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RASHTRIYA SWASTHYA BIMA YOJANA

RASHTRIYA SWASTHYA BIMA YOJANA. Dr. Mohmmedirfan H. Momin Assistant Professor Community Medicine Department Government Medical College, Surat. The workers in the unorganized sector constitute about 94%

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RASHTRIYA SWASTHYA BIMA YOJANA

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  1. RASHTRIYA SWASTHYA BIMA YOJANA Dr. Mohmmedirfan H. Momin Assistant Professor Community Medicine Department Government Medical College, Surat.

  2. The workers in the unorganized sector constitute about 94% • One of the major insecurities for workers in the unorganized sector is absence of health cover. • Insecurity relating to absence of health cover, heavy expenditure INTRODUCTION

  3. Loss of earning and progressive deterioration of health. • Illness remains one of the most prevalent causes of human deprivation in India. • Health insurance is one way of providing protection to poor households against the risk of health spending leading to poverty INTRODUCTION

  4. It is a new health insurance scheme of a Central Government for the Below Poverty Line (BPL) families in the unorganized sector. • Which was announced by the Prime Minister Manmohan Singh on Independence Day (August 15, 2007). • It was formally launched on October 1, 2007 by Ministry of Labour and Employment, Government of India. What is RSBY?

  5. Poor • Self-Employed • Employers not identifiable • Illiterate • Migratory • Lack of skills CHARACTERSTICS OF UNORGANIZED SECTOR WORK FORCE

  6. The main objective of RSBY is to provide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization • Recognizing the diversity with regard to public health infrastructure, socioeconomic conditions and the administrative network, the health insurance scheme aims to facilitate launching of health insurance projects in all the districts of the States in a phased manner for BPL workers over a period of 5 years. OBJECTIVE

  7. Contribution by Government of India: 75% of the estimated annual premium of Rs.750, subject to a maximum of Rs. 565 per family per annum. • The cost of smart card will be borne by the Central Government. • Contribution by respective State Governments: 25% of the annual premium, as well as any additional premium. Funding Pattern

  8. The beneficiary would pay Rs. 30 per annum as registration/renewal fee. • The administrative and other related cost of administering the scheme would be borne by the respective State Governments. • Additionally, the cost of the smart cards will also be borne by the Central Government @ Rs.60/- per card. Funding Pattern

  9. Rashtriya Swasthya Bima Yojana provides cover for hospitalization expenses upto Rs. 30,000/- for a family of five on a floater basis. • Transportation charges are also covered up to a maximum of Rs. 1,000/- with Rs. 100/- per visit. the insurance coverage

  10. Coverage under the scheme would be provided for BPL workers and their families [up to a unit of five). • A family would thus comprise the Household Head, spouse, and up to three dependents. • The dependents would include such children and/or parents of the head of the family as are listed as part of the family in the BPL data base. HOUSEHOLD ELIGIBILITY CRITERIA

  11. If the parents are listed as a separate family in the data base, they shall be eligible for a separate card. • The definition of BPL would be the one prescribed by the Planning Commission for the purposes of determining the eligible BPL population in each State/district. HOUSEHOLD ELIGIBILITY CRITERIA

  12. It would be the responsibility of the respective State Government to verify the eligibility of specific BPL workers and their family members who would be the beneficiaries of the scheme, and to share such information with the insurance provider. • To this end, an authenticated BPL list [or lists where the covered area includes urban and rural areas] providing the details of each BPL family will be prepared by the State Government/Nodal agency. HOUSEHOLD ELIGIBILITY CRITERIA

  13. The data would be provided in the prescribed electronic format to the insurer. • The State Governments may, if required, seek the assistance of an outside agency for the task of data entry. • However, the responsibility for providing the correct data shall be that of the State Government and it would be expected of the State Government that it shall put in place a foolproof system of supervision and authentication of the data. HOUSEHOLD ELIGIBILITY CRITERIA

  14. The Insurer shall enroll the BPL beneficiaries based on the soft data provided by the State Government/Nodal Agency and issue Smart card as per Central Government specifications through Smart Card Vender and handover the same to the beneficiaries at enrolment station/village level itself during the enrolment period. ENROLMENT OF BENEFICIARIES

  15. Further the enrolment process shall continue at designated centers agreed by the Government /Nodal Agency after the enrolment period is over to provide the smart card for remaining beneficiaries. • Insurer in consultation with the State Government/ Nodal Agency shall chalk out the enrolment cycle up to village level in a manner that representative of Insurer, Government/Nodal Agency and smart card vender can complete the task in scheduled time. ENROLMENT OF BENEFICIARIES

  16. The process of enrolment shall be as under: (a) The data relating to BPL families in the selected districts shall be entered into prescribed software by the concerned State Government/Nodal Agency. (b) A soft and hard copy of this data shall be provided by the State Government/Nodal Agency to the INSURER selected by the State Government/Nodal Agency. ENROLMENT OF BENEFICIARIES

  17. (c) The Insurer will arrange for preparation of the smart card as per the prescribed stipulation. (d) A schedule of programme shall be worked out by the Government/Nodal Agency in consultation with the Insurer for each enrolment station/village in the district. (e) Advance publicity of the visit of representatives of the State Government and the Insurance Provider shall be done by the State Government/Nodal Agency in respective villages. ENROLMENT OF BENEFICIARIES

  18. (f) List of BPL should be posted prominently in the enrolment station/village by the Insurer. • (g) The representatives shall visit each enrolment station/village in the selected district jointly on the pre-schedule dates for purpose of taking photograph of the head of the family and the thumb impression of the head of the family and the other eligible member of the family, enrolment and issuance of smart card. ENROLMENT OF BENEFICIARIES

  19. Smart Card Registration Process RSBY CARD RSBY CARD

  20. KFO Confirmation Photograph of the Head of the Family Thumb Impression of all members Enrolment

  21. SMART CARD

  22. (h) The softwares to be used by the Insurance Company for the purpose of enrolment and thereafter for the purpose of transaction at the hospitals and data transmission therefrom shall be the ones approved by the Central Government. ENROLMENT OF BENEFICIARIES

  23. Each enrolment team in the villages is accompanied by a Field Key Officer (FKO) who identifies the beneficiaries at the time of enrollment. • FKO is also provided with a smart card and his job is to identify the beneficiary and authenticate their smart card by his FKO card and finger print. Without FKO’s authentication the smart card with the beneficiary will not work. How does the Government ensure that the correct beneficiary is getting the Smart card?

  24. The detail of each family which is authenticated by the FKO also gets copied in the FKO card and insurance company is paid based on the number of beneficiaries obtained from the FKO card. How does the Government ensure that the correct beneficiary is getting the Smart card?

  25. FKOs are representative of the Government. • They can be different entities in different districts. • For example Health Workers, Gram Vikas Adhikaris Patwaris, etc. have been given the role of FKO by different State Governments. • RSBY mandates the presence of FKOs at the enrollment station for the enrollment process. FKOs

  26. The beneficiary shall be eligible for coverage of the financial costs of such inpatient health care services as would be negotiated by the respective State government with the insurer(s), as well as agreed daycare procedures not requiring hospitalization. • However, the following minimum features of the health insurance plan would be as follows : (a) Total sum insured of Rs.30,000 per BPL family per annum on a family floater basis. HEALTH SERVICES BENEFIT PACKAGE

  27. (b) Pre-existing conditions to be covered, subject to minimal exclusions. An indicative list of exclusions is provided in Annexure II. (c) Coverage of health services related to hospitalization and services of a surgical nature which can be provided on a daycare basis. Annexure-III contains an indicative list of daycare treatment. (d) Cashless coverage of all health services in the insured package. HEALTH SERVICES BENEFIT PACKAGE

  28. (e) Provision for a smart-card based system of beneficiary identification/verification and point of service processing of client transactions. (f) Provision for reasonable pre and post-hospitalization expenses for one day prior and 5 days after hospitalization, but subject to a maximum share of the total costs of the hospitalization. HEALTH SERVICES BENEFIT PACKAGE

  29. (g) Provision for transport allowance (actual with limit of Rs.100 per visit) but subject to an annual ceiling of Rs.1000. • In addition to the above minimum, in their proposals, States should specify in detail the proposed package of health services to be covered under the Scheme, as well as the proposed exclusions. HEALTH SERVICES BENEFIT PACKAGE

  30. How To Use Card Go To Hospital Patient Go To Doctor Shows Card Advise Hospitalization After Treatment Again Thumb Impression is Taken and updated in System RSBY COUNTER Verifies Thumb Impression Check Limit and issue Slip Process Card

  31. Process Overview

  32. The scheme will be implemented by the State Government in a phased manner in the next five years. • The entire country will be covered by 2012-13. • In districts where the Scheme is introduced, it would supercede the Universal Health Insurance Scheme (UHIS). IMPLEMENTATION SCHEDULE

  33. The State Government shall formulate project/projects for providing health insurance benefits, taking into account the aforementioned points, for the workers and their families in the unorganized sectors for a defined geographical area, preferably a district. • While formulating the project/projects, the following aspects may be considered: FORMULATION OF THE PROJECTS

  34. There must be a clearly defined institution capable of organizing a health insurance programme. • It can be an autonomous body, State Government Department, a Cooperative Society or even an NGO. FORMULATION OF THE PROJECTS

  35. The organization should have the technical skills to understand the concept of health insurance, should be able to design a programme that is technically sound, should have skills to be able to discuss with the community and should have the administrative capacity to organize the programme. FORMULATION OF THE PROJECTS

  36. There must be a network of health care providers (public and private). • The Project should incorporate use of private and all public healthcare providers, including ESI hospitals. • There should be some basic data available regarding the demographic profile of the District. FORMULATION OF THE PROJECTS

  37. The cost of the scheme, i.e., total premium per year, along with the procedure adopted to arrive at the premium. • The procedure for collecting the registration/renewal fee from the beneficiary should be outlined in the proposal. FORMULATION OF THE PROJECTS

  38. A Cell would be constituted in the Ministry, administering the scheme, to assist the State Governments in formulating projects. • The Cell would be headed by a Sr. Advisor who would be assisted by two Advisors. • The expert would be hired on contract basis or on deputation. SETTING UP OF TECHNICAL CELL:

  39. The Cell would perform following functions: a) Plan the insurance scheme based on the requirements of State; b) Workout financial implication and other details; SETTING UP OF TECHNICAL CELL:

  40. c) Assist the State Governments in the preparation of pilot projects d) Assist in the effective implementation of the Scheme. e) Monitor and evaluate the implementation of the project. The proposal for launching health insurance project would be submitted to the Administrative Ministry for approval along with all the financial implications and details. SETTING UP OF TECHNICAL CELL:

  41. The State Government will be required to select one or more health insurers on a periodic basis according to a tender process which would take account of both the price of the insurance package and technical merit of the proposal. • The tender should be open to both public and private sector health insurers who meet the relevant IRDA (The Insurance Regulatory Development Authority) standards. REQUIREMENT OF TENDER TO SELECT INSURANCEPROVIDER

  42. If the period of the contract with the successful bidder exceeds one year, the State should provide for performance indicators or other mechanisms to extend the contract annually. REQUIREMENT OF TENDER TO SELECT INSURANCEPROVIDER

  43. A Committee consisting of the following shall examine the proposals submitted by the State Governments and grant approval to the projects: i) Joint Secretary/Director General Labour Welfare, Ministry of Labour & Employment Convener ii) Representatives of Ministry of Finance Member APPROVAL AND MONITORING COMMITTEE:

  44. iii) Representatives of Ministry of Health and Family Welfare Member iv) Representatives of Planning Commission Member • The Committee will also periodically monitor and review the progress of the projects. APPROVAL AND MONITORING COMMITTEE:

  45. The proposals of the State Governments will be considered by the Approval and Monitoring Committee set up by the Central Government. • The elements that States would need to address in their proposals include the following: (a) Tendering and contracting procedure for insurer/partners. SUBMISSION AND APPROVAL OF THE PROPOSAL

  46. (b) Overseeing arrangements (e.g. district and block monitoring bodies). Representatives of civil society, including Panchayati Raj institutions, should be adequately represented on relevant State, District and Block level overseeing bodies. (c) Status of BPL data and its conformity with the prescribed standards, estimates of BPL population in covered districts. SUBMISSION AND APPROVAL OF THE PROPOSAL

  47. (d) Training plan of State Government, insurers and others to ensure adequate capacity for Scheme implementation. (e) IEC/awareness raising mechanisms (start-up and ongoing), including any special/extra channels for harder-to-reach groups. Role of intermediaries/NGOs/Cooperatives therein. (f) Enrollment and renewal procedures, including identification of beneficiaries. SUBMISSION AND APPROVAL OF THE PROPOSAL

  48. (g) Empanelment/accreditation of health providers, including minimum requirements for health facilities to be included in the Scheme and administrative capacity. An indicative list of requirements is provided in Annexure IV. (h) Process for smart card provision and operation. (i) MIS and database management, including collection of data on patients/providers and its use. SUBMISSION AND APPROVAL OF THE PROPOSAL

  49. (j) Evaluation of impact and performance, including provision for baseline survey(s). (k) Grievance redressal mechanisms. (l) Financing plan for State Government premium contributions and other administrative expenses to be incurred in Scheme operation. (m) How the proposed Scheme would interact with any existing health insurance schemes in the proposed district(s). SUBMISSION AND APPROVAL OF THE PROPOSAL

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