Background:

Health Insurance Scheme is a Budget Declaration for the year 2014-15. The scheme was visualized in order to provide quality healthcare to all National Food Security Scheme (NFSS) families and also to reduce the workload on government Health Institutions. Moreover, benefits like hassle free cash less treatment, improved quality of care with efficiency etc, are also envisaged.

• Aim of the Scheme:

Basic aim of scheme is Improvement in health indicators; However, some other expectations are:

• Reduction in ‘out of pocket’ expenses and providing financial security to the poor against illnesses.
• To hedge the financial risk of excess expenditure on healthcare by using Insurance as a tool.
• To successfully roll out Government’s vision of maximum Governance and minimum Government
• Create a wide health database, which may be used in making policy level changes/decisions in future.
• Bring a revolution in healthcare in rural area – by providing stimulus to Private Sector to open hospitals in rural areas and reducing the increasing burden on Government facilities.
• Beneficiaries:-
• The scheme envisages benefits for the NFSS (National Food Security Scheme) beneficiaries and RSBY (Rashtriya Swasthya Bima Yojana) beneficiaries (as RSBY is proposed to be taken over by Health Department from Oct., 15).
• Implementation of the scheme shall be done through Bhamashah Cards, but till the time Bhamashah cards are issued, identity related to NFSS and RSBY shall also be honored.
• Cover:
• Health Insurance Cover of Rs. 30,000/- for general illnesses and Rs. 3.00 lacs for critical illnesses shall be given to a family on floater basis in one year for IPD procedures.
• 7-day pre-hospitalisation and 15 days post hospitalization is covered under the scheme.
• Transport allowance of Rs. 100 to Rs. 500 for cardiac and polytrauma cases.
• Patients shall be benefitted for 1045 packages under General Illnesses, 500 packages under Critical Illnesses, and 170 packages reserved for Govt. Hospitals.
• Service Delivery Through:
• These benefits shall be cashless for the beneficiaries and services shall be provided through public health institutions and empanelled private health institutions.
• Insurer and its selection:
• Insurer for the scheme has been selected through open competitive two stage bidding process and public sector insurance company, The New India Assurance Company has been finalized at the most competitive rate across India for the scheme having most comprehensive features.
• Monitoring and Control:
• In-house claims processing software and transparent and standardized grading criteria for hospitals
• Mobile app monitoring for all government officials upto district level
• Well defined and verified medical protocols – maximum in any scheme
• Unique profit refund clause
  • Insurers do not over charge the government
  • Do not try to reject genuine claims
• Strong monitoring mechanism and removal of Third Party Administrator (TPA) in order to prevent leakages and cost escalation

Future Prospects:

• Lessened workload on Government Health Institutions immediately.
• Financial Strengthening of Medicare Relief Societies of Govt. Health Institutions.
• Poor person will be provided with an opportunity to get health services in private Health Institutions.
• A wide health database will be generated which shall be used for making policy level decisions in future.
• In will attract Private Sector to open hospitals in rural areas and reducing the increasing burden on government facilities.

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