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.
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.
