Rashtriya Swasthya Bima Yojana

https://www.rsby.gov.in 39,50,546 hospitalization cases treated till date Target :300 million BPL population of India

Contact Information
Urmila.goswami@nic.in

Introduction of the scheme

The Ministry of Labour and Employment (MoLE) launched the Rashtriya Swasthya

Bima

Yojana

(RSBY)

to

provide

health

insurance

benefits

to

the

belowthepovertyline (BPL), populations. It was launched in 2008 and is being implemented by the respective state governments. RSBY plans to cover all the entire BPL population in India (approx 300 million people) by 20122013. The objectives of RSBY are to:

o Provide financial protection from health care expenses on hospitalization O Improve access to quality health care

o Provide beneficiaries the power to choose from a national network of providers o Provide a scheme which even the illiterate can use easily

Information about the scheme

Parameter Model of scheme Details Public Private Partnership

Administration Responsibility
Scheme implementation Unit of enrolment Nature of transaction Conditions covered Insurance Cover Premium

Central and State Govt.

Insurance company The scheme will encompass all the family members of the BPL families. Cashless surgical procedures covered are 940 (160 medical conditions) A sum of 30000 rupees per family In the range of 400 to 600 per family (paid by Govt.)

Parameter Inclusions in package

Details Immediate Pre and post operative expenditure included in packages, so as to minimize the other financial expenses to the patient.

Exclusions
Network hospitals

No exclusions. Pre-existing diseases are covered from day one.

2500 empanelled hospitals

Type of agreement with network hospitals Contractual agreement with network hospitals Total number of people registered Age Limitations Insurance Company and TPAs Registration fee 3.5 Crore No 23 Insurance company and TPAs Rs. 30 per family

Health benefits provided under the scheme

The package includes:
RSBY beneficiaries are covered for hospitalization expenses of up to Rs. 30,000/ per family per year.

The family can include up to five members (including a husband, a wife, and
three dependents). Most of the surgical and medical conditions for which hospitalization is

necessary are covered in the scheme.

Package rates for 727 inpatient surgical procedures, including maternity and newborn care have been predefined.

 In addition, beneficiaries are covered for outpatient surgeries which can be done
on an outpatient basis. The benefit also includes one day pre and five day posthospitalization expenses. There is also a transportation benefit that provides Rs. 100 per visit to the beneficiary; total transport assistance cannot exceed Rs. 1000/ per annum and it is part of the total Rs. 30,000/ coverage.

Some highlights of the scheme

Some of the most noteworthy aspects of RSBY include: Empowering beneficiaries: RSBY provides freedom of choice to the patient in the selection of hospitals: They can access any public or private provider in the network across the country. Business model for all stakeholders: The scheme is designed as a business model, with incentives built in for each stakeholder: 1. Insurers: The insurer is paid a premium for each household enrolled in RSBY, therefore giving the insurer an incentive to enroll as many households as possible from the BPL list. 2. Hospitals: A hospital has the incentive to provide treatment to large number of beneficiaries as it is paid per beneficiary treated. Even public hospitals have an incentive to treat beneficiaries under RSBY as money from the insurer will flow directly to the public hospital. Insurers, in contrast, will monitor participating hospitals in order to prevent unnecessary procedures or fraud resulting in excessive claims.

3.

Intermediaries: The inclusion of intermediaries, such as NGOs and MFIs, was intentional since they have a greater stake in assisting BPL households. Intermediaries will be paid for the services they render in reaching out to the beneficiaries. 4. Government: Including public sector providers in the RSBY delivery network creates healthy competition between public and private providers which in turn provides incentives for public providers to improve their service delivery. SmartCard: Every beneficiary family is issued a biometric enabled SmartCard containing their fingerprints and photographs. All the hospitals empanelled under RSBY are IT enabled and connected to the server at the district level. This will ensure a smooth data flow regarding service utilization periodically. The SmartCard also ensures that only true beneficiaries can use sevices, reducing fraud. Portability: One key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to use his/her SmartCard in any RSBY empanelled hospital across India. This makes the scheme beneficial to the many poor families that migrate from one place to the other. Cashless: RSBY transactions are completely cashless. Beneficiaries do not pay cash for any services unless they exceed the annual allowance of Rs. 30,000/. Providertoinsurer dealings are also paperless, as all claims are processed and paid electronically.

Key stakeholders
1. Insurers

2. Hospitals
3. Intermediaries 4. Government

Patient Process Flow

Steps Taken by a Patient to Access Aarogyasri

The process for reporting and paying claims is designed to be simple and cashless from the perspective of the provider and beneficiary. In general, the process looks as follows: 1. A patient comes to a provider to receive care and goes straight to the RSBY help desk; the patients identity is verified via fingerprints 2. The patient visits the doctor who assess his/her health condition; doctor prescribes a treatment

3. Assistant at RSBY help desk checks whether procedure is in the list of prespecified
packages. Procedures are priced/paid to the provider on a casebased payment system a. If procedure is on list, appropriate prescribed package is selected, patient is scheduled for procedure, and the amount to be paid out is blocked b. If not on list, help desk checks with insurer to price and get approval to conduct procedure, patient is schedule for procedure, and the predetermined amount to be paid is blocked

4. In patient treatment is provided to the beneficiary. 5. Upon release of beneficiary from hospital, SmartCard is swiped again with fingerprint verification a. Beneficiary is paid by the hospital Rs. 100/ as transportation expense at time of discharge b. The prespecified cost of procedure is deducted from the amount available on the

card
6. After rendering service to patient, hospital sends an electronic report and claim to the insurer/TPA

7. The insurer/TPA reviews the records and information and makes payment to the
hospital (electronically) within a specified time period (agreed upon between insurer/TPA and hospital)