Framework for Ayushman Bharat – National Health Protection Mission (AB-NHPM)
The Government of India recently got cabinet approval for Modi government’s much-touted MODICare or ‘Ayushman Bharat – National Health Protection Mission‘ (AB-NHPM). The scheme provides free health insurance benefits cover to over 40% of total population of the country and is already making waves across the world. World Health Organisation (WHO) director-general Tedros Adhanom Ghebreyesus in his recent statement praised the Ayushman Bharat – National Health Protection Scheme and said that the scheme has the true potential to change the lives of millions of Indians.
The scheme comes in the backdrop of the fact that various Central Ministries and State/UT Governments have launched health insurance/ protection schemes for their own defined set of beneficiaries. To achieve improved efficiency, reach and coverage, there is a critical need to converge these schemes such as Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).
- More than 10 crore families to be covered. RSBY and SCHIS to be subsumed under Ayushman Bharat (AB-NHPM.
- AB-NHPM will have a defined benefit cover of Rs. 5 lakh per family per year.
- Beneficiaries of the scheme can cashless benefits from any “in network” private/public hospital across the country. Public hospitals will be assumed to be “in network” all the time.
- In partnership with NITI Aayog, a robust, modular, scalable and interoperable IT platform will be made operational which will entail a paperless, cashless transaction. 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-Authorization 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, inter alia, include print media, electronic media, social media platforms, traditional media, IEC materials and outdoor activities.
- The government will make the payments of treatment cost on package rate as predefined by the government to control the costs. Package rate will factor in all costs associated with the treatment. However, to the beneficiaries, it will be a cashless transaction all the time.
- The different categories in the rural areas include families having only one room with “kucha” walls and “kucha” roof, families having no adult members among others. 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 government will setup Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) and Ayushman Bharat National Health Protection Mission Governing Board (AB-NHPMGB) to provide policy directions and fostering coordination between Centre and States.
- The scheme will also have a full-time CEO designated for implementation purpose.
How will the scheme be implemented?
The government has envisioned setup of a new agency – Ayushman Bharat National Health Protection Mission Agency (AB-NHPMA) to manage the scheme at the national level. Under the programme, the state health agencies will be responsible for the implementation of the NHPM at the local level. The center will suggest the state governments to set up a dedicated Stage Health Agency (SHA) to manage the scheme. They do not have to necessarily set up a “new” agency, but any existing setup like existing Trust/Society/Not for Profit etc will be fine. States can also decide to use an insurance company directly.
Decreased cost of In-Patient Care:
Ayushman Bharat/ National Health Protection Mission is going to help the common man immensely. At present, an estimated 80% of inpatient hospitalization is born in out of the pocket way. A total of 68% rely on their own savings and around 25% people rely on borrowings to meet these expenses. Ayushman Bharat is going to reduce this number, as around 40% of the total population will be covered under the scheme.
- Increased benefit cover for the poorest and the most vulnerable sections of the country, amounting to almost 40% of the population.
- Almost all the secondary and many tertiary hospitalizations (except a negative list) are going to be covered as part of the scheme.
- Each family will be provided with a coverage of 5 lakh for each family, and family size is not a constraint at all.
The scheme has many hidden benefits for the beneficiaries as well –
- Increased access to quality health and medication.
- The health needs of the individual, which often used to get ignored due to lack of the financial resources, can be taken care of with the additional resources provided by the scheme.
- After the scheme is implemented, timely treatments of ailment can be ensured. This will lead to improvement in health, highly satisfied patients, job creation and productivity and efficiency improvements. Hence, overall improvement in the quality of life can be guaranteed.
Who will get benefits?
Ayushman Bharat (AB-NHPM) is going to provide cover to about 10.74 crores poor and deprived rural families and identified the occupational category of urban workers’ families as per the latest census covering both rural and urban population. The scheme will be flexible in nature i.e. any changes coming to Census data in future or its formulation will be considered and can be incorporated very easily.
- The Central and State Governments will share total expenses accrued in premium payment in the specified ratio as per Ministry of Finance guidelines in vogue.
- The total expenditure will depend on actual market-determined premium paid in States/UTs where AB-NHPM will be implemented through insurance companies.
- In States/UTs where the scheme will be implemented in Trust/Society mode, the Central share of funds will be provided based on actual expenditure or premium ceiling (whichever is lower) in the predetermined ratio.
About Ayushman Bharat Scheme
The Ayushman Bharat Scheme is the biggest ever government-sponsored health scheme launched by any country. The scheme will benefit over 50 crore poor families living in India. The Ayushman Bharat scheme also faces many challenges and even though, it was recently launched, there have already been many opponents of the scheme.
RSBY was launched in the year 2008 by the Ministry of Labour and Employment and provides cashless health insurance scheme with benefit coverage of Rs. 30.000/- per annum on a family floater basis [for 5 members], for Below Poverty Line (BPL) families, and 11 other defined categories of unorganized workers. To integrate RSBY into the health system and make it a part of the comprehensive health care vision of Government of India, RSBY was transferred to the Ministry of Health and Family Welfare (MoHFW) w.e.f 01.04.2015. During 2016-2017, 3.63 crore families were covered under RSBY in 278 districts of the country and they could avail medical treatment across the network of 8,697 impaneled hospitals.