Finally, the government has unveiled the proposed rates for over 1,354 treatment packages, ranging from Rs1,000 to over Rs1.50 lakh, for the Pradhan Mantri Rashtriya Swasthya Suraksha Mission that will be managing National Health Protection Scheme(NHPS) promising up to Rs 5 lakh cover for 10 crore poor families in the country.
The health insurance scheme aims to cover nearly 50 crore beneficiaries from over 10.74 crore “deprived” families as per socio-economic and caste census (SECC) data with an annual health cover of Rs 5 lakh per family per year. This cover will take care of almost all secondary care and most tertiary care procedures. There is no cap on family size and age in the scheme, ensuring that nobody is left out.
The government issued a 205-page draft Model Tender document on Wednesday. The document is expected to help States select insurance companies for the scheme.
The basic risk cover includes hospitalisation expenses such as registration, nursing and boarding charges in general ward. Besides, consultation fees, surgical equipment and procedure charges and cost of implants, medicines, diagnostic tests and food to patients are also covered. The scheme also covers follow-up care along with pre- and post-hospitalisation expenses.
The packages include 23 specialties such as cardiology, ophthalmology, orthopaedics, urology and oncology, etc, an official said.
Around 610 of the 1,354 packages listed would be mandated for pre-authorisation by the insurance company, according to the draft.
The registration process for hospitals are expected to begin by June 15, while the States will be in charge of the bidding process for insurance companies in a couple of weeks,” said Indu Bhushan, chief executive of Ayushman Bharat adding that the scheme will be ready for a roll-out by August.
For instance, the rate for an orthopaedic procedure like application of skin traction has been set at Rs1,000, while aortic arch replacement under cardio thoracic surgery would be Rs 1.60 lakh.
For instance, the rate for vertebral angioplasty with single stent has been fixed at Rs 50,000, whereas that with double stent will cost Rs 65,000. Similarly, the price for total knee replacement is fixed at Rs 80,000, whereas a C-section will be charged at Rs 9,000. The list also includes paediatric surgeries, different packages for cancer treatment as well as mental disorders.
The insurer is not liable to make any payments under the policy for expenses incurred in conditions that do not require hospitalisation, congenital external diseases, fertility-related procedures, vaccinations, suicide and persistent vegetative state.
Bhushan said CGHS and Rashtriya Swasthya Bima Yojana (RSBY) rates have been used as reference prices for fixing the rates under the scheme.
The rates under the new scheme are on an average 15-20% lower than that of CGHS, he said
“Hospitals accredited by the National Accreditation Board for Hospitals and HealthcareProviders (NABH) will be allowed to charge 10-15% more than the rates set in this document, said Bhushan.
Lower prices mean beneficiaries of the scheme will be able to opt for more number of procedures under the cover if required or can even enrol more family members for treatment.
Bhushan said the scheme also entails added incentives for private hospitals, especially those providing quality services. “If a hospital is certified by NABH for entry level, it can get 10% more, whereas those certified for advanced level will get 15% more as incentive. Besides, we also want to give advantage to hospitals in lagging areas and such hospitals will get an additional 10%,” he said.
Bhushan said IT infrastructure is the backbone of the scheme and currently the ministry is working to put that in place so that hospitals and providers from across the country can be brought on the platform. The IT platform, to be launched by July, has been modelled on the existing health insurance portal for Telangana.
“These (guidelines) are only indicative. States have been given the flexibility to look at them and they may make some changes,” he said.
In case of multiple surgeries, the highest package rate will be waived for the first treatment, and 50% and 25% of the package rate will be provided for the second and third treatment. The rest will be borne by the policy holder.