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About the Scheme
How it Works
Success Stories
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:
| Financing for RSBY
RSBY is a Government sponsored scheme for the BPL population of India. The majority of the financing, about 75 percent, is provided by the Government of India (GOI), while the remainder is paid by the respective state government. Government of India’s contribution is 90 percent in case of North-eastern states and Jammu and Kashmir and respective state Governments need to pay only 10% of the premium.
Beneficiaries need to pay only Rs. 30 as the registration fee. This amount shall be used for incurring administrative expenses under the scheme.
| Selection of Insurance Company
State governments engage in a competitive public bidding process and select a public or private insurance company licensed to provide health insurance by the Insurance Regulatory Development Authority (IRDA) or enabled by a Central legislation. The technical bids submitted must include a number of elements as per GOI requirements. 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/ set of districts. The financial bid is essentially an annual premium per enrolled household. 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 members.
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. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time.
| Preparation of BPL Data
RSBY provides health insurance for the enrolled BPL families from each district up to a maximum number of households based on the definition and the figures provided for each state by the union Planning Commission. State Government must prepare and submit the BPL 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 BPL 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. However, state governments alone are responsible for the accuracy of their BPL lists. Preparation of BPL data in the specified format is necessary for implementing the scheme in the district.
| Enrollment of Beneficiaries
An electronic list of eligible BPL households is provided to the insurer using a pre-specified data format. An enrollment schedule for each village, along with dates, is prepared by the insurance company with the help of the district level officials. As per the schedule, the BPL list is posted in each village at enrollment station and prominent places prior to the enrollment and the date and location of the enrolment in the village is publicized in advance. Mobile enrollment stations are set up at local centers (e.g., public schools) at each village. These stations are equipped by the insurer with the hardware required to collect biometric information (fingerprints) and photographs of the members of the household covered and a printer to print smart cards with a photo. The smart card, along with an information pamphlet describing the scheme and the list of hospitals, is provided on the spot once the beneficiary has paid the 30 rupee fee. The process normally takes less than ten minutes. The cards are handed over in a plastic cover.
A government officer (called Field Key Officer – FKO) needs to be present and must insert his/ her own, government-issued smart card to verify the legitimacy of the enrolment. (In this way, each enrollee can be tracked to a particular state government official). In addition to the FKO, an insurance company representative/ smart card agency representative must be present. At the end of the each day of enrolment, the list of households which have been issued smart cards is sent to the state nodal agency. This list of enrolled households is maintained centrally and is the basis for financial transfers from the Government of India to the state governments.
RSBY has a provision whereby an insurer has to hire intermediaries (e.g. NGOs, MFIs, etc.) to provide grassroots outreach and assist members in utilizing the services after enrollment.
| Empanelment of Health Care Providers
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 enrollment of the beneficiaries. The insurer shall empanel enough hospitals in the district so that beneficiaries need not travel very far to get the heath 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 enrollment. 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.
| Utilisation of Services by Beneficiaries
The transaction process begins when the member 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 checks with the insurer regarding the price for that procedure. 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 and it is part of Rs. 30,000/- coverage. No proof is required to be submitted by the beneficiary to get the transportation assistance.
| Claim Settlement
After rendering the service to the patient, the hospitals need to send an electronic report to the insurer/ Third Party Administrator (TPA). The Insurer/ TPA after going through the records information will make the payment to the hospital within a specified time period which has been agreed between the Insurer and the hospital.
| Portability of Smart Card
On receipt of the smart card and consequent to the commencement of the policy, the beneficiary shall be able to use health service facilities in any of the RSBY empanelled hospital across India. Any hospital which is empanelled under RSBY by any insurance company will provide cashless treatment to the beneficiary.
| Monitoring and Evaluation
Information relating to transactions that take place each day at each hospital is sent through a phone line to a district server. A separate set of pre-formatted tables are generated for the insurer and for the government respectively. This allows the insurer to track claims, transfer funds to the hospitals and investigate in the case of suspicious claim patterns through on-site audits.