When Union Finance Minister Arun Jaitley announced the “Ayushman Bharat Health Protection Mission” in Budget 2018 in February, he termed it as the “world’s largest government funded health care programme”. The scheme is scheduled to be launched on August 15 on the occasion of the Independence Day and the Centre has released the model tender documents for its new health insurance scheme. A staggering 10.74 crore families will be covered under this scheme.
Criteria for getting covered
Rs 5 lakh will be given to Rs 10.74 crore families under Ayushman Bharat-National Health Protection Mission (AB-NHPM) or Pradhan Mantri Rashtriya Swasthya Suraksha Mission. Beneficiaries will be selected as per the Socio Economic Caste Census (SECC) data of 2011. The right beneficiaries will be selected from deprivation and automatic inclusion criteria in rural areas, and defined occupational categories in urban areas. All pre-existing conditions will be covered. However, there will be minimal exclusions for pre- and post-surgical conditions, according to Indian Express report.
Initially, beneficiaries will be identified through their mobile numbers and later by a unique ID. “The mobile numbers of all the 10.74 crore NHPM beneficiaries will be seeded in the system. That will be their identification number for the purposes of NHPM. Obviously, they will have to show some identification document,” a senior official said. Beneficiaries of the existing Rashtriya Swasthya Bima Yojana for migrant labourers will be automatically included, with their cover enhanced from Rs 30,000. There is no cap on family size.
A CEO will head the National Health Agency and it be the nodal agency for implementation. States and Union Territories will devise their own modes of implementation. FM Jaitley during his budget speech in the Parliament said adequate funds will be provided for smooth implementation of this programme. According to a report, funding will differ from state to state. Funding will be shared at a 60:40 ratio for most states. Apart from this, Northeast states, Jammu and Kashmir, Himachal Pradesh and Uttarakhand will enjoy 90:10 fund sharing formula. There will be full central funding for UTs without a legislature.
States which are participating
According to Indian Express report, states like Andhra Pradesh, Telengana, MP, Assam, Sikkim and Chandigarh have opted for using a trust model. Gujarat and Tamil Nadu will use “mixed mode implementation”. In a trust model, bills are reimbursed directly by the government. In an insurance model, the government pays a fixed premium to an insurance company, which pays the hospitals. Bihar and Uttar Pradesh have, in principle, said they will be part of the scheme and will implement it through a trust. However, officials in the Ayushman Bharat Secretariat are uncertain about West Bengal, Delhi, Odisha, Punjab and Karnataka.
The Niti Aayog had initially estimated premium per family per year at Rs 1,082 but this was rejected as too little by insurance companies in early consultations. Estimates have “rationalised” since then but the new tender has come with a catch. States have been divided into two categories, with different administrative costs allowed based on claim ratio (the percentage of insured people who have claimed reimbursement in a given year). The document lays down that for a claim ratio up to 120%, states will not pay any additional premium. Beyond 120%, the state will pay 50% of the additional premium. The rest will have to be borne by insurance companies, according to a report by The Indian Express.