Ayushman Bharat: What is the insurance cover available to beneficiaries? – Decoding Insurance

Ayushman Bharat

Ayushman Bharat is an ambitious initiative of Government of India to address health holistically, through primary, secondary and tertiary care systems, covering both prevention and health promotion as well as providing access to good quality health care services. The programme has two components:

(i) Health and Wellness Centre: – National Health Policy, 2017 envisions creation of 1,50,000 Health and Wellness Centres which will bring health care closer to the homes of the people. These centres will provide Comprehensive Primary Health Care (CPHC), covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services. The Budget 2018 has allocated Rs.1200 crore for this flagship programme.

(ii) National Health Protection Mission (NHPM): – NHPM largely a mass insurance scheme managed and administered by the Ministry of Health and Family Welfare, Government of India through National Health Agency. It is being said that when fully implemented, the AB-NHPM will become the world’s largest government funded health protection mission.

The program was declared by Hon’ble Finance Minister of India, Shri Arun Jaitley as part of Budget 2018 and was formally launched by Hon’ble Prime Minister of India Shri Narendra Modi on 14th April, 2018 with the inauguration of the first Health and Wellness Centre at Jangla Development Hub, Bijapur district of Chhattisgarh. As a whole, Ayushman Bharat adopts a continuum of care approach, utilising above two inter-related components.

Point of discussion of this article will be the insurance component or Ayushman Bharat – National Health Protection Mission (AB-NHPM) also dubbed ‘ModiCare’, which is expected to be launched on 15th August 2018.

Updated 15.08.2018: In his speech on 72nd Independance Day, 15th August 2018, Prime Minister Shri Narendra Modi announced that the scheme will be launched on 25th Semtember, the birth anniversary of Deendayal Upadhyay.

Brief of the scheme

  • Objective of AB-NHPM is to reduce out of pocket hospitalisation expenses, reduce unmet needs and improve access of identified families to quality inpatient care and day care surgeries for treatment of diseases and medical conditions through a network of both public and empanelled private facilities or Empanelled Health Care Providers (EHCP).
  • To benefit 74 crore poor deprived families or around 50 crore beneficiaries.
  • At national level AB-NHPMA would be put in place. States/ UTs would implement the scheme by a dedicated entity called State Health Agency (SHA)
  • States/ UTs can decide to implement the scheme through an Insurance Company or directly through the Trust/ Society or use an Integrated Model.

Who are eligible for cover?

  • Families included in Socio-Economic Caste Census (SECC) 2011 Database of the State/ UT under the deprivation criteria of D1 (Households with one or less room, kuccha walls and kuccha roof), D2 (No adult member in household between age 18 and 59), D3 (Female headed household with no adult male member between 16 and 59), D4 (Households with differently able member with no other able bodied adult member), D5 (SC/ST Households) and D7 (Landless households deriving a major part of their income from manual labour), Automatically Included (households without shelter, destitute, living on alms, manual scavenger families, primitive tribal groups, legally released bonded labour) category and 11 defined occupational un-organised workers in Urban Sector (including rag-pickers, beggars, domestic workers, cobblers, hawkers, construction workers, plumbers, painters and security guards) are covered.
  • For states where RSBY is currently operational, RSBY Beneficiary Families not figuring in the SECC Database will also be covered
  • The beneficiaries will be identified using Aadhaar and/or Ration Card and / or any other specified identification document produced by the beneficiary at the point of contact.
  • Once successfully identified, the beneficiary will be provided with a print of AB-NHPM e-card which can be used as reference while availing benefits
  • New family members can be added (by birth or marriage) after validation
  • There is no limit on family size, age or gender.

Benefits

  • Risk Cover (RC) of INR 5,00,000 (Rupees Five Lakh only) per eligible AB-NHPM beneficiary family unit per annum.
  • Cover to be provided on a cashless basis up to the basic risk cover
  • Cover includes:
  • Hospitalization expense benefits
  • Day care treatment benefits (as applicable)
  • Follow-up care benefits
  • Pre (3 days) and post (15 days) hospitalization expense benefits
  • New born child/ children benefits
  • All pre-existing conditions, diseases, illnesses or injuries are covered from Day one
  • Package rates for procedures has been defined. Any treatment beyond defined procedures is available up to INR 1,00,000 (Rupees One Lakh only)
  • Secondary and tertiary level of medical and surgical care treatment shall be provided

Package Rates

  • Package Rates (in case of surgical procedures or interventions or day care procedures)/ Flat Per Day Rate (in case of medical treatments) of 1350 Procedures across 23 Specialities has been defined (breakup shown below).
S.No Specialty No. of packages
1 Cardiology 38
2 Cardio-thoracic surgery 71
3 Cardio-vascular surgery 21
4 Opthalmology 42
5 ENT 94
6 Orthopaedics 101
7 Polytrauma 13
8 Urology 161
9 Obstetrics & Gynaecology 73
10 General Surgery 253
11 Neurosurgery 82
12 Interventional Neuroradiology 12
13 Plastic & reconstructive 9
14 Burns management 12
15 Oral and Maxillofacial Surgery 9
16 Paediatric medical management 100
17 Neo-natal 10
18 Paediatric cancer 12
19 Paediatric surgery 34
20 Medical packages 70
21 Oncology 112
22 Emergency Room Packages (Care requiring less than 12 hrs stay) 4
23 Mental Disorders Packages 17
Total 1350
  • Cover available for Package Rate/ Flat Per Day Rate amount for defined treatment or procedures or for an appropriate amount for undefined treatment or procedures
  • Follow up care prescription for identified packages are also defined
  • Any expenses beyond Basic Risk Cover, has to be paid by beneficiary
  • Package Rates or Flat Per Day Rate includes:
  1. Registration charges.
  2. Bed charges (General Ward).
  3. Nursing and boarding charges.
  4. Surgeons, Anaesthetists, Medical Practitioner, Consultants fees etc.
  5. Anaesthesia, Blood Transfusion, Oxygen, O.T. Charges, Cost of Surgical Appliances etc.
  6. Medicines and drugs.
  7. Cost of prosthetic devices, implants etc.
  8. Pathology and radiology tests.
  9. Diagnosis and Tests, etc.
  10. Food to patient.
  11. Pre and Post Hospitalisation expenses
  12. Any other expenses.
  • Surgical and Medical packages will not be allowed to be availed at the same time

Exclusions

  • Conditions that do not require hospitalization and can be treated under Out Patient Care
  • expenses incurred primarily for evaluation / diagnostic purposes only during the hospitalized period and expenses on vitamins and tonics etc unless forming part of treatment for injury or disease as certified by the attending physician
  • Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc. unless arising from disease or injury and which requires hospitalisation for treatment.
  • Congenital external diseases or defects or anomalies, Convalescence, general debility, “run down” condition or rest cure.
  • Fertility related procedures, Hormone replacement therapy for Sex change or treatment which results from or is in any way related to sex change.
  • Vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident),
  • Intentional self-injury/suicide
  • Persistent Vegetative State

Payment of Premium

Entire premium will be borne by Centre and/ or State in various proportions depending on the implementing State.

S.No. Central & State Premium Split Ratio
1 For 8 North-East and 3 Himalayan States:
Centre: State:: 90:10
2 For other States: Centre: State:: 60:40
3 For Union Territories with Legislation:
Centre: State:: 60:40
4 For Union Territories without Legislation: Centre: State:: 100:0

Portability

AB-NHPM offers portability of benefits across states implementing AB-NHPM at any EHCP. Package Rates of the EHCP where benefits are being provided will be applicable while payment.

Ayushman Bharat programme will envisage to build a new and healthy India by 2022 and ensure enhanced productivity, well-being and job creation.

Read More:
  1. India Portal [https://www.india.gov.in/spotlight/ayushman-bharat-national-health-protection-mission]
  2. Ayushman Bharat homepage [https://www.abnhpm.gov.in/]
  3. Govt. Press Release [http://www.pib.gov.in/PressReleaseIframePage.aspx?PRID=1518544]
  4. Health and Wellness Centre launch [http://pib.nic.in/newsite/PrintRelease.aspx?relid=178688]
Disclaimer: The author of this post does not have any political affiliation, nor does this post prefer or support any specific political part. The purpose of the post is to share the benefits of the mass insurance scheme, for ease of understanding by the general public.
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3 thoughts on “Ayushman Bharat: What is the insurance cover available to beneficiaries? – Decoding Insurance

  1. Update on 15.08.2018: In his speech on 72nd Independance Day, 15th August 2018, Prime Minister Shri Narendra Modi announced that the scheme will be launched on 25th Semtember, the birth anniversary of Deendayal Upadhyay.

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