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RASHTRIYA SWASTHYA BIMA YOJANA Dr. Mohmmedirfan H. Momin Assistant Professor Community Medicine Department Government Medical College, Surat. 1
INTRODUCTION 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 2
INTRODUCTION 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 3
What is RSBY? :
What is RSBY? 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. 4
CHARACTERSTICS OF UNORGANIZED SECTOR WORK FORCE:
CHARACTERSTICS OF UNORGANIZED SECTOR WORK FORCE Poor Self-Employed Employers not identifiable Illiterate Migratory Lack of skills
OBJECTIVE 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. 6
8 the insurance coverage: the insurance coverage Rashtriya Swasthya Bima Yojana provides cover for hospitalization expenses upto Rs. spouse.per visit. 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. 30.000/. 11 HOUSEHOLD ELIGIBILITY CRITERIA : HOUSEHOLD ELIGIBILITY CRITERIA 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. 565 per family per annum.000/. 100/. the cost of the smart cards will also be borne by the Central Government @ Rs.with Rs. Additionally. and up to three dependents. and to share such information with the insurance provider. as well as any additional premium.per 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. 1. 30 per annum as registration/renewal fee.Funding Pattern : Funding Pattern Contribution by Government of India: 75% of the estimated annual premium of Rs. The administrative and other related cost of administering the scheme would be borne by the respective State Governments. subject to a maximum of Rs.for a family of five on a floater basis.750. 12 . A family would thus comprise the Household Head. 10 HOUSEHOLD ELIGIBILITY CRITERIA : HOUSEHOLD ELIGIBILITY CRITERIA If the parents are listed as a separate family in the data base.60/. 9 HOUSEHOLD ELIGIBILITY CRITERIA : HOUSEHOLD ELIGIBILITY CRITERIA Coverage under the scheme would be provided for BPL workers and their families [up to a unit of five). The cost of smart card will be borne by the Central Government. Contribution by respective State Governments: 25% of the annual premium. Transportation charges are also covered up to a maximum of Rs. To this end. they shall be eligible for a separate card. 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. 7 Funding Pattern : Funding Pattern The beneficiary would pay Rs.
HOUSEHOLD ELIGIBILITY CRITERIA : HOUSEHOLD ELIGIBILITY CRITERIA The data would be provided in the prescribed electronic format to the insurer. However. Government/Nodal Agency and smart card vender can complete the task in scheduled time. 14 ENROLMENT OF BENEFICIARIES: ENROLMENT OF BENEFICIARIES 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. if required. 16 ENROLMENT OF BENEFICIARIES: ENROLMENT OF BENEFICIARIES (c) The Insurer will arrange for preparation of the smart card as per the prescribed stipulation. 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. (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. 17 . (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. The State Governments may. 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. (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. seek the assistance of an outside agency for the task of data entry. 13 ENROLMENT OF BENEFICIARIES: ENROLMENT OF BENEFICIARIES 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. 15 ENROLMENT OF BENEFICIARIES: ENROLMENT OF BENEFICIARIES 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.
23 How does the Government ensure that the correct beneficiary is getting the Smart card?: How does the Government ensure that the correct beneficiary is getting the Smart card? Each enrolment team in the villages is accompanied by a Field Key Officer (FKO) who identifies the beneficiaries at the time of enrollment. 24 . Without FKO’s authentication the smart card with the beneficiary will not work. enrolment and issuance of smart card. 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. 18 Smart Card Registration Process: Smart Card Registration Process 19 RSBY CARD RSBY CARD Slide 20: Thumb Impression of all members Photograph of the Head of the Family KFO Confirmation Enrolment 20 Slide 21: 21 SMART CARD: SMART CARD 22 ENROLMENT OF BENEFICIARIES: ENROLMENT OF BENEFICIARIES (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. (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 OF BENEFICIARIES: ENROLMENT OF BENEFICIARIES (f) List of BPL should be posted prominently in the enrolment station/village by the Insurer.
(d) Cashless coverage of all health services in the insured package. RSBY mandates the presence of FKOs at the enrollment station for the enrollment process. subject to minimal exclusions. as well as agreed daycare procedures not requiring hospitalization. 27 HEALTH SERVICES BENEFIT PACKAGE: HEALTH SERVICES BENEFIT PACKAGE (b) Pre-existing conditions to be covered. 25 FKOs: FKOs FKOs are representative of the Government. have been given the role of FKO by different State Governments. (f) Provision for reasonable pre and post-hospitalization expenses for one day prior and 5 days after hospitalization.30. 29 HEALTH SERVICES BENEFIT PACKAGE: .How does the Government ensure that the correct beneficiary is getting the Smart card?: How does the Government ensure that the correct beneficiary is getting the Smart card? 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.000 per BPL family per annum on a family floater basis. However. 28 HEALTH SERVICES BENEFIT PACKAGE: HEALTH SERVICES BENEFIT PACKAGE (e) Provision for a smart-card based system of beneficiary identification/verification and point of service processing of client transactions. An indicative list of exclusions is provided in Annexure II. 26 HEALTH SERVICES BENEFIT PACKAGE: HEALTH SERVICES BENEFIT PACKAGE 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). For example Health Workers. They can be different entities in different districts. Annexure-III contains an indicative list of daycare treatment. etc. but subject to a maximum share of the total costs of the hospitalization. (c) Coverage of health services related to hospitalization and services of a surgical nature which can be provided on a daycare basis. Gram Vikas Adhikaris Patwaris. the following minimum features of the health insurance plan would be as follows : (a) Total sum insured of Rs.
35 FORMULATION OF THE PROJECTS: FORMULATION OF THE PROJECTS The organization should have the technical skills to understand the concept of health insurance. a Cooperative Society or even an NGO. In districts where the Scheme is introduced. 30 Slide 31: How To Use Card RSBY COUNTER Process Card Verifies Thumb Impression Check Limit and issue Slip Advise Hospitalization After Treatment Again Thumb Impression is Taken and updated in System Patient Go To Hospital Shows Card Go To Doctor 31 Slide 32: Process Overview 32 IMPLEMENTATION SCHEDULE : IMPLEMENTATION SCHEDULE The scheme will be implemented by the State Government in a phased manner in the next five years. should be able to design a programme that is technically sound. 33 FORMULATION OF THE PROJECTS: FORMULATION OF THE PROJECTS The State Government shall formulate project/projects for providing health insurance benefits. States should specify in detail the proposed package of health services to be covered under the Scheme. It can be an autonomous body. the following aspects may be considered: 34 FORMULATION OF THE PROJECTS: FORMULATION OF THE PROJECTS There must be a clearly defined institution capable of organizing a health insurance programme. In addition to the above minimum.1000. for the workers and their families in the unorganized sectors for a defined geographical area. While formulating the project/projects. in their proposals. preferably a district. should have .HEALTH SERVICES BENEFIT PACKAGE (g) Provision for transport allowance (actual with limit of Rs.100 per visit) but subject to an annual ceiling of Rs. as well as the proposed exclusions. State Government Department. The entire country will be covered by 2012-13. taking into account the aforementioned points. it would supercede the Universal Health Insurance Scheme (UHIS).
37 FORMULATION OF THE PROJECTS: FORMULATION OF THE PROJECTS The cost of the scheme. i. The expert would be hired on contract basis or on deputation. 38 SETTING UP OF TECHNICAL CELL: : SETTING UP OF TECHNICAL CELL: A Cell would be constituted in the Ministry. b) Workout financial implication and other details. The procedure for collecting the registration/renewal fee from the beneficiary should be outlined in the proposal. 39 SETTING UP OF TECHNICAL CELL: : SETTING UP OF TECHNICAL CELL: The Cell would perform following functions: a) Plan the insurance scheme based on the requirements of State. total premium per year.. 41 REQUIREMENT OF TENDER TO SELECT INSURANCE PROVIDER : REQUIREMENT OF TENDER TO SELECT INSURANCE PROVIDER 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 Project should incorporate use of private and all public healthcare providers. 36 FORMULATION OF THE PROJECTS: FORMULATION OF THE PROJECTS There must be a network of health care providers (public and private). along with the procedure adopted to arrive at the premium. The tender . 40 SETTING UP OF TECHNICAL CELL: : SETTING UP OF TECHNICAL CELL: c) Assist the State Governments in the preparation of pilot projects d) Assist in the effective implementation of the Scheme. There should be some basic data available regarding the demographic profile of the District. Advisor who would be assisted by two Advisors.skills to be able to discuss with the community and should have the administrative capacity to organize the programme. The proposal for launching health insurance project would be submitted to the Administrative Ministry for approval along with all the financial implications and details. including ESI hospitals. administering the scheme.e. e) Monitor and evaluate the implementation of the project. to assist the State Governments in formulating projects. The Cell would be headed by a Sr.
District and Block level overseeing bodies. 45 SUBMISSION AND APPROVAL OF THE PROPOSAL : SUBMISSION AND APPROVAL OF THE PROPOSAL The proposals of the State Governments will be considered by the Approval and Monitoring Committee set up by the Central Government. Ministry of Labour & Employment Convener ii) Representatives of Ministry of Finance Member 44 APPROVAL AND MONITORING COMMITTEE: : APPROVAL AND MONITORING COMMITTEE: 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. 47 SUBMISSION AND APPROVAL OF THE PROPOSAL : .g. the State should provide for performance indicators or other mechanisms to extend the contract annually. 42 REQUIREMENT OF TENDER TO SELECT INSURANCE PROVIDER : REQUIREMENT OF TENDER TO SELECT INSURANCE PROVIDER If the period of the contract with the successful bidder exceeds one year. Representatives of civil society. including Panchayati Raj institutions. (c) Status of BPL data and its conformity with the prescribed standards.should be open to both public and private sector health insurers who meet the relevant IRDA (The Insurance Regulatory Development Authority) standards. estimates of BPL population in covered districts. should be adequately represented on relevant State. district and block monitoring bodies). The elements that States would need to address in their proposals include the following: (a) Tendering and contracting procedure for insurer/partners. 43 APPROVAL AND MONITORING COMMITTEE: : APPROVAL AND MONITORING COMMITTEE: 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. 46 SUBMISSION AND APPROVAL OF THE PROPOSAL : SUBMISSION AND APPROVAL OF THE PROPOSAL (b) Overseeing arrangements (e.
48 SUBMISSION AND APPROVAL OF THE PROPOSAL : SUBMISSION AND APPROVAL OF THE PROPOSAL (g) Empanelment/accreditation of health providers. Role of intermediaries/NGOs/Cooperatives therein. (m) How the proposed Scheme would interact with any existing health insurance schemes in the proposed district(s). the State Government will. the Government of India shall undertake the following actions in order to operationalize the Health Insurance scheme: (a) Issuance and periodic revision of guidelines for the Scheme. intimate the Central Government about the payment of the premium to the Insurance Company.SUBMISSION AND APPROVAL OF THE PROPOSAL (d) Training plan of State Government. (f) Enrollment and renewal procedures. 52 RESPONSIBILITIES OF GOVERNMENT OF INDIA: RESPONSIBILITIES OF GOVERNMENT OF INDIA In addition to its financing commitment. on receipt of this information. 51 RELEASE OF FUNDS: : RELEASE OF FUNDS: On the approval of the project. (e) IEC/awareness raising mechanisms (start-up and ongoing). 50 SUBMISSION AND APPROVAL OF THE PROPOSAL : SUBMISSION AND APPROVAL OF THE PROPOSAL The Central Government Approval and Monitoring Committee would assess all State Government proposals to ensure that credible implementation arrangements were in place for all of the above. (b) Establishment of an Approval . (k) Grievance redressal mechanisms. insurers and others to ensure adequate capacity for Scheme implementation. from time to time. including identification of beneficiaries. including collection of data on patients/providers and its use. including any special/extra channels for harder-to-reach groups. including provision for baseline survey(s). An indicative list of requirements is provided in Annexure IV. (i) MIS and database management. shall release its share of premium. The Central Government. 49 SUBMISSION AND APPROVAL OF THE PROPOSAL : SUBMISSION AND APPROVAL OF THE PROPOSAL (j) Evaluation of impact and performance. (l) Financing plan for State Government premium contributions and other administrative expenses to be incurred in Scheme operation. including minimum requirements for health facilities to be included in the Scheme and administrative capacity. (h) Process for smart card provision and operation.
implementation and monitoring/evaluation of the Scheme. support staff. database management team. who would be assisted by two Advisors. 54 RESPONSIBILITIES OF GOVERNMENT OF INDIA: RESPONSIBILITIES OF GOVERNMENT OF INDIA This would include determination of the protocol for nationally unique identification numbers for BPL families. and such other expert personnel as determined from time to time to be necessary to support effective implementation of the Scheme.and Monitoring Committee to assess health insurance proposals submitted by State Governments for Government of India financing contribution. 56 RESPONSIBILITIES OF GOVERNMENT OF INDIA: RESPONSIBILITIES OF GOVERNMENT OF INDIA The Cell would be headed by a Senior Advisor. 58 RESPONSIBILITIES OF GOVERNMENT OF INDIA: . specification of the minimal technical standards of the smart card. establishment of common reporting protocols for States as part of scheme monitoring and such other design and implementation issues considered necessary for the functioning of a coherent national system. 57 RESPONSIBILITIES OF GOVERNMENT OF INDIA: RESPONSIBILITIES OF GOVERNMENT OF INDIA The Cell would carry out the following functions: i. Provide technical support to States in development of health insurance schemes for submission to the Central Government. development of such protocols and common standards as may be necessary to ensure effective functioning of the Scheme on a national basis. ensuring timely transfer of the Central financing share of insurance premium. 53 RESPONSIBILITIES OF GOVERNMENT OF INDIA: RESPONSIBILITIES OF GOVERNMENT OF INDIA c) In consultation with the States. 55 RESPONSIBILITIES OF GOVERNMENT OF INDIA: RESPONSIBILITIES OF GOVERNMENT OF INDIA (d) Establishment of a Technical Support Cell within the Ministry of Labour and Employment which would provide expert inputs to Central and State Governments on matters pertaining to the design.
RESPONSIBILITIES OF GOVERNMENT OF INDIA ii. (c) Other basic infrastructure necessary to ensure successful implementation of the Scheme (e. 60 DISTRICT SELECTION BY STATES: DISTRICT SELECTION BY STATES States would be responsible for proposing selected district(s) for inclusion in the Scheme. 63 MONITORING AND EVALUATION: : MONITORING AND EVALUATION: The State Government will put in place a well defined mechanism for monitoring and evaluation of the pilot project at the time of its implementation. 59 RESPONSIBILITIES OF GOVERNMENT OF INDIA: RESPONSIBILITIES OF GOVERNMENT OF INDIA iv. subject to such requirements for empanelment as agreed to between the State Government and insurers. roads). Provide the Approval and Monitoring Committee with such financial estimates as may be necessary to assess the budgetary implications of both Central and State Government commitments under the Scheme. including monitoring and evaluation. In proposing districts for inclusion in the Scheme. electricity. iii. subject to the phased maximum number of districts per State as outlined in Annexure I. 61 DISTRICT SELECTION BY STATES: DISTRICT SELECTION BY STATES (b) Adequate presence of potential intermediaries which can partner with health insurers to ensure effective outreach and grassroots support to beneficiaries in various aspects of operation of the Scheme. At the Central Government level. Undertake and/or commission detailed evaluation studies on Scheme functioning. Provide ongoing support to State Governments (coordinating with similar Cells at State level) on technical issues in implementation of the Scheme in individual States.g. Provide technical inputs to the Approval and Monitoring Committee which will allow it to carry out its monitoring and evaluation functions effectively. v. 62 ELIGIBLE HEALTH SERVICES PROVIDERS: ELIGIBLE HEALTH SERVICES PROVIDERS Both public (including ESI) and private health providers which provide hospitalization and/or daycare services would be eligible for inclusion under the insurance scheme. States should ascertain that districts have: (a) An adequate network of hospitals/health facilities which meets minimum standards for service delivery and operation of transactions related to the Scheme. the Cell constituted for examining project proposals shall also periodically monitor and .
A separate set of pre-formatted tables are generated for the insurer and for the government respectively. 66 Nodal Agency GUJARAT : Nodal Agency GUJARAT Nodal Agency Name : Deptt.com 67 Gujrat / Tapi Report Updated On: 5.2010 Family Enrolled India 14.Patel Designation : Add. This allows the insurer to track claims. Dir. Family Welfare Fax : 07923253311 Tel. : 07923253311 E-mail ID : rsbygujarat@gmail. (Rigorous M&E methods are being designed and may be supported by the World Bank. No.evaluate the performance of each pilot project with a view to evolving workable models which can be upscaled for wider application.) Periodic reports would be made publicly available on the internet and through published reports.2009 To 31. 64 How the transactions at the Hospitals would be monitored? : How the transactions at the Hospitals would be monitored? Information on the transactions that take place each day at each hospital is uploaded through a phone line to a database on a district server.3. 65 How the transactions at the Hospitals would be monitored? : How the transactions at the Hospitals would be monitored? Governments are able to monitor utilization of the program by members and to some extent.3. begin to measure the impact of the program.4.900 as on 7/04/2010 68 Slide 69: 6/25/2011 Dr Muhammedirfan 69 THANK YOU THANK YOU 3/3 .00 Period of Policy From :1.K.008.2010 Total BPL Family : 76145 Family Enrolled : 54548 Number of hospitalization : 5408 Hospitalization Value (Rs.4.) : 16693700.2010 : Gujrat / Tapi Report Updated On: 5. B. transfer funds to the hospitals and investigate in the case of suspicious claim patterns through on-site audits.Of Health & Family Welfare Nodal Officer : Dr.