Rashitya Swasthiya Bima Yojna (RSBY) is a health insurance plan for the poor segment of the society. Today in India, about 93 percent of total work force consists in the unorganized sector. There have been certain governmental initiatives to implement some social security measures for specific occupational groups. However, the coverage under these initiatives was diminutive. There are still a large number of workers devoid of any social security protection. This is particularly worrisome in the case of an illness, for medical care and hospitalization take away a prominent part of their savings and the workers and their families are let to suffer from great uncertainties. The little advancement in health facilities is inadequate and limited in bringing relief to a large section of underprivileged families and ailments continue to prevail as the single big cause of human deprivation in India.
Social experts have identified health insurance as an effective method to provide safety to poor households in the case of health spending that usually leads to poverty. Usually the costs of such health insurances are high and many times there advantages have been poorly propagated. Hence, the poor remain ignorant or unwilling to opt for health insurance. There is also a difficulty in organizing and administering health insurance, particularly in rural areas. Therefore, keeping in mind the necessity for supplying social security to these workers, the Central Government has presented the Rashtriya Swasthya Bima Yojana (RSBY). In the financial year 2012-2013 the scheme had more than 3.5 crore Smart Cards and about fifty lakhs cases of hospitalization.
GENSIS of RSBY
Earlier only a select group was targeted by the government to provide the benefit of health insurance cover. These beneficiaries were selected either at the state level or the national level. In majority of cases, the schemes proved unsuccessful in fulfilling the desired objectives as there were problems either with design or with the implementation of the schemes (in some cases the problem was with both design and implementation).
The Government of India undertook a study to determine the causes of earlier failures of health insurance schemes and designed a novel scheme that avoided the drawbacks of the earlier schemes and going a step further, supplied a world class model. During this study, the experts critically evaluated the existing and earlier health insurance schemes with a goal to learn from their good practices and seek lessons from the errors. The experts also studied good health insurance models from around the world. With this experience they were able to design an innovative scheme in the form of RSBY. The scheme officially came into effect from 1st April 2008.
RSBY- The Scheme
RSBY has been initiated by the Ministry of Labour and Employment, Government of India. Its purpose is to deliver health insurance security for Below Poverty Line (BPL) people. The aim of RSBY is to supply security to BPL families from monetary burdens rising out of health jolts that comprise hospitalization.ELIGIBILITY
- Unorganized segment workforces of the BPL group and the members of their families (maximum five members) would benefit from this scheme.
- The implementing agencies are given the authority to ascertain the eligibility of the unorganized sector labours and their family members who have applied under the scheme.
- The eligible persons would be provided smart cards for identification purposes.
Different state governments offer different benefits under the RSBY scheme based on geographical and people requirement. Nevertheless, the respective state governments are required to include certain below mentioned minimum advantages in the scheme:
- Along with the unroganized sector worker, his family of five units would be covered.
- The overall Sum Insured shall be Rs. 30 thousand per family on a per annum basis. This amount would be carried forward on a family floater basis.
- There would be a provision of cashless attendance to all the covered illnesses.
- The hospitalization expenses would take care of the majority of common diseases with very little exclusion.
- There will be a cover on all pre-existing sicknesses.
- There would be a provision of transportation costs with an overall limit of Rs. One thousand. The per visit transportation cost would have an upper limit of Rs. One hundred.
- Contribution by Government of India: The Central Government would pay 75 percent of the estimated yearly premium of Rs. 750, subject to a maximum of Rs. 565 per family on an annual basis. The Central Government would also bear the expense of the issue of smart cards.
- Contribution by respective State Governments: The State Governments would pay 25 percent of the annual premium, along with any added premiums.
- The beneficiary would have to pay an annual payment of Rs. 30 for registration and renewal fee.
- The State Governments would bear the costs related to administrative and other associated charges of the administration of the scheme.
- The insurer is given an electronic list of entitled BPL households using a pre-specified data format.
- The insurance organization works in tandem with the district level officers to prepare every village’s enrolment schedule and respective dates.
- Each village posts the list of BPL households at the enrolment stations and prominent places according to the schedule. This list is posted prior to the enrolment and an effort is made to familiarize the public with the date and location of the enrolment in advance inside the village.
- Additionally, each village sets up mobile enrolment stations at local centres such as public schools and post offices.
- The insurer equips these stations with the essential hardware needed to collect biometric information in the form of fingerprints, camera to photograph the covered members, and printer to print out the smart cards with an attached photo. The insurer further provides the applicant with a smart card and an information pamphlet that describes the scheme and provides the list of hospitals covered under this scheme.
- This smart card is instantly provided by the concerned government officer after authentication once the beneficiary has paid the fee of Rs. 30.
- The whole process takes less than ten minutes of time and the cards are delivered to the recipient in plastic covers.
- The smart card performs a variety of functions like authenticating the beneficiary through biometrics and photographs and providing information about the patient.
- It empowers the beneficiary to engage in cashless transactions at the designated hospitals.
- The benefits under a smart card could easily be ported across the country.
- The beneficiary can collect the smart card after authenticated at the enrolment station.
- If biometrics fails then the photograph of the head of the family on the smart card could be utilized to authenticate the identification.
- At the time of enrolment, the beneficiary is provided an all-inclusive list of hospitals (both public and private) that accept the RSBY smart card.
- Apart from smart card, the beneficiary is also given a helpline number wherein the smart card holder can put in his or her query.
- On the basis of qualifying conditions, both public and private hospitals would be empanelled by the insurance company. This gives flexibility to the beneficiary in choosing his or her preferred hospital.
- The hospitals will provide free treatment up to a charge of Rs. 30 thousand.
- In the instance of a cashless service, it will be the hospital’s responsibility to get the claim from the insurer. This will save previous time of the patient and his family.
RSBY comes under government’s incessant initiative to provide health insurance to BPL group workers. The special features of this scheme are given as:
- Business Models for all Stake Holders: The scheme was initiated as a business model for a social sector scheme with inducements put together for each stakeholder. This business model design is favourable both with regards to expansion of the scheme and also for its long-term sustainability.
- Cashless and Paperless Transaction: The beneficiary receives cashless treatment in any of the empanelled hospices. The person is required to just bring in the allotted smart card and fulfil authentication through the biometrics. The scheme is also paperless, because the participating providers do not have to send all the papers associated with treatment of the insurer. The provider just need to send online claims to the insurer and is paid through electronic means.
- Empowerment of Beneficiary: The participating BPL families get freedom of choice between public and private hospitals. Moreover, the smart card holder becomes an attractive client because he or she would help in significant revenues that a hospital could earn through the scheme.
- Government: – The government pays just an annual higher upper limit pay of Rs. 750 to each household and is able to supply quality health care access to the BPL citizens. The scheme is beneficial at another level. It increases the competition between public and private hospitals, thereby ensuring that each provide quality health care to the people.
- Hospitals: The hospitals get an incentive to supply treatment to a large population listed under the RSBY scheme. This in-turn helps in the flow of large revenues. Contrarily, the insurers are able to monitor the participating hospitals so as to avert needless processes or scam arising in disproportionate claims.
- Information Technology (IT) Intensive: Each member of the RSBY household is provided with unique identification in the form of a biometric enabled smart card that has their fingerprints and photographs. Entire hospitals empanelled under RSBY are IT supported and connected to the server at the district level. This enables a smooth data flow with regards to periodic service utilization.
- Insurers: The insurer is given premium for every family enrolled under the RSBY scheme. Hence, the insurer is motivated to enrol all the members of his family under the BPL list. This ensures a better coverage for the targeted beneficiaries.
- Intermediaries: The scheme takes the assistance of certain intermediaries who have greater stake in helping the BPL families like the NGOs and the MFIs. Each intermediary is given specific imbursement for delivering their services in reaching out to the beneficiaries.
- Portability: RSBY’s prominent feature is that a registered beneficiary residing in a specific geographical district would be able to avail to use the government issued smart card in any RSBY empanelled hospital in all parts of the country. Hence, poor families can enjoy its benefits as they migrate from one place to another in search for work. Cards could even be split for migratory labours to carry a part of the coverage with them individually.
- Robust Monitoring and Evaluation: RSBY is developing a strong monitoring and evaluation system. An intricate backend data management system is being established to track any transaction inside the country and supply sporadic methodical reports. The government acquired basic information should be publicly broadcasted to permit mid-course enhancements in the scheme. It might also help in competition in the course of ensuing tender procedures with the insurers by publicizing the data and reports.
- Safe and Fool Proof: The system is made fool proof through the combined usage of biometric enabled smart card and a strategic management system. The strategic management system of RSBY confirms that the card is provided to the deserving recipient and there occurs answerability with regards to issuance of the smart card and its usage. The biometric enabled smart card makes sure that the card is not misused by a factual beneficiary and evades any occurrence of scam.
CENTRAL COMPLAINT & GRIEVANCE REDRESSAL SYSTEM
- Central Complaint and Grievance Redressal System (CGRS) guarantees that the complaints associated with RSBY is cleared up at the earliest through ICT which mechanically tracks and follows the status of the grievance.
- An online complaint regarding the scheme could be filed by all the stake holders.
- There is also an availability of online tracking of the complaint.