Process Flow

Process Flow

Process Flow of the Beneficiary Treatment in the Network Hospital

Step 1:

Beneficiaries 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 2:

The Aarogya mithras at the Network Hospital examines the referral card and BPL ration card and facilitates the beneficiary to undergo preliminary diagnosis and basic tests.

Step 3:

The Network Hospital, based on the diagnosis, admits the patient and sends preauthorization request to the Insurance company and the Aarogyasri Health Care Trust.

Step 4:

Specialists of the Insurance Company and the Trust examine the preauthorization request and approve preauthorization if all the conditions are satisfied.

Step 5:

The Network Hospital extends cashless treatment and surgery/therapy to the beneficiary.

Step 6:

Network Hospital after performing the surgery/therapy forwards the original bill, discharge summary with signature of the patient and other relevant documents to Insurance Company for settlement of the claim.

Step 7:

Insurance Company scrutinize the bills and gives approval for the sanction of the bill.

Working Pattern

Working Pattern

TRAUMA AND ACCIDENTS SURGERIES

6 TRAUMA & ACCIDENTS SURGERIES (Where major surgical procedure is involved; excluding accident trauma cases covered under the MV Act.)
164 6.1 Neurosurgical Trauma 30,000
165 6.2 Polytrauma 50,000
166 6.3 Longbone Fractures (Surgical Correction) 15,000

BURNS

5 BURNS
5.1 30% - 50% Burns
157 5.1.1 upto-40% with Scalds( Conservative) 35,000
158 5.1.2 upto-40% Mixed Burns(with Surgeries) 50,000
159 5.1.3 upto-50% with Scalds (Conservative) 60,000
160 5.1.4 upto-50% Mixed Burns( with Surgeries) 70,000
5.2 Above 50% Burns
161 5.2.1 upto-60% with Scalds (Conservative) 80,000
162 5.2.2 Up to-60% Mixed Burns (with Surgeries) 1,00,000
163 5.2.3 Above 60% Mixed Burns (with Surgeries) 1,20,000

NEUROSURGERY

4 NEUROSURGERY
119 4.1 Craniotomy and Evacuation of Haematoma –Subdural 40,000
120 4.2 Craniotomy and Evacuation of Haematoma –Extradural 40,000
121 4.3 Evacuation of Brain Abscess-burr hole 40,000
122 4.4 Excision of Lobe (Frontal,Temporal,Cerebellum etc.)40,000
123 4.5 Excision of Brain Tumours -Supratentotial 40,000
124 4.6 Excision of Brain Tumours -Subtentorial 45,000
125 4.7 Surgery of Cord Tumours 25,000
126 4.8 Ventriculoatrial /Ventriculoperitoneal Shunt 20,000
127 4.9 Excision of Cervical Inter-Vertebral Discs 25,000
128 4.10 Twist Drill Craniostomy 25,000
129 4.11 Subdural Tapping 25,000
130 4.12 Ventricular Tapping 25,000
131 4.13 Abscess Tapping 20,000
132 4.14 Vascular Malformations 40,000
133 4.15 Peritoneal Shunt 15,000
134 4.16 Atrial Shunt 15,000
135 4.17 Meningo Encephalocele 25,000
136 4.18 Meningomyelocele 25,000
137 4.19 C.S.F. Rhinorrhoea 20,000
138 4.20 Cranioplasty 30,000
139 4.22 Posterior Cervical Dissectomy 15,000
140 4.23 Anterior Cervical Dissectomy 15,000
141 4.24 Meningocoele Excision 25,000
142 4.25 Ventriculo-Atrial Shunt 20,000
143 4.26 Anterior Cervical Spine Surgery with fusion 45,000
144 4.27 Anterior Lateral Decompression 30,000
145 4.28 Cervical or Dorsal Laminectomy 25,000
146 4.29 Combined Trans-oral Surgery & CV Junction Fusion 30,000
147 4.30 C.V. Junction Fusion 20,000
148 4.31 Depressed Fracture 15,000
149 4.32 Discectomy 25,000
150 4.33 Spinal Fusion Procedure 50,000
151 4.34 Spinal Intra Medullary Tumours 50,000
152 4.35 Spinal Bifida Surgery Major 20,000
153 4.36 Spina Bifida Surgery Minor 15,000
154 4.37 Stereotactic Procedures 20,000
155 4.38 Trans Sphenoidal Surgery 20,000
156 4.39 Trans Oral Surgery 25,000

RENAL (KIDNEY)

kidney 1: A longitudinal section, B nephron and adjacent blood vessels; 1 renal papilla, 2 renal column, 3 capsule, 4 renal pyramid, 5 calyx, 6 ureter, 7 renal pelvis, 8 renal vein, 9 renal artery, 10 interlobar artery, 11 arcuate artery, 12 interlobular artery, 13 interlobar vein, 14 cortex, 15 interlobular vein, 16 renal sinus, 17 arcuate vein, 18 medulla, 19 vasa recta, 20 loop of Henle, 21 collecting duct, 22 arcuate vein, 23 arcuate artery, 24 proximal convoluted tubule, 25 glomerulus, 26 Bowman's capsule, 27 distal convoluted tubule





3 RENAL
106 3.1 HaemoDialysis (Pre Transplant only) 1,000
107 3.1.1 A.V. Fistule 3,000
108 3.2 Renal Transplantation surgery 1,30,000
109 3.2.1 Post Transplant immunosuppressive Treatment upto 1 year 60,000
110 3.3.1 Open Pylolithotomy 10,000
111 3.3.2 Open Nephrolithotomy 10,000
112 3.3.3 Open Cystolithotomy 10,000
113 3.3.4 PCNL 10,000
114 3.3.5 Laparoscopic Pylolithotomy 15,000
115 3.3.6 ESWL 10,000
116 3.3.7 Nephrostomy 2,000
117 3.3.8 DJ stunt 1,000
118 3.4 Renal Angioplasty 60,000

COBALT 60 THERAPY

2A Cobalt 60 Therapy (only as pre / post surgery Therapy protocol)
94 2.A.1 Radical Treatment 20,000
95 2.A.2 Palliative Treatment 10,000
96 2.A.3 Adjunctive Therapy 15,000
2B Linear Accelerators (only as pre / post surgery Therapy protocol)
97 2.B.1 Radical Radiotherapy 25,000
98 2.B.2 Palliative Radiotherapy 15,000
2.C Brachy Therapy (only as pre / post surgery Therapy protocol)
99 2.C.1 Intracavitary 3,000 per application
100 2.C.2 Head & Neck 15,000
101 2.C.3 Breast 15,000
102 2.C.4 Soft Tissue Sarcoma 15,000
2.D Chemotherapy (only as pre / post surgery Therapy protocol)
103 2.D.1 Single Drug Therapy per day 500 per day
104 2.D.2 Multiple Drug Therapy per day 750 per day
105 2.D.3 Infusional Chemotherapy 2,000 per day

CANCER-SURGERIES

2 CANCER – Surgeries
2.1 Head & Neck
41 2.1.1 Composite Resection & Reconstruction 60,000
42 2.1.2 Neck Dissection - any type 25,000
43 2.1.3 Hemiglossectomy 15,000
44 2.1.4 Maxillectomy - any type 25,000
45 2.1.5 Thyroidectomy - any type 20,000
46 2.1.6 Parotidectomy - any type 20,000
47 2.1.7 Laryngectomy - any type 40,000
48 2.1.8 Laryngopharyngo Oesophagectomy 75,000
49 2.1.9 Hemimandibulectomy 25,000
50 2.1.10 Wide excision 25,000
2.2 Gastrointestinal Tract
51 2.2.1 Oesophagectomy - any type 60,000
52 2.2.2 2. Gastrectomy - any type 40,000
53 2.2.3 3. Colectomy - any type 40,000
54 2.2.4 4. Anterior Resection 50,000
55 2.2.5 5. Abdominoperenial Resection 40,000
56 2.2.6 6. Hepatectomy - any type 60,000
57 2.2.7 7. Whipples - any type 75,000
58 2.2.8 8. Pancreatectomy - any type 60,000
59 2.2.9 9. Triple Bypass & other Bypasses 25,000
2.3 Genito Urinary System
60 2.3.1 Radical Nephrectomy 40,000
61 2.3.2 Radical Cystectomy 60,000
62 2.3.3 Other Cystectomies 40,000
63 2.3.4 Total Penectomy 25,000
64 3.3.5 Partial Penectomy 15,000
65 2.3.6 Inguinal Block Dissection - one side 15,000
66 2.3.7 Radical Prostatectomy 60,000
67 2.3.8 High Orchidectomy 15,000
68 2.3.9 Bilateral Orchidectomy 10,000
69 2.3.10 Emasculation 30,000
2.4 Gynaecological Oncology
70 2.4.1 Hysterectomy 25,000
71 2.4.2 Radical Hysterectomy 30,000
72 2.4.3 Surgery for Ca Ovary - early stage 25,000
73 2.4.4 Surgery for Ca Ovary - advance stage 40,000
74 2.4.5 Vulvectomy 15,000
75 2.4.6 Salpingo - oophorectomy 25,000
76 2.4.7 Dilatation and Curratage 1,000
77 2.4.8 Examination under Anesthesia 1,000
2.5 Tumors of the Female Breast
78 2.5.1 1. Mastectomy - any type 25,000
79 2.5.2 2. Axillary Dissection 15,000
80 2.5.3 3. Wide excision 5,000
81 2.5.4 4. Lumptectomy 3,000
82 2.5.5 5. Breast reconstruction 25,000
83 2.5.6 6. Chest wall resection 20,000
2.6 Skin Tumors
84 2.6.1 1. Wide excision 10,000
85 2.6.2 2.Wide excision + Reconstruction 20,000
86 2.6.3 3.Amputation 20,000
2.7 Soft Tissue and Bone Tumors
87 2.7.1 1. Wide excision 15,000
88 2.7.2 2. Wide excision + Reconstruction 25,000
89 2.7.3 3. Amputation 20,000
2.8 Cancer Lung
90 2.8.1 1. Thorocotomy 25,000
91 2.8.2 2. Lobectomy 40,000
92 2.8.3 3. Pneumonectomy 45,000
93 2.8.4 4. Pleurodecis 2,000
2.9 Radiotherapy (only as pre/post surgery therapy protocol)

CARDIAC SURGERIES AND COST

1 CARDIAC Cost
1 1.1 Coronary Bypass Surgery -------------------------------- 95,000
2 1.2 Coronary Bypass Surgery-post Angioplasty -------------- 1,05,000
3 1.3 Coronary Baloon Angioplasty---------------------------- 60,000
4 1.4 Total Correction of Tetralogy of Fallot --------------- 95,000
5 1.5 Ruptured sinus of valsulva Correction------------------ 95,000
6 1.6 TAPVC Correction -------------------------------------- 95,000
7 1.7 Intra cardiac Repair of ASD & VSD --------------------- 75,000
8 1.8 Patent Ductus Arteriousus -Surgery-PDA ---------------- 20,000
1.9 Ross Procedure Intracardiac Repair of Complex congenital heart diseases
9 1.9.1 With Special Conduits ------------------------------- 1,25,000
10 1.9.2 Without Special Conduits --------------------------- 95,000
11 1.10 Balloon Valvotomy- Cardiology ----------------------- 20,000
12 1.11 Open Pulmonary Valvotomy --------------------------- 75,000
1.12 Valve Repairs
13 1.12.1 With Prosthetic Ring ------------------------------ 1,00,000
14 1.12.2 Without Prosthetic Ring --------------------------- 85,000
1.13 Systemic Pulmonary Shunts
15 1.13.1 With Graft ---------------------------------------- 20,000
16 1.13.2 Without Graft ------------------------------------- 20,000
17 1.14 Closed mitral valvotomy ----------------------------- 20,000
18 1.15 Mitral Valve Replacement (With Valve)---------------- 1,20,000
19 1.16 Aortic Valve Replacement (With Valve)---------------- 1,20,000
20 1.17 Double Valve Replacement (With Valve)---------------- 1,50,000
21 1.18 Mitral Valvotomy (Open)------------------------------ 80,000
22 1.19 Pericardiostomy surgery CT -------------------------- 10,000
23 1.20 Pericardiectomy ------------------------------------- 30,000
24 1.21 Pericardio Centesis --------------------------------- 2,000
25 1.22 Permanent Pacemaker Implantation--------------------- 75,000
26 1.23 Temporary Pacemaker Implantation -------------------- 10,000
1.24 Coaractation-Arota Repair
27 1.24.1 With Graft ---------------------------------------- 32,000
28 1.24.2 Without Graft ------------------------------------- 25,000
29 1.25 Aneurysm Resection & Grafting ----------------------- 1,25,000
30 1.26 Intrathoracic Aneurysm -Aneurysm not Requiring Bypass (with Graft)- 65,000
31 1.27 Intrathoracic Aneurysm -Requiring Bypass (With Graft)--- 1,25,000
32 1.28 Dissecting Aneurysms -------------------------------- 75,000
33 1.29 Vertebral Angioplasty ------------------------------- 75,000
34 1.30 Annulus aortic ectoria with valved conduits---------- 1,50,000
1.31 Aorto-Aorto Bypass ---------------------------------- 55,000
35 1.31.1 With Graft ---------------------------------------- 60,000
36 1.31.2 Without Graft ------------------------------------- 45,000
1.32 Femoro- Poplitial Bypass
37 1.32.1 With Graft ---------------------------------------- 45,000
38 1.32.2 Without Graft ------------------------------------- 25,000
1.33 Femorofemoral Bypass
39 1.33.1 With Graft ---------------------------------------- 45,000
40 1.33.2 Without Graft ------------------------------------- 25,000

PREMIUM

Premium

The Government has borne the entire premium on behalf of the beneficiary.

BENEFICIARY

Beneficiary

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 lakh 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

ABOUT SCHEME

About Scheme

RAJIV AAROGYASRI COMMUNITY HEALTH INSURANCE SCHEME FOR THE BPL FAMILIES IN THE STATE OF ANDHRA PRADESH

INTRODUCTION

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, laparoscope 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/therapy. 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.

THE SCHEME

Name : The name of the scheme shall be "RAJIV AAROGYASRI COMMUNITY HEALTH INSURANCE SCHEME�

Objective:

To improve access of BPL families to quality medical care for treatment of diseases involving hospitalization and surgery/therapy through an identified network of health care providers. In the initial phase, the scheme would provide coverage for the following system;

Heart
Cancer
Neurosurgery
Renal diseases
Burn
Poly trauma cases.(except cases covered under motor vehicle accidents.)
The Scheme will be implemented in three selected districts of Andhra Pradesh as on pilot basis (Viz. Mahaboobnagar, Anantapur, Srikakulam.)

Beneficiaries:

The scheme is intended to benefit below poverty line (BPL) population in the 3 backward districts of the State viz. Ananthapur, Mahaboobnagar and Srikakulam on a pilot basis. According to a recent enumeration, there are 23,16,426 BPL families in three districts of the State, comprising of a population of 8339854. Database and photograph in electronic format of these families is available in white ration cards issued by the Civil Supplies Department. District wise profile of the BPL families is given below:

S.No Districts No of BPL Families BPL population
1 Anantapur 870616 3134218
2 Mahaboobnagar 781777 2814397
3 Srikakulam 664233 2391239
Total 23,16,626 83,39,854

Family:

Family means the group of individuals as indicated in a white ration card (BPL card).

Enrollment:

There is no separate enrollment procedure,the white ration card with photograph / age indicated in the white ration cards (BPL cards) will be taken as the proof for enrollment. The white card (BPL card) will be the Health Card.

Sum Insured on Floater Basis:

he scheme shall provide coverage for meeting expenses of hospitalization and surgical 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 not exceeding Rs.5,00,00,000/- (Rupees five Crores) shall also be provided as buffer to take care of the expenses, if it exceeds the original sum. i.e., Rs.1,50,000/- on one individual. In such cases an amount up to Rs.50,000/- to that individual will be additionally provided.

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 (ie. from 00:00 hours of 01.04.2007 to midnight of 31.03.2008)

Requirements for enrollment of Hospitals:

HOSPITAL / NURSING HOME: means any institution in Andhra Pradesh established for indoor medical care and treatment of disease and injuries and which either

Hospital / Nursing Home run by Government fulfilling relevant requirements of the scheme. OR In case of networked hospital, it 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 be able to provide necessary records of the insured patient to the Insurer or his representative as and when required.
Using ICD and OPQS codes for Drugs, Diagnosis, Surgical procedures etc.
Having sufficient experience in the specific identified field.
Additional Benefits:

Hospital should be in a position to provide following additional benefit to the BPL beneficiaries related to identified systems:

Free OPD consultation
FREE tests and medical treatment required for beneficiaries, who ultimately do not end up in surgery/therapy.
Minimum 10-12 free Health Camps in villages in a year for the screening of the BPL patient suffering from the identified ailments. Villages shall be identified in consultation with the trust.
Free transport to the patient identified for surgery/therapy.
The Government will pay the insurance premium on behalf of the BPL beneficiaries.

IMPLEMENTATION PROCEDURE:

The entire scheme WILL BE implemented through insurance firm. An MOU has been signed with the company STAR HEALTH AN ALLIED INSURANCE FIRM on 08.03.07.

Procedure

The contact point would be PHC and Government hospitals in the District, where Insurer will have a help desk known as Aarogyasri Help Desk. The desk will be managed by a Aarogyasri Health Coordinator (AHC) to be appointed and paid by the Insurer.
Aarogyasri Help Desk at PHC / Government Hospitals will refer patients on the recommendation of the PHC/Government Doctors to one of the Network Hospitals or hospital of the BPL family member's choice with in the network. At the Network Hospital Insurer will establish Aarogyasri Assistance Counters and will facilitate the referred BPL family member to go through the tests and there after if needed for the surgical treatment.
White Ration Card (BPL Card) holders can also directly approach Aarogyasri Assistance Counters at the Network Hospital for examination and treatment.
For treatment of poly-trauma and burns cases Insurer will set up the network of hospitals closer to the people preferably at the mandal level.
The Aarogyasri Assistance Counters at the network hospitals will facilitate cashless transaction and formalities connected with discharge of patient and enable forwarding the bills for payment to the Hyderabad zonal Office of Insurer.
Not withstanding whatever stated above, if a patient gets admitted directly in a network hospital and fulfills all the criteria for the benefits under the scheme, his/her case will be considered.
MONITORING MECHANISM:

TRegular 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 Medical and Health Officer (Member-Convener)
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.

Members:

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.

GRIEVANCE MECHANISM:

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.
Central Committee:

Committee chaired by Chief Executive Officer of the Trust will entertain all the appeals on the decisions taken by the District Committee. The decision taken by the committee will be final and binding on the both parties.

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 UNIQUE FEATURES OF THE POLICY ARE

The scheme will encompass all the family members of the BPL families.
All the family members whose photographs and details appear on 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.).
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 Mahboobnagar, Anatapur, Srikakulam three backward districts of the state on pilot basis.
Entire premium will be paid by the govt. for the first year.
Preexisting diseases are covered from day one.