Rashtriya Swasthya Bima Yojana (RSBY)

Rashtriya Swashtya Bima Yojana Insurance Coverage

The sum insured amount ranges up to Rs. 30,000 on a family floater basis and it can cover up to 5 members of the BPL household. This medical insurance scheme also provides a cover for transportation charges of Rs. 100 per visit to the hospital, up to a maximum of Rs. 1000. The scheme commences from the next month of the enrollment date.

Benefits to the Beneficiary

The Rashtriya Swasthya Bima Yojana allows the beneficiaries of the BPL households and workers in the unspecified sectors, to select health care options from public and private hospitals. The insured easily get treatment in the best hospitals as the scheme offers the healthcare providers significant revenue.

Eligibility Criteria to Buy Rashtriya Swasthya Bima Yojana Scheme

• The eligibility criterion to avail the health benefits of the Rashtriya Swasthya Bima Yojana Scheme is as follows:
• The individual should be working in an unorganized sector that is a part of the BPL household. People who are registered under welfare boards are also eligible to enter the program
• There is no upper limit to apply for the RSBY scheme. It is suitable for every member of a person’s family, irrespective of their age.
• This scheme can benefit nearly one-third of our population as it is available for everyone who is eligible to buy it.

Claim Settlement Procedure

Once the treatment is taken by the patient, the empanelled hospital will send an electronic report to the Third Party Administrator (TPA) or the insurance provider. The TPA or the insurer will then go through the information records and will pay off the hospital within the stipulated time based on the agreement between the hospital and the insurer.

Portability of Smart Card

Once the policy is issued the beneficiary will receive a smart health card and it can be used to avail health care services in any of the network hospitals who are registered with RSBY across India. All the empanelled hospitals under RSBY offer cashless hospitalization to the insured members.

RSBY includes a set of inter-related and complex activities. Here’s a quick rundown of the broad sets of activities:

Financing for Rashtriya Swashtya Bima Yojana

RSBY is a sponsored by the Government of India and is designed for the BPL population of India. Major financing is done by the Government of India (75%), and the remaining is paid by the respective state government. In the North-eastern states and in J&K the Government of India’s contributes 90 percent in and the respective state Governments only need to pay 10% of the insurance premium.

And beneficiaries only need to pay registration fees of 20 rupees.  And this amount can be utilized for administrative expenses that were incurred under the scheme.

How is the Selection of the Health Insurance Provider Done?

A competitive public bidding process is conducted by the state governments to select a public or private insurance provider that holds IRDA license to provide health insurance in India. Then the insurance company with the lowest financial bid is chosen as the health insurer in the state or the set of districts. This financial bid is the annual premium for every registered household.

The health insurance company needs to agree with the coverage benefit fixed by the Government of India through cashless hospitalization by using smart cards. Only one insurance company can function in one district. However, more than one insurer can operate in a particular state.

How is the BPL Data Prepared?

RSBY gathers figures for each state from the Union Planning Commission. RSBY provides insurance cover to enrolled BPL households from each district. The State Government needs to prepare and submit the BPL data in a specific electronic format as given by the Government of India.

It includes all the details of the family members such as their names, age, details of the head of the family members, relationship with the head of the household. The BPL data needs to be prepared in the specified format for the scheme to be implemented in the district.

How is the Enrollment of Beneficiaries Done?

The health insurance company gets an electronic list of all the eligible Below the Poverty Line in a pre-specified data format. The insurance company prepares an enrollment schedule with dates for each village (based on the data and with the help of the district officials).

This list is then posted in each village at the prominent enrollment stations. The insurer then collects the biometric information based on the fingerprints and photographs of the members of the BPL households. The beneficiary only needs to pay Rs. 30 as fees and they are given a smart card and an information pamphlet with the details of RSBY and the list of network hospitals.

A Field Key Officer or a government officer and a representative from the insurance company representative should be present to authenticate the legitimacy of the enrolment. A consolidated list is then sent to the state nodal agency. The list of the BPL households is maintained centrally and on the basis of this list the Government of India makes financial transfers to the state governments.

How is the Empanelment of Health Insurance Companies Done?

Once the insurance company is selected, the empanelment of hospitals should be also be done along with it. The health insurance company should make sure that there are enough network hospitals in the district to allow them to avail the treatment in the nearest hospital.

These network hospitals should have a dedicated Rashtriya Swashtya Bima Yojana (RSBY) desk with trained personnel. The hospital list can consist of both private and public hospitals that are willing to participate. The health insurance company should also provide a list of RSBY network hospitals to the insured members at the time of registration.

Utilization of Services by Beneficiaries

The transaction process starts when the beneficiary visits the network hospital. Once the beneficiary reaches the RSBY help desk at the network hospital, his identity will be verified with his smart card, fingerprints, and photograph.

In the case of hospitalization, the associate at the help desk will check the listed procedure for the specified package and will also check the price from the health insurance provider.

Once the beneficiary gets discharged from the hospital, his smart card will be again swiped and the fingerprint will be verified and the pre-determined cost of the medical treatment will be deducted from the smart card.

The compensation provided includes the transportation expense of Rs. 100 while getting discharged from the hospital. And the maximum limit is up to Rs. 1000 for every year for a sum insured of Rs. 30,000. The beneficiary doesn’t need to furnish any proof to avail the transportation assistance.

Monitoring and Evaluation

All the information related to the hospital transactions is sent via phone line to the district server. The data is generated in the pre-formatted tables for the government and the insurance company respectively. This way the insurer can transfer funds to the hospitals, track claims, and also investigate in the case of dubious claim patterns.