RASHTRIYA SWASTHYA BIMA YOJANA

INDIA …composition of workforce

CHARACTERSTICS OF UNORGANIZED SECTOR WORKFORCE Poor Self-Employed Employers not identifiable Illiterate Migratory Lack of skills (Unskilled)

RASHTRIYA SWASTHYA BIMA YOJANA Benefits Total sum insured of Rs 30,000 per BPL family on a family floater basis Pre-existing diseases to be covered Coverage of health services related to hospitalization and services of surgical nature which can be provided on a day-care basis

RASHTRIYA SWASTHYA BIMA YOJANA Benefits Cashless coverage of all eligible health services. Provision of Smart Card. Provision of pre and post hospitalization expenses. Transport allowance @ Rs.100 per visit

FUNDING Contribution by GOI : 75% of the estimated annual premium of Rs 750, subject to a maximum of Rs. 565 per family. Contribution by the State Governments: 25% of the annual premium and any additional premium beyond Rs 750. Beneficiary to pay Rs. 30 per annum as Registration Fee/ Renewal Fee Administrative cost to be borne by the State Government. Cost of Smart Card to be borne by the Central Government. An additional amount of Rs.60 per beneficiary would be available for this purpose.

FUTURE COURSE OF ACTION …….understanding the process What have the State Governments to do? What is the role of Insurance Companies? Role of Health Service Providers? Role of Smart Card Service Providers? Role of Social Aggregators/NGOs/MFIs/Intermediaries

WHAT HAVE THE STATE GOVERNMENTS TO DO? Identify/Set-up a State Nodal Agency which is a separate legal entity under the control of the State Government Select 20% Districts at the earliest. All the Districts have to be covered in the next five years. Chosen Districts should have adequate network of health facilities/hospitals which meet minimum standards. Prepare data relating to BPL families and health related infrastructure. Communicate the yearly schedule of coverage along with the names of the districts to the Central Government as well as the Insurance Companies. Finalize the tender document. Take a view on the package rates. Advertise.

POST ADVERTISEMENT PHASE TASKS FOR STATE GOVERNMENTS Organise State-level workshop for sensitizing the officials, Hospital staff and the NGOs. (The cost will be borne by the Central Government) Pre-bid Conference with the Insurance Companies. Procure list of BPL families, including soft copies, from the concerned Districts and hand over these soft copies, for test run, to the Central Government Technical Team.

POST ADVERTISEMENT PHASE TASKS FOR STATE GOVERNMENTS Plan for delivery of cards Work out a tentative village-wise visit plan on the basis of BPL List. Identify locations where cards could be issued. Identify occasions (market days etc.) when the scheme and the delivery programme could be publicized. Identify the staff which would provide authentication at the time of issue of cards. (A pre-identified official will accompany the team) Prepare for training of Government officials for issue of Smart Cards. Understand and operate the Key Management System

POST ADVERTISEMENT PHASE TASKS FOR STATE GOVERNMENTS Get the Contract Document legally vetted. Intimate Central Government in case assistance is required for technical evaluation. Prepare template of proposal to be sent to Central Government. Finalize a date for signing of MOU with Central Government and Contract with Insurance company. Put in place an institution for smooth fund flow to Insurance Companies.

WHAT HAVE THE STATE GOVERNMENTS TO DO WHAT HAVE THE STATE GOVERNMENTS TO DO? PROPOSAL TO THE CENTRAL GOVERNMENT Tender Document issued by the State Government. Minutes of the Committee approving the proposal at the State level

ROLE OF INSURANCE SERVICE PROVIDER Study the profile of the Districts. Empanel the hospitals, both public and private, on the basis of the guidelines (also take a view on the package rates) and subsequently enter into an arrangement with them. Procure hardware, like smart card reading machines, as per the specifications and provide them to the network hospitals. (Cost of these equipments and maintenance thereof shall be borne by the concerned hospitals) Enter into an arrangement with the Smart Card Service Providers and NGOs/intermediaries. Organize District-level training workshops for network hospital personnel and for NGOs/intermediaries after selection.

IMPLEMENTATION OF THE SCHEME Signing of MOU between the Central and the State Government. Contract between the State Government and the Insurance Provider. Delivery of Smart Card to commence

SMART CARD What is Smart Card? How will it operate? Who would bear the cost?

SMART CARD The Process Smart cards to be provided by the selected Insurance Company. The Insurance Company can outsource this task. (The guidelines are being worked out and will be sent within ten days) BPL family details will be provided in a predefined electronic format by the respective State Governments to the Insurance Company for the Districts selected for health insurance coverage.

SMART CARD The process A detailed village-wise schedule will be worked out by the State Government in consultation with the selected Insurance Provider. Representatives of the respective State Governments and the Insurance Provider to visit each village jointly in the selected District(s). Advance publicity of these visits by the State Governments

SMART CARD The Process Photograph of the head of the family and thumb impressions of all the family members to be taken during the visit to the village. Collection of Rs.30 from the beneficiary as registration fee by the Insurance Service Provider (This would be adjusted against the amount of premium to be paid to the Insurance Company.)

SMART CARD The Process Handing over the smart card and insurance related pamphlet, in local language, by the Insurance Provider to the beneficiary. The smart card would entitle the beneficiary at the time of the delivery of the card.

PERIOD OF INSURANCE … in one District The Scheme shall commence operation from the first of the month after the next month from the date of issue of smart card. Thus, if the initial smart cards are issued anytime during the month of February in a particular district, the scheme will commence from 1st of April. The scheme will last for one year till 31st March of next year. This would be the terminal date of the scheme in that particular district. Thus, cards issued during the intervening period will also have the terminal date as 31st March of the following year.

PERIOD OF INSURANCE ….an illustration Sl. No. Smart card issued upto Insurance will start Policy period Premium 1. February, 2008 1st April, 2008 1st April to 31st March Full 2. March, 2008 1st May, 2008 Upto 31st March, 2009 3. April, 2008 1st June, 2008 4. May, 2008 1st July, 2008 9/12 5. June, 2008 1st August, 2008 8/12 6. July, 2008 1st September, 2008 7/12 7. August, 2008 1st October, 2008 6/12 Enrolment will freeze from September, 2008 for above policy period.

PERIOD OF INSURANCE …. in another District In case the initial cards themselves are issued in another district in subsequent months, e.g. May, the scheme itself will commence from 1st of July and will have a terminal date of 30th of June of the next year. The cards issued subsequently will also have 30th June as the terminal date. However, the commencement of insurance for cards issued subsequently in that district will be determined by the logic mentioned earlier.

PROCESS FLOW The State Government selects the Districts and identifies the State Nodal Agency. The Nodal Agency advertises to seek quotes from the Insurance Companies. Submission of quotes / bids by Insurance Companies.

PROCESS FLOW Arrangement by the Insurance Service Provider with: Health Service Providers Smart Card Service Intermediaries/ NGOs/ MFIs Examination and evaluation of quotation and selection of the Insurance Service Provider. Preparation and submission of proposal to the Central Government. Evaluation and Approval of the proposal by the Central Government.

PROCESS FLOW Signing of MoU between the Central and the State Government / Nodal Agency. Signing of MoU between the Nodal Agency and the Insurance Service Provider. Handing over the BPL Data by the State Government to the Insurance Service Provider.

PROCESS FLOW Preparation of village-wise plan by the Nodal Agency/State Government for delivery of smart cards in consultation with the Insurance Company. Preparation of a brochure by the Insurance Co. listing out the benefits and the contact numbers as well as the hospitals. Premium claim by the Insurance Company from the State Nodal Agency. Village-wise delivery of smart cards, along with a brochure. Collection of Rs.30 as registration fee to be adjusted against the premium. Claim of 75% of the premium from the Central Government. Visit to the Hospital by I.P.

PROCESS FLOW Verification of the Thumb impression. Admission of the patient, blocking of the anticipated amount (on the basis of the amount indicated in the medical procedures) on the card and payment of transportation charges. Treatment of the patient and taking care of the expenses thereon.

PROCESS FLOW Settlement of claims. Discharge of the patient and debiting of the final amount from the smart card. Lodging of claims by the Health Service Providers from the Insurance Company. Settlement of claims.

SOME INTERESTING FEATURES OF THE SCHEME For the first time IT tools being used for the poorest of the poor………by them, for them It is a ‘business model’ with business opportunity for all.

………..let us make it work