RAJIV AAROGYASRI COMMUNITY HEALTH INSURANCE SCHEME – Phase III FOR BPL POPULATION IN 5 DISTRICTS OF ANDHRA PRADESH
There is a felt need in the State to provide financial protection to families living below poverty line for the treatment of major ailments such as cancer, kidney failure, heart and neurosurgical diseases etc., requiring hospitalization and surgery/therapy. Government hospitals lack the requisite facility and the specialist pool of doctors to meet the statewide requirement for the treatment of such diseases. Large proportions of people, especially below poverty line borrow money or sell assets to pay for the treatment in private hospitals. Health Insurance could be a way of removing the financial barriers and improving access of poor to quality medical care; of providing financial protection against high medical expenses; and negotiating with the providers for better quality care. Government of Andhra Pradesh has accordingly implemented a Community Health Insurance Scheme by name Rajiv Aarogyasri in Anantapur, Mahabubnagar, Srikakulam as Phase I project and East Godavari, West Godavari, Chittoor, Nalgonda and Ranga Reddy as Phase II. Government after careful assessment of the scheme has now decided to expand the scheme with some modifications. Accordingly the third phase expansion is planned from 15-04-08 in five districts viz. Medak, Karimnagar, Kadapa, Prakasam and Nellore as Phase III
In order to operate the scheme professionally in a cost effective manner, public private partnership is envisaged between the Insurance Company, the private sector hospitals and the State agencies. State government/ Trust will guide the Insurance Company in establishing network of hospitals, fixing of treatment protocol and costs, treatment authorization, claims scrutiny and any other related work, such that the cost of administering the scheme is kept at the lowest, while making full use of the resources available in the Government system. Private hospitals fulfilling minimum qualifications in terms of availability of inpatient medical beds, laboratory, equipments, operation theatres etc. and a track record in the treatment of the specified diseases can be enlisted for providing treatment to the BPL families under the scheme. Premium under this scheme will be borne by the Government / Trust.
The scheme is intended to benefit below poverty line (BPL) population in the 5 districts of the State viz. Medak, Karimnagar, Kadapa, Prakasam and Nellore. There are 34.87 lakh BPL families in the five districts comprising of a population of 1.23 crores. Database and photograph of these families is available in ‘Health Cards’ to be issued by the Trust based on the BPL ration card issued by the Civil Supplies Department. District wise profile of the BPL families is given below:
Note: Such of the ‘Health Card’ holders who are covered for the specified diseases by other insurance scheme such as CGHS, ESIS, Railway, RTC etc., will not be eligible for any benefit under the scheme.
Sum Insured on Floater Basis:
The scheme will provide coverage for meeting expenses of hospitalization and surgical procedures of beneficiary members up to Rs.1.50 lakhs per family per year subject to limits, in any of the network hospitals. The benefit on family will be on floater basis i.e. the total reimbursement of Rs.1.50 lakhs can be availed of individually or collectively by members of the family.
Cost for cochlear Implant Surgery with Auditory -Verbal Therapy will be reimbursed by the Trust to the Insurance Company on actual basis up to a maximum of Rs.6.50 lakhs for each case.
Cash less Transaction
It is envisaged that for each hospitalization the transaction will be cashless for covered procedures. Enrolled BPL beneficiary will go to hospital and come out without making any payment to the hospital subject to procedure covered under the scheme. The same is the case for diagnostics if eventually the patient does not end up in doing the surgery or therapy.
Pre existing diseases
All diseases under the proposed scheme will be covered from day one. A person suffering from any disease prior to the inception of the policy will also be covered.
Process Flow of the Beneficiary Treatment in the Network Hospital
Beneficiaries approach nearby PHC/Area Hospitals/District Hospital/Network Hospital. Aarogya Mithras placed in the above hospitals facilitate the beneficiary. If beneficiary visits any other PHC/Government hospital other than the Network Hospital, the doctors will give him a referral card to the Network Hospital after preliminary diagnosis. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the Villages and can get the referral card based on the diagnosis.
The Aarogya mithras at the Network Hospital examines the referral card and BPL ration card and facilitates the beneficiary to undergo preliminary diagnosis and basic tests.
The Network Hospital, based on the diagnosis, admits the patient and sends preauthorization request to the Insurance company and the Aarogyasri Health Care Trust.
Specialists of the Insurance Company and the Trust examine the preauthorization request and approve preauthorization if all the conditions are satisfied.
The Network Hospital extends cashless treatment and surgery/therapy to the beneficiary.
Network Hospital after discharge forwards the original bill, discharge summary with signature of the patient and other relevant documents to Insurance Company for settlement of the claim.
Insurance Company scrutinize the bills and gives approval for the sanction of the bill.
Network hospital will provide follow-up free consultation and medicines supplied by the Trust for the patients undergoing treatment under the scheme for a period of up to one year from eleventh day of discharge.
The insurer should ensure that the empanelled hospitals follow the packages worked out by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital charges etc. In other words the package should cover the entire cost of patient from date of reporting to his discharge from hospital 10 days after surgery/therapy, making the transaction truly cashless to the patient.
- Aarogyamithras in PHCs/ CHCs/ Area Hospitals/ Government Hospitals etc: The unique nature of the scheme demands the insurance company to appoint Aarogyamithras in consultation with the trust in all PHCs, CHCs, Area Hospitals and District Hospitals for propagating the scheme, mobilizing people for health camps, counseling beneficiaries, facilitating the referral/treatment of these patients and follow-up. For effective and instant communication all the Aarogyamithras will have to be provided with cell phone CUG connectivity by the Insurance Company.
- Aarogyamithras in Network Hospitals: The Insurance company also needs to appoint at least two Aarogyamithras at all network hospitals to facilitate admission, treatment and cashless transaction of patient round the clock. The Aarogyamithras should also help hospitals in pre-auth, claim settlement and follow-up. They should also ensure proper reception and care in the hospital and send regular MIS. Insurance Company shall provide all Aarogyamithras with cell phone having CUG connectivity with SMS based reporting framework for effective and instant communication. The insurance company shall ensure that prefabricated Aarogyamithra kiosks with all additional requirements as per the design approved by the Trust is put up in all hospitals. The role of Aarogyamithra can be modified by the Trust from time-to-time.
The insurer will provide uniform and arrange the workshops/training sessions for the Aarogyamithras on the guidelines specified by the Trust.
Surgery / Medical Procedure Packages in Aarogyasri Scheme