Tuesday, July 22, 2008


Modern medicine, with its advancement in technology has made rapid strides in diagnosis and treatment of many a complicated disease, hitherto unattended thus reducing the morbidity and mortality enormously and improving quality of life. While advent of non-invasive diagnostic tools like CT Scan, MRI, Ultra Sound and radio isotope studies made diagnosis of disease more specific, the latest gadgets such as video endoscopes, laproscope etc. made treatment and surgical procedures less cumbersome and simple.
Hence there is a felt need in the State to provide medical assistance to families living below poverty line for the treatment of serious ailments such as cancer, kidney failure, heart and neurosurgical diseases etc., requiring hospitalization and surgery. Available network of government hospitals do not have the requisite equipment or the facility or the specialist pool of doctors to meet the state wide requirement for the treatment of such diseases. Large proportions of people, especially below poverty line borrow money or sell assets to pay for hospitalization. Presently many people suffering from such diseases are approaching the Government to provide financial assistance to meet hospitalization expenses for surgical procedures.During the period from 14.05.2004 to 26.06.2007, financial assistance to a tune of Rs. 168.52 crores has been provided from CM's Relief Fund in 55361 cases to meet hospitalization expenses for such people. From the experience gained, it is now felt that the assistance could be institutionalized so that its benefit can be accessed by poor people across the State easily and in a trouble free manner. Health Insurance could be a way of removing the financial barriers and improving access of poor to quality medical care; of providing financial protection against high medical expenses; and negotiating with the providers for better quality care.
In order to operate the scheme professionally in a cost effective manner, public private partnership will be promoted between the Insurance Company / TPA, the private sector hospitals and the State agencies. Aarogyasri Health Care Trust recently setup by the State Government for the implementation of the Scheme will assist the insurance company / TPA / Beneficiaries and coordinate with Medical and Health Deptt., District Collectors, Civil Supplies Department etc.
Salient Features of the Scheme proposed for implementation in the 5 districts of Chittoor, East Godavari, Nalgonda, Ranga Reddy and West Godavari
Name : The name of the scheme is Rajiv Aarogyasri Community Health Insurance Scheme.
To improve access of BPL families to quality medical care for treatment of identified diseases involving hospitalization, surgery and therapies, through an identified network of health care providers. The scheme would provide coverage for the following system
Cancer treatment
Chemo Therapy
Radio Therapy
Renal diseases
Poly trauma cases (not covered by the Motor Vehicles Act)
Cochlear Implant Surgery with Auditory-Verbal Therapy for Children below 6 years (only services will be provided by the Insurance Company and costs to be reimbursed by the Trust on case to case basis.)
The scheme is intended to benefit below poverty line (BPL) population in the 5 districts of the State viz. West Godavari, East Godavari, Nalgonda, Ranga Reddy and Chittoor. There are 48.23 lakhs BPL families in the five districts comprising of a population of 1.68 crores. Database and photograph of these families will be available in Health Cards to be issued by the Trust based on the BPL ration card issued by the Civil Supplies Department. District wise profile of the BPL families is given below:
No of Mandals
No. Of. Municipalities
BPL Cards
BPL population
East Godavari
9 12,21,143
West Godavari
Such of the Health Card holders who are covered for the specified diseases by other insurance scheme such as CGHS, ESIS, Railway, RTC etc., will not be eligible for any benefit under the scheme
Health Cards:
All eligible families in the proposed districts will be provided with Rajiv Aarogyasri Bhima Health Cards.These health cards are issued based on BPL ration card data. These Health Cards/BPL ration cards will be basis for identification of Beneficiary under the scheme.
Means head of the family, spouse, dependent children and dependent parents as enumerated and photographed on the Rajiv Aarogyasri Health Card/ BPL card. The photograph indicated in the Health Card/ BPL card will be taken as the proof for determining the eligibility of the beneficiary.
GOAP / Trust will provide the details of each BPL family covered under the Scheme through the Health Card/ BPL Card. This Health Card will be a part of enrollment / identification for availing the health insurance facility
Sum Insured on Floater Basis:
The scheme shall provide coverage for meeting expenses of hospitalization, surgical and therapeutic procedures of beneficiary members up to Rs.1.50 lakhs per family per year subject to limits, in any of the network hospitals. The benefit on family will be on floater basis i.e. the total reimbursement of Rs.1.50 lakhs can be availed of individually or collectively by members of the family
Buffer / Corporate Sum Insured:
An additional sum of Rs 10 crores shall be provided as Buffer / corporate floater to take care of expenses if it exceeds the original sum i.e. Rs 1.50 lakhs per Individual/family. In such cases an amount upto Rs. 50000/- per individual/family shall be additionally provided on the recommendation of the committee set up by the trust.
In case of Renal Transplant Surgery with Immunosuppressive therapy, the buffer amount of Rs.50, 000 if required will also gets applied automatically up to 1 year.
Cash less Transaction:
It is envisaged that for each hospitalization the transaction shall be cashless for covered procedures. Enrolled BPL beneficiary will go to hospital and come out without making any payment to the hospital subject to procedure covered under the scheme.
Pre existing diseases:
All diseases under the proposed scheme shall be covered from day one. A person suffering from any of the identified disease prior to the inception of the policy shall also be covered.
Pre and Post hospitalization:
This part has been made as a part of package. The package shall cover the entire cost treatment of patient from date of reporting to his discharge from hospital and 10 days after discharge and complications while in hospital, making the transaction truly cashless to the patient.
Procedure for enrollment of Hospitals
The hospitals shall be separately empanelled for phase II of the scheme
HOSPITAL / NURSING HOME: means any institution in Andhra Pradesh established for indoor medical care and treatment of disease and injuries and the networked hospital should comply with minimum criteria as under:
It should have at least 50 inpatient medical beds
Fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and X-ray, E.C.G. etc for the care and treatment of injured or sick persons as in-patient.
Fully equipped Operation Theatre of its own wherever surgical operations are carried out
Fully qualified nursing staff under its employment round the clock.
Fully qualified doctor(s) should be physically in charge round the clock.
Maintaining complete record as required on day-to-day basis and is able to provide necessary records of the insured patient to the Insurer or his representative as and when required.
Having sufficient experience in the specific identified field.
The Hospital should agree to the packages for each identified intervention/surgery as approved by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation and hospital charges etc. In other words the package should cover the entire cost of treatment of the patient from date of reporting to his discharge from hospital and 10 days after discharge and any complication while in hospital, making the transaction truly cashless to the patient. The post operative hospital stay in all surgical procedures shall be minimum of 10 days.
For the empanelment of Chemo And Radio -Therapy, the hospital should have infrastructure for Radiotherapy with Services of Radiation Oncologist and Medical Oncologist
For the empanelment of Cochlear Implant Surgery, the hospital should have Services of Trained ENT Surgeon and Auditory Verbal Therapist. And
Hospital should be in a position to provide following additional benefit to the BPL beneficiaries related to identified systems:
MoU with network Hospital
The insurance company shall sign MoU with all the hospitals to be empanelled under the scheme for phase II. This MoU is subject to the approval of the Trust. Empanelled medical institutions are supposed to extend medical aids to the beneficiary under the scheme. A provision will be made in MOU of non-compliance/default clause while signing them. Such matter shall be looked in to by the Trust
Payment of Premium:
The Trust / Government will pay the insurance premium on behalf of the BPL beneficiaries to the Insurance Company directly in installments.
Period Of Insurance:
The insurance coverage under the scheme shall be in force for a period of one year from the date of commencement of the policy (say from 00:00 hours of 05.12.2007 to midnight of 04.12.2008)
Implementation procedure:
The entire scheme is intended to be implemented as cashless hospitalization arranged by the Insurance Company. The following table represents the process flow of treatment to the beneficiary
Process Flow of the Beneficiary Treatment in the Network Hospital
Step 1Beneficiaries approach nearby PHC/Area Hospitals/District Hospital/Network Hospital. Aarogya Mithras placed in the above hospitals facilitate the beneficiary. If beneficiary visits any other PHC/Government hospital other than the Network Hospital, he/she will be given a referral card to the Network Hospital after preliminary diagnosis by the doctors. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the Villages and can get the referral card based on the diagnosis.
Step 2The Aarogya mithras at the Network Hospital examines the referral card and health card/BPL ration card and facilitates the beneficiary to undergo preliminary diagnosis and basic tests.
Step 3The Network Hospital, based on the diagnosis, admits the patient and sends preauthorization request to the Insurance company and the Aarogyasri Health Care Trust.
Step 4Specialists of the Insurance Company and the Trust examine the preauthorization request and approve preauthorization if all the conditions are satisfied within 12 working hours.
Step 5The Network Hospital extends cashless treatment and surgery to the beneficiary.
Step 6Network Hospital after performing the surgery forwards the original bills, diagnostic reports, case sheet, and satisfactory letter from patient, discharge summary duly signed by the patient and other relevant documents to Insurance Company for settlement of the claim.
Step 7Insurance Company scrutinizes the bills and gives approval for the sanction of the bill and shall make the payment within agreed period.
CampsHealth Camps are to be conducted in all Mandal Head Quarters, Major Panchayats and Municipalities. A minimum of 1300 camps have to be held in the five districts in the policy year. The insurer should ensure that at least one free medical camp is conducted by each network hospital per week at the place suggested by the trust. They should carry necessary screening equipment along with specialists (as suggested by the Trust) and other para-medical staff. They should also work in close liaison with district co-coordinator, DM&HO in consultation with district collector.
District Level Co-ordinationDistrict level offices with necessary infrastructure have to be set-up by the Insurance Company. The Insurer needs to have district level monitoring staff with district coordinators and regional coordinators (in charge of a group of mandals within the district). District coordinators/ Regional coordinators of the insurance company should monitor Aarogyamithras, co-ordinate with network hospital, district administration and peoples representatives for effective implementation of programme. They should ensure that camps are held as per schedule, arrange for canvassing for the camp, mobilize patients and follow up the beneficiaries. He/She should work in close liaison with district administration under the supervision of district collector. He should also ensure proper flow of MIS and report to trust on day-to-day basis about the progress of the scheme in the district. The company should ensure that dedicated staff is made available for the scheme. There shall be at least one doctor to be placed in each district. Further wherever the concentration of the network hospitals is more additional doctors need to be placed. The Insurance Company shall follow the instructions of the Trust in this regard.
State Level Co-Ordination The company should nominate responsible officer/ officers to properly coordinate above work and ensure proper implementation of scheme up to the satisfaction of trust. They should review the progress with trust on day-to-day basis and be responsible to implement the suggestions of trust for effectively running the scheme. The Project Office of the Insurance Company shall be separately established at convenient place for better coordination with the Trust. The project office shall report to the CEO of the Trust on a daily basis. The following departments shall be established by the Insurance Company in the Project Office:
24 hour call center with toll free help line
MIS Department to collect, collate and report data on a real-time basis. This department will also have a subunit with operators who collect hourly information from the Aarogyamithras, regional co-coordinators, district coordinators etc. Based on this the reverse flow of dissemination of information shall also take place. There shall be subunits for each district. The MIS department shall also follow-up the cases at all levels. The department shall also generate reports as desired by the Trust.
IT Department to ensure that the website with e-preauthorisation, claim settlement and real-time follow-up is maintained and updated on a 24-hour basis.
Pre-authorisation Department with specialist doctors for each category of diseases shall work along with the Trust doctors to process the preauthorization within 12 working hours. The doctors shall also undertake inspection of hospitals.
Claims Settlement Department
Health Camp Departmentto plan, intimate, implement and follow-up the camps as per the directions of the Trust.
Other departments required for Office work.
Aarogya Mithras
Aarogyamithras in PHCs/ CHCs/ Area Hospitals/ Government Hospitals etc: The unique nature of the scheme demands the insurance company to appoint Aarogyamithras in consultation with the trust in all PHCs, CHCs, Area Hospitals and District Hospitals for propagating the scheme, mobilizing people for health camps, counseling beneficiaries, facilitating the referral/treatment of these patients and follow-up. For effective and instant communication all the Aarogyamithras will have to be provided with cell phone CUG connectivity by the Insurance Company.
Aarogyamithras in Network Hospitals: The Insurance Company also needs to appoint Aarogyamithras at all network hospitals to facilitate admission, treatment and cashless transaction of patient. The Aarogyamithras should also help hospitals in pre-auth and claim settlement. They should also ensure proper reception and care in the hospital and send regular MIS. For effective and instant communication all the Aarogyamithras will have to be provided with cell phone CUG connectivity by the Insurance Company.
Online MIS and E-Preauthorisation.
The Insurance Company should post enough dedicated staff, so as to ensure free flow of daily MIS and ensure that progress of scheme is reported to trust in the desired format on a real-time basis. The company should establish proper networking for quick and error-free processing of preauthorisations. This will be done through a dedicated website of the Trust, the maintenance cost of which will be borne by the Insurance Company. The preauthorisation has to be done in co-ordination with trust i.e., by a team of doctors from the Trust and the Insurance company. The trust will provide necessary specialists and technical committees to evaluate special cases. The website will be a repository of information and will have the following features:
General Information on the scheme.
Details of patients reporting in the PHC/CHC/Government Hospitals/ District hospitals on daily basis
Details of Health Camps and daily reporting of health camps
Details of patients getting referred from the health camps.
Details of in-patients and out patients in the network hospitals
Costing of the Tests done in the network hospitals
Surgery details.
Discharge details.
Real-time reporting.
Claim settlement
Follow-up of patient after surgery etc.
Medical Auditors:
The company should appoint enough number of medical officers who does pre-authorization in consultation with trust. The Company shall also recruit specialized doctors for regular inspection of hospitals, attend to complaints from beneficiaries directly or through Aarogyamithras for any deficiency in services by the hospitals and also to ensure proper care and counseling for the patient at network hospital by coordinating with Aarogyamithras and hospital authorities.
Regular review meetings on the performance/administration of the Scheme would be held between the GoAP/Trust and the Insurer at the District level and at the State Level. The composition of the monitoring committees shall be as follows:
District level:
Chairman: Distirct Collector
Project Director. DRDA
District coordinator of the Insurer.
Representative of Zilla Samakhya.
State level:
Chairman: Principal Secretary, HM & FW Department and Vice Chairman of Aarogyasri Health Care Trust.
CEO, Aarogyasri Health Care Trust (Convener)
State Coordinator/Zonal Manager of the Insurer.
Any member of the trust Board
Technical Committee member nominated by the Trust
The Chairmen of the above committees may invite any Member of the Legislative Assembly whose constituency falls in the three districts/elected members of Panchayati Raj Institutions for the meetings. Fortnightly meetings shall be organised at both district and State level preferably on alternate Mondays. The agenda and issues to be discussed would be mutually decided in advance. The minutes of the meeting at the district and state level will be drawn and a copy will be forwarded to GoAP and Trust. The Insurer shall also put in place a mechanism of their own to monitor the scheme on a real time basis. Detailed reports on the progress of the scheme and issues if any emerging out of such meetings shall be reported to GoAP/Trust.
District Level Committee:
Committee chaired by District Collector with following members will form the grievance redressel cell at the district level. The decision by the committee at the state level is preferred.
Members of the Committee:
District Coordinator (DCHS)
Superintendent of District Hospital
Member from the Technical Committee(Nominated by the trust)
Representative from the Insurance firm.
Members of the Committee:
Representative of the Trust
Technical Committee Member
Representative from the Insurance firm.
A toll-free number will be made available at Hyderabad where any complaints can be registered. The insurer shall keep track of the complaints and report on the action taken to the Central Committee. The beneficiaries can also send telegrams to CEO of the Trust/ CMD's Secretariate/Zonal Office of the Insurer. The details of toll-free Numbers/addresses will be made available with supervision of Executive Director of the Insurer at the Corporate Office will be made.
The scheme will encompass all the family members of the BPL families.
All the family members whose photographs and details appear on health card / white ration card are the eligible for benefit.
The members are insured against surgeries on KIDNEY, HEART, BRAIN, CANCER, BURN INJURIES and ACCIDENTS (other than those covered by MV Act.), Cochlear Implant surgery.
The scheme envisages cashless transaction. Patient gets admitted, operated and discharged without paying any money.
Immediate Pre and post operative expenditure included in packages, so as to minimize the other financial expenses to the patient.
Scheme is introduced in East Godavari, West Godavari, Ranga Reddy, Nalgoda, Chitoor districts of the state on Phase II.
Entire premium will be paid by the govt. for the first year.
Preexisting diseases are covered from day one.

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