Introduction:
There is a felt need to provide financial protection to families living below poverty line for the treatment of major ailments, requiring hospitalization and surgery. In order to bridge the gap in provision of Tertiary care facility and the specialist pool of doctors to meet the state wide requirement for the treatment of such diseases particularly in rural areas the Government of Karnataka has taken the initiative in this direction. Health insurance could be a way of removing the financial barriers and improving accessibility to quality medical care by the poor. Government of Karnataka intends to implement Health Insurance Scheme by name Vajpayee Arogyashree for the BPL families of Karnataka in a phased manner.
Objectives:
To improve access of BPL families towards quality tertiary medical care for treatment of identified diseases involving hospitalization, surgery and therapies through an identified network of health care providers.
• To Cover Catastrophic Illnesses
• Universal Coverage of BPL (Rural + Urban)
• Catastrophic illnesses can wipe out decades of savings of BPL families
• To protect life time savings of BPL families which would be wiped out in case of catastrophic illness.
Types of Services:
• Cardiovascular diseases
• Cancer Treatment
a) Surgery
b) Chemotherapy
c) Radiotherapy
• Neurological diseases
• Renal diseases
• Burns
• Poly trauma cases (Not covered by Motor vehicle insurance)
• Neo-natal cases
Beneficiaries:
The scheme is intended to benefit below poverty line (BPL)families both in urban & rural areas in Karnataka, in a phased manner. Identification of these families are based on a BPL ration card issued by the Food and Civil Supplies Department. All eligible families (family of 5 members) in the proposed districts are provided with BPL cards issued by Department of Food and Civil Supplies. These BPL ration cards will be basis for identification of beneficiary under the scheme until Biometric health cards are issued.
Families:
The Health Insurance Scheme will cover 5 members of a family as enumerated and photographed on the BPL card. The name/ photograph indicated in the BPL card will be taken as proof of identity of the Beneficiary.
Enrolment:
Department of Food and Civil Supplies, Govt. of Karnataka will provide the details of each BPL family covered under the scheme through the BPL card. This BPL card will be a part of enrollment/ identification for availing the health insurance facility
ID Cards:
Vajpayee Arogyasri will distribute ID cards to the beneficiary families.
Payment of Premium:
Government of Karnataka/ Trust will pay the premium on behalf of the BPL beneficiaries for the insurence.
Benefit Package:
The Benefit Package will cover tertiary care for catastrophic diseases. Sum assured will be Rs.1,50,000/- on a family floater basis per year. Additional buffer of Rs.50,000/- per year for the entire family on a case to case basis (if the total expenditure exceeds more than Rs.1,50,000/-) will be provided. The benifit availed by the family will be on a floater basis for a total reimbursement of Rs.1, 50,000/- which can be availed individually or collectively by members of the family.
Cashless Transaction:
It is envisaged that during each hospitalization the transaction shall be cashless for procedures covered under this scheme. Enroled BPL beneficiary can go to a network hospital and obtain treatment without making any payment to the hospital for procedures provided under the scheme.
Pre-Existing Diseases:
All diseases proposed under the scheme shall be covered under the scheme from day one. A person suffering from any of the identified diseases prior to the inception of the policy shall also be covered.
Procedure for Enrolment of Hospitals:
All the Public Hospitals (District Hospitals, Government/ Private Medical Colleges) and identified Private Hospitals/ Nursing Homes shall individually be empanelled. Private Hospitals/ Nursing Homes meaning, any institution in Karnataka established for in-patient surgical care and the Networked Hospital should comply with minimum qualifying criteria for empanelment. For the empanelment of Super Specialty treatment of Neurology, Heart, Cancer treatment (Surgery, Chemotherapy and Radiotherapy), Renal, Burns and Poly-Trauma cases (not covered by the Motor Vehicles Act) and Neo-natal care, the Hospital should have super specialty infrastructure of the same along with services of specialists.
The concerned agency will provide supporting services of Health Insurance, like creating awareness among the community by conducting Health awareness/ check up camps, through “Arogyamitras” in the concerned areas.
Role of Arogyamitras in the hospital
• To create publicity and awareness
• Maintain Help Desk at Hospital
• Receive the beneficiary
• Verify the beneficiary Criteria (eligibility criteria)
• Facilitate consultation with doctors
• Fill up the referral cards
• Guide the patient to the next centre
• To counsel the patients who may require one of the listed treatments
• To guide the patients either to a Government Hospital or to a network hospital for further tests.
• Follow up the referred cases
• To act as a guide and friend to the beneficiary.
Memorandum of Understanding (MoU) with Network Hospitals:
The trust shall sign the MoU with all the Hospitals to be empanelled under the scheme. The Empanelled Medical Institutions will extend Medical Aids to the beneficiary under the scheme.
Claims Settlement:
Vajpayee Arogyashree shall settle the claim within 21 days of receving the claims from the network hospital.
Camps:
Health Camps will be conducted in all Gram Panchayats and Municipalities. A minimum number of one free medical camp will be conducted by each Network Hospital per week at a place suggested by the Trust. They will carry necessary screening equipment along with specialist and other Para-medical staff as suggested by the Trust and will also work in close liaison with District Coordinator, District Health Officer in consultation with Deputy Commissioner.
Hospitalization Period:
The minimum period for which the insured person is admitted in the hospital as in-patient and stays there for the sole purpose of receiving the necessary and reasonable treatment for the disease/ ailment contracted/ injuries sustained during the period of policy, shall be 24 hours.
State Level Coordination:
• 24 hour Call center with toll free help line
• MIS to collect and report data on a real-time basis. Collect hourly round the clock information from Arogya Mitra, regional coordinators, district coordinators…etc. MIS shall follow up the cases at all levels. They shall also generate reports as desired by the Directorate of Health and Family Welfare Services.
• 24 X 7 online computer control room to ensure that the website with e-preauthorization, claims settlements, and real-time follow-up is to be maintained and updated.
• Pre-Authorization Section with specialist doctors for each category of diseases shall work along with the Directorate of Health and Family Welfare Services doctors to process the claims.
District Level Committee:
A committee chaired by Deputy Commissioner will form the Grievance Redressal Cell at the District level.
Expected Outcomes:
1. To Cover Catastrophic Illnesses which are not covered by other Health Insurance Schemes.
2. Universal Coverage of BPL (Rural + Urban) 78 lakh families in a Phased manner
3. Super Specialty Surgical care to be made available to vulnerable sections of the society