The workers in the unorganized sector constitute about 93% of the total work force in the country. The Government has been implementing some social security measures for certain occupational groups but the coverage is miniscule. Majority of the workers are still without any social security coverage. One of the major insecurities for workers in the unorganized sector is the frequent incidences of illness and need for medical care and hospitalization of such workers and their family members. Despite the expansion in the health facilities, illness remains one of the most prevalent causes of human deprivation in India.
It has been clearly recognized that health insurance is one way of providing protection to poor households against the risk of health spending leading to poverty. The poor are unable or unwilling to take up health insurance because of its cost, or lack of perceived benefits. Organizing and administering health insurance, especially in rural areas, is also difficult. Recognizing the need for providing social security to these workers, the Central Government has introduced the Rashtriya Swasthya Bima Yojana (RSBY). Till March 25, 2013, the scheme had 34,285,737 Smart Cards and 5,097,128 hospitalization cases.
In the past, the Government had tried to provide a health insurance cover to selected beneficiaries either at the State level or National level. However, most of these schemes were not able to achieve their intended objectives. Often there were issues with either the design and/ or implementation of these schemes.
Keeping this background in mind, Government of India decided to design a health insurance scheme which not only avoids the pitfalls of the earlier schemes but goes a step beyond and provides a world class model. A critical review of the existing and earlier health insurance schemes was done with the objective of learning from their good practices as well as seeks lessons from the mistakes. After taking all this into account and also reviewing other successful models of health insurance in the world in similar settings, RSBY was designed. It has started rolling from 1st April 2008.
RSBY- The Scheme
RSBY has been launched by Ministry of Labour and Employment, Government of India to provide health insurance coverage for Below Poverty Line (BPL) families. The objective of RSBY is to provide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization.
- Unorganized sector workers belonging to BPL category and their family members (a family unit of five) shall be the beneficiaries under the scheme.
- It will be the responsibility of the implementing agencies to verify the eligibility of the unorganized sector workers and his family members who are proposed to be benefited under the scheme.
- The beneficiaries will be issued smart cards for the purpose of identification.
The beneficiary shall be eligible for such in - patient health care insurance benefits as would be designed by the respective State Governments based on the requirement of the people/ geographical area. However, the State Governments are advised to incorporate at least the following minimum benefits in the package / scheme:
- The unroganised sector worker and his family (unit of five) will be covered.
- Total sum insured would be Rs. 30,000/- per family per annum on a family floater basis.
- Cashless attendance to all covered ailments
- Hospitalization expenses, taking care of most common illnesses with as few exclusions as possible
- All pre-existing diseases to be covered
- Transportation costs (actual with maximum limit of Rs. 100 per visit) within an overall limit of Rs. 1000.
- Contribution by Government of India: 75% of the estimated annual premium of Rs. 750, subject to a maximum of Rs. 565 per family per annum. The cost of smart card will be borne by the Central Government.
- Contribution by respective State Governments: 25% of the annual premium, as well as any additional premium.
- The beneficiary would pay Rs. 30 per annum as registration/renewal fee.
- The administrative and other related cost of administering the scheme would be borne by the respective State Governments
An electronic list of eligible BPL households is provided to the insurer, using a pre-specified data format. An enrollment schedule for each village along with dates is prepared by the insurance company with the help of the district level officials. As per the schedule, the BPL list is posted in each village at enrollment station and prominent places prior to the enrollment and the date and location of the enrolment in the village is publicized in advance. Mobile enrollment stations are set up at local centres (e.g., public schools) in each village.
These stations are equipped by the insurer with the hardware required to collect biometric information (fingerprints) and photographs of the members of the household covered and a printer to print smart cards with a photo. The smart card, along with an information pamphlet, describing the scheme and the list of hospitals, is provided on the spot once the beneficiary has paid the 30 rupee fee and the concerned Government Officer has authenticated the smart card. The process normally takes less than ten minutes. The cards shall be handed over in a plastic cover.
Smart card is used for a variety of activities like identification of the beneficiary through photograph and fingerprints, information regarding the patient. The most important function of the smart card is that it enables cashless transactions at the empanelled hospital and portability of benefits across the country. The authenticated smart card shall be handed over to the beneficiary at the enrollment station itself. The photograph of the head of the family on the smart card can be used for identification purpose in case biometric information fails.
A list of the hospitals (both public and private) (External website that opens in a new window) will be provided at the time of enrollment. A helpline number will also be provided along with the smart card. Based on the qualifying criteria, both public and private hospitals will be empanelled by the insurance company. The beneficiary will have the option to choose hospitals where they want to go.
No payment for the treatment cost up to Rs. 30000/- would be paid to the hospital.
In case of Cashless service, the patient will not have to spend any amount for taking the treatment and hospitalization. It is the job of hospital to claim from the insurer.
Unique Features Of Rsby
The RSBY scheme is not the first attempt to provide health insurance to low income workers by the Government in India. The RSBY scheme, however, differs from these schemes in several important ways.
- Empowering the Beneficiary
- RSBY provides the participating BPL household with freedom of choice between public and private hospitals and makes him a potential client worth attracting on account of the significant revenues that hospitals stand to earn through the scheme.
- Business Model for all Stakeholders
- The scheme has been designed as a business model for a social sector scheme with incentives built for each stakeholder. This business model design is conducive both in terms of expansion of the scheme as well as for its long run sustainability.
- The insurer is paid premium for each household enrolled for RSBY. Therefore, the insurer has the motivation to enroll as many households as possible from the BPL list. This will result in better coverage of targeted beneficiaries.
- A hospital has the incentive to provide treatment to large number of beneficiaries as it is paid per beneficiary treated. Even public hospitals have the incentive to treat beneficiaries under RSBY as the money from the insurer will flow directly to the concerned public hospital which they can use for their own purposes. Insurers, in contrast, will monitor participating hospitals in order to prevent unnecessary procedures or fraud resulting in excessive claims.
- The inclusion of intermediaries such as NGOs and MFIs which have a greater stake in assisting BPL households. The intermediaries will be paid for the services they render in reaching out to the beneficiaries.
- – By paying only a maximum sum up to Rs. 750/- per family per year, the Government is able to provide access to quality health care to the below poverty line population. It will also lead to a healthy competition between public and private providers which in turn will improve the functioning of the public health care providers.
- Information Technology (IT) Intensive
- Every beneficiary family is issued a biometric enabled smart card containing their fingerprints and photographs. All the hospitals empanelled under RSBY are IT enabled and connected to the server at the district level. This will ensure a smooth data flow regarding service utilization periodically.
- Safe and foolproof
- The use of biometric enabled smart card and a key management system makes this scheme safe and foolproof. The key management system of RSBY ensures that the card reaches the correct beneficiary and there remains accountability in terms of issuance of the smart card and its usage. The biometric enabled smart card ensures that only the real beneficiary can use the smart card.
- The key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to use his/ her smart card in any RSBY empanelled hospital across India. This makes the scheme truly unique and beneficial to the poor families that migrate from one place to the other. Cards can also be split for migrant workers to carry a share of the coverage with them separately.
- Cash less and Paperless transactions
- A beneficiary of RSBY gets cashless benefit in any of the empanelled hospitals. He/ she only needs to carry his/ her smart card and provide verification through his/ her finger print. For participating providers it is a paperless scheme as they do not need to send all the papers related to treatment to the insurer. They send online claims to the insurer and get paid electronically.
- Robust Monitoring and Evaluation
- RSBY is evolving a robust monitoring and evaluation system (External website that opens in a new window). An elaborate backend data management system is being put in place which can track any transaction across India and provide periodic analytical reports. The basic information gathered by government and reported publicly should allow for mid-course improvements in the scheme. It may also contribute to competition during subsequent tender processes with the insurers by disseminating the data and reports.
Central Complaint and Grievance Redressal System (External website that opens in a new window) (CGRS) ensures that the grievance relating to RSBY is disposed by the use of ICT which automatically tracks and pursues the status. All the stake holders can file an online complaint (External website that opens in a new window) about the Scheme. Online tracking facility of the complaint is also available. Users can refer the manual (External website that opens in a new window) for detailed information related to CGRS.
- State-wise scheme status (External website that opens in a new window)
- Empanelled Hospitals (External website that opens in a new window)
- De-Empanelled Hospitals (External website that opens in a new window)
- FAQs on RSBY (External website that opens in a new window)
- Policy and Guidelines (External website that opens in a new window)
- Online Complaint on RSBY (External website that opens in a new window)
- RSBY Videos (External website that opens in a new window)