Ayushman Bharat - National Health Protection Mission
22 March 2018
AB-NHPM will have a defined benefit cover of Rs. 5 lakh per family per year.
This cover will take care of almost all secondary care and most of tertiary care procedures. To ensure that nobody is left out (especially women, children and elderly) there will be no cap on family size and age in the scheme.
The benefit cover will also include pre and post-hospitalisation expenses. All pre-existing conditions will be covered from day one of the policy. A defined transport allowance per hospitalization will also be paid to the beneficiary.
Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.
AB-NHPM will be an entitlement based scheme with entitlement decided on the basis of deprivation criteria in the SECC database, The different categories in rural area include families having only one room with kucha walls and kucharoof; families having no adult member between age 16 to 59; female headed households with no adult male member between age 16 to 59; disabled member and no able bodied adult member in the family; SC/ST households; and landless households deriving major part of their income from manual casual labour, Also, automatically included families in rural areas having any one of the following: households without shelter, destitute, living on alms, manual scavenger families, primitive tribal groups, legally released bonded labour. For urban areas, 11 defined occupational categories are entitled under the scheme.
The beneficiaries can avail benefits in both public and empanelled private facilities. All public hospitals in the States implementing AB-NHPM, will be deemed empanelled for the Scheme.
Hospitals belonging to Employee State Insurance Corporation (ESIC) may also be empanelled based on the bed occupancy ratio parameter. As for private hospitals, they will be empanelled online based on defined criteria.
To control costs, the payments for treatment will be made on the basis of a package rate, to be defined by the centre in advance. The package rates will include all the costs associated with treatment. For beneficiaries, it will be a cashless, paper less transaction. Keeping in view the sate specific requirements, States and union territories will have the flexibility to modify these rates within a limited bandwidth.
According to the government, one of the core principles of Ayushman Bharat - National Health Protection Mission (AB-NHPM) is to co-operative federalism and flexibility to states.
There is provision to partner the states through co-alliance. This will ensure appropriate integration with the existing health insurance and protection schemes of various central ministries and departments and state governments (at their own cost). State governments will be allowed to expand AB-NHPM both horizontally and vertically. States will be free to choose the modalities for implementation. They can implement through insurance company or directly through a trust or society or a mixed model.
For giving policy directions and fostering coordination between Centre and States, the centre proposes to set up Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) at apex level chaired by union health and family welfare minister (MoHFW). It is proposed to have an Ayushman Bharat National Health Protection Mission Governing Board which will be jointly chaired by Secretary (HFW) and Member (Health), NITI Aayog with financial advisor, MoHFW, additional secretary and mission director, Ayushman Bharat National Health Protection Mission, MoHFW (AB-NHPM) and joint secretary (AB-NHPM), MoHFW as members.
The CEO, Ayushman Bharat - National Health Protection Mission, will be the member secretary, state secretaries of health department may also be members as per the requirement.
The centre proposes to establish an Ayushman Bharat - National Health Protection Mission Agency (AB-NHPMA) to manage the AB-NHPM at the operational level in the form of a Society. AB-NHPMA will be headed by a full time CEO of the level of secretary or additional secretary to the government of India.
States would need to have state health agency to implement the scheme states will have the option to use an existing trust, society, not for profit company / state nodal agency or set up a new body or the state health agency to implement the scheme and act as state health agency. At the district level also, a structure for implementation of the scheme will need to be set up.
To ensure that the funds reach state health agency on time, the transfer of funds from the central government through AB-NHPMA to state health agencies would be made through an escrow account directly. States have to contribute its matching share of grants within a defined time frame.
"In partnership with NITI Aayog, a robust, modular, scalable and interoperable IT platform will be made operational which will entail a paperless, cashless transaction," an official government release said. It added, "This will also help in prevention / detection of any potential misuse / fraud / abuse cases. This will be backed by a well-defined grievance redressal mechanism. In addition, pre-authorisation of treatments with moral hazards (potential of misuse) will be made mandatory.
In order to ensure that the scheme reaches the intended beneficiaries and other stakeholders, a comprehensive media and outreach strategy will be developed, which will, include print media, electronic media, social media platforms, traditional media, IEC materials and outdoor activities.
The implementation strategy at the national level to manage, an Ayushman Bharat National Health Protection Mission Agency (AB-NHPMA) would be put in place. Statesand union territories will be advised to implement the scheme through a dedicated entity called state health agency (SHA). They can either use an existing trust, society, not for profit company or the state nodal agency or set up a new entity to implement the scheme.
States and union territories also have the flexibility to implement the scheme through an insurance company or directly through the a body or use an integrated model.
(See report: Union cabinet approves 'Modicare' national health scheme)