Bhamashah Swasthaya Bima YojanaRajasthan

Bhamasha Swasthaya Bima Yojana

Launched on 13th December, 2015 for around 1 crore eligible families of Rajasthan in compliance of Budget Declaration of Hon’ble Chief Minister, Rajasthan.

Organogram-State Level

Organogram-District Level

Bhamasha Swasthaya Bima Yojana• Beneficiary: Families identified under – National Food Security Act (NFSA) and

– Rashtriya Swasthya Bima Yojana (RSBY).

• Health Insurance Coverage: Rs. 30,000 (for general illnesses) and Rs. 3.00 lacs (for critical illnesses) per family per year.

• Disease Coverage: Total 1715 disease packages – 1148 Secondary

– 500 Tertiary

– 67 Govt. reserved packages

– Covering 14 specialties.

Secondary Packages (1148) Tertiary Package (500) Government PKg (67)Specialty No. of Pkg

Dentistry 36

ENT 155

General Medicine 36

General Surgery 402

Neurosurgery 59

Obstertics & Gynaecology

93

Oncology 10

Ophthalmology 64

Orthopedics 202

Paediatrics 31

Urology 124

Specialty No. of Pkg

Cardiology & CTVS 122

Chest Surgery 20

ENT 2

General Medicine 16

General Surgery 21

Neurosurgery 64

Oncology 178

Orthopedics 10

Paediatrics 8

Plastic Surgery 13

Urology 46

Specialty No. of Pkg

ENT 14

General Surgery 18

Obstertics & Gynaecology

25

Ophthalmology 10

Continue…• Govt Hospitals (n=480): Medical College &

associated hospitals, DH, SDH, Satellite hospitals and CHCs

• Private Hospitals (n=568) empanelled under the scheme,

• Empanelment of Pvt hospitals is responsibility of Insurance Company.

Information on govt and empanelled private hospitals is available at webpage of scheme http://health.rajasthan.gov.in/bsby

No. of Private Hospitals Empanelled So No. of Private Hospitals Empanelled So FarFar

Increasing number of

hospitals depicts increasing

interest of private sector

Increasing number of

hospitals depicts increasing

interest of private sector

Stakeholders in the Scheme

Responsibility of Stakeholders• Medical & Health:

– Overall planning & execution of scheme– Payment of premium to Insurer– Monitoring & Grievance Redressal of pvt & govt hospitals

• NIAC:NIAC:– Providing Insurance Cover to entitled families– Empanelment of private hospitals– Training & orientation of SM & Nodal Officers– Claim processing and payment

• DoIT:DoIT:– Preparing software for the scheme– Establishment of Call Center– Support in IT related issues – Issuing Bhamashah Card to all.

Admission & TID

Generation by Hospital

Admission & TID

Generation by Hospital

Eligibility Verification of

Family and individual

Identity using Bhamashah

Card / Bhamashah Slip / RSBY

Card

Eligibility Verification of

Family and individual

Identity using Bhamashah

Card / Bhamashah Slip / RSBY

Card

Checking available

amount in wallet of

family

Checking available

amount in wallet of

familyStarting

TreatmentStarting

Treatment

Blocking Package

Blocking Package

Online Pre-Authorization Request and Approval by

NIAC

Online Pre-Authorization Request and Approval by

NIAC

Discharge & online claim submission

Discharge & online claim submission

Claim Approval & Online Payment to

Hospital

Claim Approval & Online Payment to

Hospital

Secondary Package

Secondary Package

Tertiary Package

Tertiary Package

Patient will be received at hospital by Swasthya Margdarshak after IPD

advise by doctor

Patient will be received at hospital by Swasthya Margdarshak after IPD

advise by doctor

Process Flow under BSBY

What makes us different……

Rajasthan RSBY Maharashtra Tamil Nadu

Sum insuredSecondary – 30,000Tertiary – 3,00,000

30,000 2,50,000 1,50,000

Coverage ComprehensiveSecondary and

TertiarySecondary Tertiary Tertiary

Target populationNFSA (includes 15

categories) and RSBY

BPL familiesBPL & APL families

BPL families

Packages 1715 1300 972 1016

Verification of beneficiary

Bhamashah Card BiometricYellow / Orange

cardBiometric

Multipurpose call center

Yes No No No

Progress So Far..

Total No. of Claims Enlisted

0

50000

100000

150000

200000

250000

300000

350000

400000

3228 2006352906

97800

154178

228800

300751

364187386433

Number of Claims

Total Amount of Enlisted Claims (Rs. in Lac)

164.23 1016.432742.05

4873.94

7397.41

10736.41

14045.47

17069.8418177.17

0

5000

10000

15000

20000

31-12-2015 29-02-2016 30-04-2016 30-06-2016 10/8/2016

Rs. In Lac

Total No. of Claims Submitted

0

50000

100000

150000

200000

250000

300000

350000

2611 1659044319

83406

132820

197070

261073

313893335992

Number of Claims

Total Amount Submitted (Rs. in Lac)

0

2000

4000

6000

8000

10000

12000

14000

16000

124.9 769.552135.56

3888.84

6086.3

8903.33

11771.29

14112.315192.39

Rs. In Lac

Total No. of Claims Approved

0

50000

100000

150000

200000

250000

1736 1214231221

57384

89043

130702

177485

216938239524

Number of Claims

Claim approvals raised by around 86,000 in

last two months

Total Claims Approved (Rs. in Lac)

0

2000

4000

6000

8000

10000

12000

31-12-2015 31-01-2016 29-02-2016 31-03-2016 30-04-2016 31-05-2016 30-06-2016 31-07-2016 10/8/2016

73.75493.74

1419.89

2520.02

3693.65

5194.58

7196.23

9015.43

10270.27

Rs. In Lac

Approvals raised by around 40.00 cr in only

two months

Total No. of Claims Paid

1597922042 34580

83639

142605

209558

0

50000

100000

150000

200000

250000

Number of Claims

Rise of approximately

1,25,000 claims in last two months

Total Amount Paid (Rs. in Lac)

0.00

2000.00

4000.00

6000.00

8000.00

10000.00

till 29th Feb, 2016

31-03-2016 30-04-2016 31-05-2016 30-06-2016 28-07-2016

338.26 678.35 1303.533098.67

5260.00

8117.47

Rs. In Lac

Rise of 51 crores in last two

months

Pvt Contribution in Total Claim Booking

Critical Diseases Treated under The Scheme

•Cardiovascular & Cardio Thoracic and Vascular Surgery:

Bypass surgery (CABG): 305 claims amounting Rs. 2.27 crore

Heart Valve Repair: 512 claims amounting Rs. 5.43 crore.

Angioplasty: 2135 claims worth of Rs. 11.61 crore.

Congenital Heart Disease:102 claims amounting Rs. 67.44

lac.

•Cancer: 11602 claims of cancer treatment (Chemotherapy,

Radiotherapy and Surgery) amounting Rs. 14.96 crore.

•Brain Surgery: 1112 claims amounting Rs. 3.26 crore.

•Spinal Surgery: 796 claims amounting Rs. 2.41 crore.

•Lung Surgery: 75 claims amounting Rs. 24.08 lac rupees.

•Plastic Surgery: 233 claims amounting Rs. 81.67 lac.

•Cardiovascular & Cardio Thoracic and Vascular Surgery:

Bypass surgery (CABG): 305 claims amounting Rs. 2.27 crore

Heart Valve Repair: 512 claims amounting Rs. 5.43 crore.

Angioplasty: 2135 claims worth of Rs. 11.61 crore.

Congenital Heart Disease:102 claims amounting Rs. 67.44

lac.

•Cancer: 11602 claims of cancer treatment (Chemotherapy,

Radiotherapy and Surgery) amounting Rs. 14.96 crore.

•Brain Surgery: 1112 claims amounting Rs. 3.26 crore.

•Spinal Surgery: 796 claims amounting Rs. 2.41 crore.

•Lung Surgery: 75 claims amounting Rs. 24.08 lac rupees.

•Plastic Surgery: 233 claims amounting Rs. 81.67 lac.

IEC Activities

BSBYBSBYLED BOARD LED BOARD ON TOP OF ON TOP OF

PVT PVT HOSPITALSHOSPITALS

LED Boards on Roads

Pamphlet Printed for IEC of the Scheme & Pvt. Empanelled Hospitals

Facebook page- regular updationFacebook page- regular updation

Regular Updates on Google+ and blog

Success Stories of BSBY across Districts

• ASHA Samwad with more

than 46,000 ASHAs

through Video

Conference under the

chairmanship of Hon’ble

Health Minister, GoR

• Three rounds

accomplished so far for

orientation regarding

BSBY

Video Conferences with ASHA

BSBY ASHA KIT

IEC of BSBY Through Auto Riksha

Bhamashah Samsya Samadhan Shivir • Extensive IEC of the BSBY in Bhamashah Samsya

Samadhan Shivir being held during 25th July, 2016 to 5th

August, 2016 at each panchayat HQ.

Official Webpage of BSBY

Grievance Redressal

Redressal of Grievances • State (SGRC) and District Grievance Redressal

Committees (DGRC) are formulated. – SGRC: under the Chairmanship of CEO, RSHAA– DGRC: under the Chairmanship of District Collector

• Formulation of State Appellate Authority under the chairmanship of Principal Secretary, M&H

• Rajasthan Sampark Portal: Public grievance portal for inhabitants of state, can also register their complain at this portal.

• Integrated Toll Free Centre: 1800-180-6127 for redressal of any query and registering complaint.

• Most comprehensive health cover

• Provision for Fund Enhancement- Rs. 10.00 cr as corpus

• 2% of the premium is dedicated for IEC.

• Minimum Document Protocol (MDP)

• No Third Party Administrator

• Unique profit refund clause to ensure optimum premium utilization and discourage insurer from rejecting genuine claims

• Reimbursement to the hospital within 21 days of submission of claim .

Unique Features

Thanks