Community Health Insurance Model for

Indira Kranthi Patham

Sanjeevini

Objectives

Improve the quality of life through various healthcare initiatives thereby reducing the severity of poverty resulting from health related catastrophes

Provide quality Healthcare services at affordable costs

Community Development through Health education on Preventive Health, Nutrition and Sanitation

Proposed Model

Network Partners

Network the Hospitals at Mandal Level Super Specialty hospitals at Dist level

Tie-up with NWH to provide consultation by Lady Doctor at PHC once in a week.

Benefits

Preventive Healthcare- Community Development, Education on Nutrition and Sanitation

Medical Conditions

Free OPD consultation, Discount on Drugs & Diagnostics

Surgical Conditions

At Village level through Heralth Assiastants and Health Workers

Refferal Hospitals

Referral Hospitals

Referral Hospitals

Benefits of the Scheme

• Free OPD consultation• Discount on Diagnostics• Hospitalization Cover for Surgeries• Hospitalization Cover for Medical Conditions

admission for family• Community Development Activities

Treatment to be taken at Network Hospitals Only Treatment in General ward only

Out Patient Consultation

PHC level: consultation with lady doctors once in a week Network Hospital (NWH): consultation free of cost

Diagnostics:

Basic diagnostics will be done at PHC level free of cost

Diagnostics at NWH will be done at a fixed discounted rate.

Quality Medicines1.    Free of cost at PHC level2.    Discounted rate at NWH ( drug depots of Velugu)

Services under the Scheme

Medical and Secondary and Tertiary Surgical Care: through Referral Network Hospitals, up to a maximum amount of 30000/-Covers more than 1650 surgeries –includes all categories of complex and common surgeries, OBG – includes normal delivery, LSCS and HysterectomyGeneral SurgeryGastroenterologyOrthopaedics – includes fracture surgeriesGenito-UrologyEndocrinology ENT.

100% Cashless facility

Hospitalization cover: Family floater hospitalization policy

Cover- Inpatient treatment requiring hospitalization for more than 24 hours. Maximum amount payable is Rs 5000/- under the Family Package 4. Cover would include consultation, investigation and room charges, medicines and consumables.

Bed charges, doctor fees and Investigation charges will be fixed.

10% of Co-Payment on the final bill.

Diagnostics

• Investigations like X-ray, Blood tests, Urine tests Ultrasound CT, MRI, etc covered

• Can be done at Network Hospitals at special discounted rates

Cashless Service at Network Hospitals• ID cards will be issued to every member

enrolled. • Member produces card at Network hospitals

to avail of services. • Hospital seeks pre-authorization from ZS for

giving cashless service or any planned procedure

• Based on eligibility, ZS gives authorization to Hospitals to start treatment.

• Member to undergo the required treatment• Member will sign on claim form, at discharge • He pays only for exclusions under the

scheme.

Premium

• For 4 lives-Rs. 260/yearPremium Collection - One time

Upfront payment

  OPD Medical Admission Surgical Treatment

Doctor’s fees Free Free Free, Included in package

Length of stay   2 Admission/Family Till fit for discharge

Medicines/consumables

Buy from Biocare or NWH Pharmacies

Included in the Package

Free, Included in Package

Investigations Pay discounted rates Included Free, Included in package

Bed charges   included Included in package

Oxygen, ventilator etc

  Beneficiary to pay for

Included in package

Nursing charges   Included Included

What do you pay for?

OPD diagnostics oxygen Ventilator & other exclusions10% of the final bill

Non-medical expenses, Implants like stents, valves & Other exclusions

Benefits

•Prosthesis and Implants including Valves, Grafts Mesh, Stents, Nails, Screws, Spectacles, Hearing Aids

•Transplants

•Cosmetic Surgery

•Malignancies – Chemotherapy,

•Angioplasty

•Autoimmune diseases

•Vaccination

•Dental surgeries

•Dialysis

•Vitamins and Tonic

•Ambulance Services

•Food and other Non Medical expenses

Any other expenditure, which are not related to illness/hospitalization

Exclusions

Implementing Agency (Zilla Samakhaya will act as TPA)

The ZS is responsible for the day-to-day operation of the Scheme. The duties will include, Ensure service standards at provider Network for hospitalization and Diagnostics

• Maintaining member database

• Arrange for cashless treatment for the beneficiary in

• Network Hospital by issuing pre-authorization

• Claims Processing and settlement

• Maintenance of accounts

• Generation of periodic report on utilization (statistics)

• Administer the scheme, avoiding misuse and fraud

• Appoint required manpower to monitor, manage and maintain the scheme.

PHC/Network Hospitals: PHCs and Hospitals enrolled under the scheme to provide services to the members of the scheme.

Responsibility:

Quality Treatment to members

Free Consultation and Discounted Investigations

START

STOP

Hospital approaches ZS with application

Inspection of Hospital facilities by ZS Representatives

Representative forwards recommendation to IKP

Site visit and Inspection by IKP Evaluation of the Hospital as per the Standards of accreditation Generation of the Inspection report on Services and facilities Submission of Report to Committee (IKP+ZS)

Final approval from Committee

Formal tie-up of the hospitals tripartite agreementTraining of Hospital co-coordinator regarding the Protocol

Updating of Database

Communication to

IKP/ZS MMS/VO HSC

Hospital Accreditation Process Flow

Enrollment• Village Organization will take the responsibility of Enrollment

• VO will collect the Enrollment from and Premium from the member and deposit with the Mandal samakhaya, hence MS will collect the premium of their Mandal and deposit with ZS

• ZS will issue ID cards in 15 days time to MS. MS will issue them to VO. VO will issue the cards to the members.

• As soon as members get the ID card they can avail the treatment at NWH

STOP

START

VO Representatives deposits the Fee to MS or ZS Bank account

Generation of Photo ID Cards and covering letters

VO Reps forwards enrollment forms to ZS

Data from Enrollment form entered into software

Attestation by VO Representative. Issuance of Receipt to member

Collection of Fee and photograph taken

Distribution of ID to members by VO Reps

Dispatch of ID Cards to VO Reps

Enrollment Filled by Member

Availing the Treatment

Beneficiary goes to Network hospital with ID Card, Receipt

Admission for Surgery

Free OPD Consultation

InvestigationSpecial rates CASHLESS

Hospitalization

Admission for Medical

treatment

Patient pays only 10% of co-payment

Member signs on the Claim Form

START

Discharge

Intimation to ZS by NWH

Pre-Authorization- from ZS

Preauthorization Method:

When a beneficiary is advised surgery/medical treatment by NWH, the Hospital sends a Pre-authorization to the ZS office seeking approval to conduct the surgery under the Scheme. The medical officer at the ZS approves the Preauthorization if all documents and requirement is in order.

In case of emergency, the Coordinating Officer at NWH shall take verbal sanction from the Implementing Agency and proceed with the surgical/medical treatment. The preauthorization for the same shall be sending to the Implementing Agency within 24 hours.

Documents to be sent: Photocopy of the ID Card

Preauthorization Flowchart

General Exceptions Sent to Hospital for supporting reports verification

Eligibility

Yes

Complicated cases

Eligible

No

Receive of Intimation from Hospital

Generation of Pre-Authorization Serial No.

Complicated/General/ Exceptions

Sent to VO Rep for verification

A-Eligibility VerificationID card, Receipt, Residential Proof B-Medical verification

Data entry into Software

START

STOP

Letter of Rejection to HospitalAuthorization letter to hospital

Medical Officer checks and fixes rate

Letter of Rejection to Hospital

NO

Claim

The Claim Form from the Hospital should be accompanied by

Photocopy of the I.D. Card

Original claim form with the signature of the beneficiary.

Final split – up bill – with the signature of the beneficiary raised in the name of “ZS.”

Original authorization issued by ZS

Original discharge summary

Operation Note from treating Doctor (Incase of surgery)

Original Investigation and Lab Reports

List of consumables prescribed

Claims FlowchartReceipt of claims

From NWH

Communication To Hospital

Communication To Hospital

Claim ID Generation

Document verification

Medical Scrutiny and Claims Processing

Approved Claims

Outward

Letter Of Settlement To the Bank By ZS

Claim pending for supportingDocuments

Collection of DDDispatch o hospital

Complete

Incomplete

Process of Reimbursement to NWH

Claims checked for required documents

Medical scrutiny of the Claim by ZS medical officers

DDs dispatched to the Hospitals

 

Controls and quality checks

Periodic quality check of Labs and Hospital service audit will be carried out by the ZS. Continuous failure to keep prescribed standards and conditions set by the ZS would result in disciplinary action against the NWH and Lab

ZS coordinators (Case Managers)

Obligations as a NWH

•All Network Hospitals (NWH) shall display a board with “Scheme Name” in Telugu prominently at the reception.

•Under the scheme, the beneficiaries are entitled to Free Out Patient services. No amount shall be collected as Registration Charges or Consultation Charges. On no account shall any amount be collected from the individual beneficiaries when admitted for surgical procedure

•The package rates mentioned are all exclusive of the implants and the prosthesis.

•The beneficiaries under the Scheme will be entitled only for General Ward Admission

OPD Record

S. No

Name of Patient

ID No Age/ Sex

Address Specialty Investi gations

Surgery Statistics Report Date:

S No

Name ID No

Age& Sex

Address Date of

Admission

Name of surgery

Specialty

Pre-autho No.

Amount

OPD Statistics Weekly Report

Name of the Hospital PlaceStatistics From: To:

Speciality No.Total upto this week

1 Cardiac Surgery2 Cardiology3 General Surgery4 General Medicine5 Neurology6 OB & G7 Ophthalmology8 Orthopaedics9 Paediatrics

10 Urology11 Vascular Surgery

T O T A L

IPD Weekly Statistics ReportName of the Hospital : District :-

Surgery Statistics From: To:

Sl.No. Surgery/Medical Admission Speciality NoTotal upto this week

12345

No. of surgeries/Medical Admissions performed for the current week :-

Details of Investigations

 Investigations No.

Total upto this week

1 Albumin2 Blood Grouping3 Blood Sugar4 Blood Urea5 CBC6 Cholestrol7 CKMB8 CPK9 Createnine

10 CT Scan11 Direct12 ECG13 Echo14 ESR15 HDL