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Active Smart Cards

36,332,475


Total Hospitalisation Cases

14,084,587

as on date: 31/03/17
About the Scheme
How it Works
RSBY involves a set of complex and inter-related activities. These activities are shown in the form of a flow chart. The broad sets of activities are given as follows:
Insurance agencies selection
State Governments through a competitive public bidding process selects a public or private insurance company licensed to provide health insurance by the Insurance Regulatory Development Authority (IRDA) or enabled by a Central legislation. All the bids which are technically qualified go to the financial evaluation stage. The insurer with the lowest financial bid is then selected for providing health insurance in the state for a particular district/ cluster of districts. The financial bid is essentially an annual premium per enrolled beneficiary family. The insurer must agree to cover the benefit package prescribed by GOI through a cashless facility that in turn requires the use of smart cards which conform to certain specifications and must be issued to all beneficiary family.
Each contract is specified on the basis of an individual district in a state and the insurer agrees to set up an office in each district. However it is pertinent to note that more than one insurer can operate in a particular state, and only one insurer can operate in a single district at any given point in time.
Hospital empanelment
After the insurance company is selected, they need to empanel both public and private health care providers in the project and nearby districts. The empanelment of the hospitals is done based on prescribed criteria. Empanelment of hospitals shall be done as soon as the insurer gets the contract and it can continue simultaneously with the enrolment of the beneficiaries. The insurer shall empanel enough hospitals in the district so that beneficiaries need not travel very far to get the health care services. For empanelment of the public hospitals, the insurer needs to coordinate with respective health department of the state.
These hospitals should install necessary hardware and software so that smart card transactions can be processed. They should also set up a special RSBY desk with a trained staff. The hospital list should allow for both public and private hospitals who agree to participate. The insurer must also provide a list of RSBY empanelled hospitals, to the beneficiaries at the time of enrolment. This list can be revised at periodic intervals as more and more hospitals are added in the list. When empanelment takes place, a nationally unique hospital ID number is generated so that transactions can be tracked at each hospital.
Preparation of Beneficiary data
RSBY provides health insurance for the enrolled BPL and other defined category of families from each district. For BPL families, Central Government subsidy is provided up to a maximum number of households based on the definition and the figures provided for each state by the Planning Commission. State Government must prepare and submit the beneficiary data in an electronic format specified by Government of India. The format requires details of all the family members including name, father or husband’s name for the head of household, age, gender and relationship with the head of household. Respective State Governments need to convert their existing beneficiary data in this format for each district and send these data to Government of India which in turn checks the compatibility of this data with the standard format and allocates the Unique Reference Number (URN) for each family. However, state governments alone are responsible for the accuracy of their beneficiary lists. Preparation of beneficiary data in the specified format is necessary for implementing the scheme in the district.
Enrolment process
After procuring beneficiary daAfter procuring beneficiary data from the district authorities, data is provided to GOI and then each beneficiary family is allotted one URN number. This data is then downloaded by the insurance company selected through competitive bidding. The selected Insurance Company prepares enrolment plan in consultation with district authorities and enrols the listed families at village level enrolment camps as per plan. At enrolment stations, one photograph of HOF, one photograph of the family and finger print of each of five members of a listed beneficiary household gets captured through enrolment kit consisted of a laptop, smart card printer, thumb reader and a camera. Beneficiary smartcard gets printed then and there at enrolment site and handed over to the family after collecting registration fee of Rs. 30/- per card. Prior hand publicity is carried out by the Insurance Company as well as district functionaries to reach out to the families for ensuring maximum enrolments.
How Services are availed by the Beneficiary
The transaction process begins when the beneficiary visits the participating hospital. After reaching the hospital, beneficiary will visit the RSBY help desk at hospital where his identity will be verified by his photograph and fingerprints which are stored on his/her smart card.
If a diagnosis leads to a hospitalization, the assistant at the help desk checks whether the procedure is in the list of pre-specified packages. If the procedure is in the list, the  appropriate prescribed package is selected from the menu. If the procedure is not in the package list, the help desk assistant takes the pre-authorization with the insurer regarding the line of treatment and pricing. Upon release of the beneficiary from the hospital, the card is again swiped along with finger print verification and the pre-specified cost of the procedure is deducted from the amount available on the card. The beneficiary is also paid by the hospital Rs. 100 as transportation expense at the time of the discharge. However, total transportation assistance cannot exceed Rs. 1000/- per year. No proof is required to be submitted by the beneficiary to get the transportation assistance.
Claim settlements
After rendering the service to the patient, the hospitals need to send an electronic hospitalisation and claims data to the insurer/ Third Party Administrator (TPA). A copy of this data is also transferred simultaneously to the server of Government. The hospitals in a District will be expected to intimate the claims, whether online or offline, to Insurance Companies, within the 24 hours, regularly. Any delay beyond this stipulated period and upto 30 days of transaction will have to be explained by the concerned Hospital. The Insurer/ TPA after going through the records information will make the payment to the hospital within a month of the receipt of claims.
Financing of the scheme
RSBY being a centrally sponsored scheme, sharing pattern of the funding between Central Government & State Government is 75%:25% respectively. However this sharing pattern changes to 90%:10% in case of North Eastern States and Jammu & Kashmir. The beneficiary has to pay a fee of Rs. 30/- every year at the time of enrolment. Apart from this, the Central Government also pays the cost of smart card which is Rs. 60/- which is included as cost of the premium. The beneficiaries contribution of INR 30/- is used by the State Nodal Agency (SNA) to meet their administrative expenses. This Rs. 30/- is adjusted from the premium share of State Government/UT when the payment is done to the insurance company.
What is the meaning of Policy Extension
This policy is generally for a year. Beneficiaries are enrolled and given the smart card embedding the family details including biometric details through enrolment camps. This procedure is supposed to be repeated each year for the purpose of beneficiary enrolment. If fresh enrolment is not done due to some reason, the policy from previous year is extended for a period decided based on the approval from GOI. The beneficiary is not charged additionally for the extension. During the extension period, insurance company is paid on pro-rata basis. During the extension period, beneficiary would get fresh Rs. 30,000 for the defined period of extension.
Grievance Redressal management
If any stakeholder has a grievance against another one during the subsistence of the policy period or thereafter, in connection with the validity, interpretation, implementation or alleged breach of any provision of the scheme, it will be settled in the following way by the Grievance Committee:
1. Grievance of a Beneficiary

     1.1
GRIEVANCE AGAINST INSURANCE COMPANY, HOSPITAL, THEIR REPRESENTATIVES OR ANY FUNCTIONARY

If a beneficiary has a grievance on issues relating to enrolment, hospitalization or any other RSBY related issue against Insurance Company, hospital, their representatives or any functionary, the beneficiary will approach DGRC. The DGRC shall take a decision within 30 days of receiving the complaint.

If either of the parties is not satisfied with the decision, they can appeal to the SGRC within 30 days of the decision of the DGRC. The SGRC shall take a decision on the appeal within 30 days of receiving the appeal. In case of dissatisfaction with the decision of the SGRC, the affected party can file an appeal before NGRC within 30 days of the decision of the SGRC. The NGRC shall take a decision on the appeal within 30 days of the receipt of appeal after seeking a report from the other party. The decision of NGRC shall be final.

    1.2 GRIEVANCE AGAINST DKM OR OTHER DISTRICT AUTHORITIES

If the beneficiary has a grievance against the District Key Manager (DKM) or an agency of the State Government, it can approach the SGRC for resolution. The SGRC shall take a decision on the matter within 30 days of the receipt of the grievance. In case of dissatisfaction with the decision of the SGRC, the affected party can file an appeal before NGRC within 30 days of the decision of the SGRC. The NGRC shall take a decision on the appeal within 30 days of the receipt of appeal after seeking a report from the other party. The decision of NGRC shall be final.

2. Grievance of a Health Care Provider

      2.1
GRIEVANCE AGAINST BENEFICIARY, INSURANCE COMPANY, THEIR REPRESENTATIVES OR ANY OTHER FUNCTIONARY

 If a Health Care Provider has any grievance with respect to beneficiary, Insurance Company, their representatives or any other functionary, the Health Care Provider will approach the DGRC. The DGRC should be able to reach a decision within 30 days of receiving the complaint.

If either of the parties is not satisfied with the decision, they can go to the SGRC within 30 days of the decision of the DGRC, which shall take a decision within 30 days of receipt of appeal. The decision of the SGRC shall be final. In case of dissatisfaction with the decision of the SGRC, the affected party can file an appeal before NGRC within 30 days of the decision of the SGRC. The NGRC shall take a decision on the appeal within 30 days of the receipt of appeal after seeking a report from the other party. The decision of NGRC shall be final.

3. Grievance of Insurance Company

     3.1 GRIEVANCE AGAINST BENEFECIARY, HOSPITAL, THEIR REPRESENTATIVES OR ANY FUNCTIONARY

 If Insurance Company has a grievance on issues relating to hospitalization or any other RSBY related issue against beneficiary, hospital, their representatives or any functionary, the 1 Insurance Company will approach DGRC. The DGRC shall take a decision within 30 days of receiving the complaint.

If either of the parties is not satisfied with the decision, they can appeal to the SGRC within 30 days of the decision of the DGRC. The SGRC shall take a decision on the appeal within 30 days of receiving the appeal. In case of dissatisfaction with the decision of the SGRC, the affected party can file an appeal before NGRC within 30 days of the decision of the SGRC. The NGRC shall take a decision on the appeal within 30 days of the receipt of appeal after seeking a report from the other party. The decision of NGRC shall be final.

      3.2 GRIEVANCE AGAINST FKO

If an insurance company has any grievance with respect to beneficiary or Field Key Officer (FKO), it will approach the DGRC. The DGRC should take a decision within 30 days of receiving the complaint.

If either of the parties is not satisfied with the decision, they can appeal to the SGRC within 30 days of the decision of the DGRC. The SGRC shall take a decision within 30 days of receiving the appeal. The decision of the SGRC on such issues will be final.

4. GRIEVANCE AGAINST DKM OR OTHER DISTRICT AUTHORITIES

If Insurance Company has a grievance against District Key Manager or an agency of the State Government, it can approach the SGRC for resolution. The SGRC shall decide the matter within 30 days of the receipt of the grievance.

In case of dissatisfaction with the decision of the SGRC, the affected party can file an appeal before NGRC within 30 days of the decision of the SGRC and NGRC shall take a decision within thirty days of the receipt of appeal after seeking a report from the other party. The decision of NGRC shall be final.

5. Grievance of any Stakeholder

   5.1 GRIEVANCE AGAINST STATE NODAL AGENCY/STATE GOVERNMENT

Any stakeholder aggrieved with the action or the decision of the State Nodal Agency/ State Government can address his/ her grievance to the NGRC, which shall take a decision on the issue within 30 days of the receipt of the grievance. An appeal against this decision within 30 days of the decision of the NGRC can be filed before Secretary, Ministry of Health & Family Welfare (Government of India), who shall take a decision within 30 days of the receipt of the appeal. The decision of Secretary (MoH&FW) shall be final.

Note: There would be a fixed date, once a month, for addressing these grievances in their respective committees (DGRC/ SGRC).This would enable all grievances to be heard/ settled within the set time frame of 30 days.
 
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