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.