TAMIL NADU

STATE HIGHLIGHTS
• Name of Scheme in the State: Pradhan Mantri Jan Arogya Yojana-Chief Minister's Comprehensive

Health Insurance Scheme (PMJAY-CMCHIS)

• Name of the State Health Agency: Tamil Nadu Health System Project (TNHSP)

• Mode of Implementation: Hybrid

• Date of Roll-Out of Scheme: 23/09/2018

• Families with E-Cards: 6683175

• Empanelled Hospitals: 2563

ROBUST MECHANISM FOR FRAUD DETECTION AND PREVENTION

Thematic Area/Division: Fraud Detection

Tamil Nadu has the distinction of establishing multifaceted fraud detection and prevention mechanisms evolved over the
years as a result of continuous monitoring. Several checks have been developed in each of the processes for accessing
and using the benefit under the scheme.

Enrolment captures biometrics to avoid identity theft / duplication. The insurance co-ordinators / Arogya
Mithras ensure that only an eligible beneficiary with valid ID can utilise the scheme and it is cross-verified by
a non-medical validation team. The medical officers scrutinise relevant records and if suspicion arises, the
case is referred to the medical vigilance team who collect necessary records from the field and verify the
particular claim from the District Medical Officers and give their recommendations. The vigilance team
collects inputs from the district vigilance officers, comprising ex-policemen of the state not below the rank of
sub-inspector. The district project officer and the district co-ordinators make periodical visits to the hospitals
and verify the beneficiaries. Hospital audits are conducted periodically including infrastructure, IP / OP
registers / pharmacy stock registers / pathology / lab registers, hospital bills, IP (beneficiary interviews).
Beneficiary follow-ups and reviews as well as call audits are also conducted.

The software triggers and the MIS team raise flags on repeated admission, prolonged stay by the same
hospital, sudden surge in any case in certain districts overlapping without camps in adjacent area, irrelevant
consultant operating / treating a beneficiary, etc., along with periodical analytics. The medical audit team
conducts organised audits based on the inputs from all the above teams verifying both concurrently and
retrospectively and provides reports apart from scrutinising mortality and morbidity cases.

41
CORPUS FUND FOR HIGH-END PROCEDURES
Thematic Area Division: Treatment of Beneficiaries

Transplantation procedures such as renal transplantation, liver transplantation, bone marrow / stem cell transplantation,
lung transplantation, heart transplantation and combined heart, lung transplantation, etc., are provided to the beneficiaries
from a corpus fund.

In addition to the sum insured to carry out high-end procedures such as transplants, a fund worth Rs 10 crore as seed
money was set up for CMCHIS beneficiaries. A proportion of the revenue generated by the government institutions
would be pooled into this fund for further sustenance. Over a period, few uncovered lifesaving procedures were covered
from this fund based on specific recommendations from experts and through appropriate government orders.

Transplantation procedures such as renal transplant, liver transplant, bone marrow / stem cell transplant, lung trans-
plant, heart transplant and combined heart and lung transplant are included. For congenital deafness due to structural
abnormalities, cochlear implant and auditory brain stem implant is also provided under the scheme. The cost in addition
to the sum insured is borne by the SHA from this corpus fund. All high-end procedures are sanctioned by a committee
of experts who meet once a month and after due medical verification process, authorise procedures under the scheme.

COVID-19 BEST PRACTICES

Thematic Area: COVID-19

Test and treatment charges in private health facility for COVID-19 were capped in Tamil Nadu. Details of bed occupancy
were also made available on the public portal for ease of access.

The Government of Tamil Nadu initiated coverage of COVID-19 under the AB PM-JAY-CMCHIS from June 5, 2020 along
with treatment charge capping in private hospitals. RT-PCR testing has also been brought under CMCHIS since April
2020 at a cost of Rs 2,500 per test, which was one of the lowest in the country. The charges were further revised to Rs
1,500 in July 2020. Furthermore, hospitals empanelled across the state were identified to treat COVID-19 and were
categorised based on the infrastructure available. Details of bed occupancy were also made available on the public portal
for ease of access. A COVID-19 control room was established to facilitate all matters related to the pandemic. Additionally,
the following initiatives were taken to ease the burden to beneficiries during
COVID-19 lockdown: � Cashless COVID-19 RT-PCR tests and treatment
under AB PM-JAY-CMCHIS � COVID-19 treatment package designing �
RTPCR Labs under AB PM-JAY-CMCHIS � Utilising 102 Ambulance for
Haemodialysis/RT-CT patient pick-up drops and for doorstep delivery of
follow-up medicines � Reserving COVID Beds, ICU and Ventilators in
empanelled private hospitals � Couriering oral chemotherapy drugs
and immunosuppressants to eligible beneficiaries � Chelation thera-
py and transfusion for thalassemia was provided for patients who were
treated in Chennai at local facilities under the scheme � Waiver of
photographs for individual dialysis sessions with insurance coordina-
tors and ward managers limiting exposure to patients as well as staff.

42