“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,” said an official statement.
Ayushman Bharat, popularly known as Modicare and tagged as world’s largest government funded public health coverage, seeks to provide Rs 5 lakh medical coverage per family per year to 10.74 crore poor and vulnerable families based on Socio Economic and Caste Census (SECC). It also proposes to strengthen the primary healthcare in the country with 150,000 health and wellness centres.
AB-NHPM, which will subsume the on-going centrally sponsored schemes – Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS)., will take care of almost all secondary care and most of tertiary care procedures.
“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 or private empanelled hospitals across the country,” said the statement.
AB-NHPM will be an entitlement based scheme with entitlement decided on the basis of deprivation criteria in the SECC database, it said.
To control costs, the payments for treatment will be done on package rate basis. The package rates will include all the costs associated with treatment and it will be a cashless transaction for the beneficiaries. States will have the flexibility to modify these rates within a limited bandwidth.
“One of the core principles of AB-NHPM is to co-operative federalism and flexibility to states,” said the statement. The states would be allowed to expand AB-NHPM both horizontally and vertically and they can implement through insurance company or Trust/Society or a mixed model.
For giving policy directions and fostering coordination between Centre and states, it is proposed to set up Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) at apex level. Further, an Ayushman Bharat National Health Protection Mission Governing Board (AB-NHPMGB) and an Ayushman Bharat – National Health Protection Mission Agency (AB-NHPMA) would also be set up.
“At the national level to manage, AB-NHPMA would be put in place. States/UTs would be advised to implement the scheme by a dedicated entity called State Health Agency,” it said.
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 and detection of any potential misuse, fraud and abuse cases.
The Cabinet noted that out of pocket (OOP) expenditure in India is over 60 per cent, which leads to nearly 6 million families getting into poverty due to catastrophic health expenditures. It said AB-NHPM will have major impact on reduction of OOP expenditure.
“This will lead to timely treatments, improvements in health outcomes, patient satisfaction, improvement in productivity and efficiency, job creation thus leading to improvement in quality of life,” it added.
The expenditure incurred in premium payment will be shared between Central and state governments in specified ratio, and the total expenditure will depend on actual market determined premium paid in the states.
“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 pre-determined ratio,” the Cabinet said.