three years. The third year will be contingent to the performance of the insurer in the first two.

  • Seven states, including two union territories, have opted for the insurance model.
  • Twenty states opted to set up trusts or subsidy pools with 60:40 contribution by central and state governments. Funds will be granted at a flat premium of Rs 500 a family for the first six months.
  • Under the mixed model—opted by eight states—claims of up to Rs 1.5 lakh will be covered by an insurer and anything exceeding that will be settled by the trust.

How Will The Scheme Be Implemented?

Jointly by the central and state governments.

Central Level
National Health Agency 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 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 selected after approval and audit through committees. A contract will then be signed between the insurer, the state and the hospital within seven days.

Budget Outlay

Even as the overall budget for the scheme is still provisional, allocation for 2018-19 was Rs 2,000 crore, according to a written response by the Minister of State for Health and Family Welfare in Parliament.

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). About 7,826 hospitals have joined so far, of which 47 percent are private, according to the latest data by the National Health Agency.

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.