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Comparative features of the four largest mass health insurance schemes
Table 20.2 Comparative features of the four largest mass health insurance schemes
Insights from India’s microinsurance success
Features Criteria Yeshasvini (Karnataka) 2003 Aarogyasri (Andhra Pradesh) 2007 RSBY (National) 2008 Kalaignar (Tamil Nadu)2009
Product Unit of enrolment Individuals Families Families Families
Sources of funds Contribution: Benefi ciary 58%
by state US$0.60 by benefi ciary +75% by centre by State
+ Government 42% (in 2009–10)
and 25% by State government in most cases
Premium Premium Premium rate in 2009–10 US$3.30 per person US$6 per family Average US$12 per family US$10 US$10 per family
Maximum insurance US$4 444 per person US$3 US$3 333 333 per per family family with with additional
US$666 per family US$2 222 over 4 years, per family
cover cover
buff er of US$1 111
Common Common operations Cardiac, ear, nose, and throat (ENT),
Oncology, cardiac, trauma,
Medical treatment, ophthalmic opera- opera-
Orthopaedic, oncology, urology, cardiol- cardiol-
general surgery, paediatric, obstetric,
gynaecological and urinary
tions, neurology, infectious diseases,
ogy, hysterectomy, ophthalmology and
ophthalmic operations
surgeries, general surgeries
gynaecological and obstetric operations
ENT
Manage- Manage-
Cost Cost containment
– TPA provides pre-authorization for
– Predefi ned diagnostic package
– Smart card to identity verifi cation and – Predefi ned diagnostic package rates and
ment
measures measures
all procedures
rates and pre-authorization con- prior authorization
pre-authorization control for medical
tools
– Tariff s for 1 600 procedures pre- pre-
trol for medical escalation – Close ended diagnostic package rates escalation,
negotiated
– MIS, medical vigilance teams and
for common operations.
– Discharge planning with liaison offi cers
deep network of project monitor- – In-depth analysis of claim experience
ing staff in hospitals
IT tools tools used – Electronic claims submission – Digital signature for all users, – Photos and biometric data of families – Digital smart card to identify benefi ciary
– Software in all network hospitals, hospitals, patient digital photographs pre- collected on smart chip at enrolment and family
linked to TPA’s systems
and post- procedure
– Smart cards enable offl ine authoriza- authoriza- authoriza- – Web-based pre-authorization and claim
– Comprehensive MIS and electro- electro- electro- tion and batch transfer of data submission
nic claims operation and payments
– – – – Webcams Webcams Webcams Webcams for for for for coordination coordination coordination coordination and and and and monitor- monitor- monitor- monitor- monitor-
ing of liaison offi cers in network hospitals
Hospital empanelment Minimum 50 in-patient beds beds beds + inten- inten-
Minimum 50 beds and other
At least 10 beds + medical, surgical,
Minimum 50 beds
criteria
sive care (ICU), ambulance, ambulance, qualifi ed
i nfrastructure criteria like ICU
diagnostic facility + registration with
doctors
with 2 ventilators
IT department
No. of full-time staff in
Less than 10 117 Approximately 10 at central level and
Less than 10
implementing agency
100 at state nodal agencies
Perform- Perform-
Number of benefi ciaries
3 million Approximately 70 million
63 million 35 million
ance
(Sept. 2010)
(20.4 million families)
Average cost per
8 240 27 848 4 262 33 720
hospitalization (INR)
Number of hospitaliza- hospitaliza-
22 55 5 25 4
tions per 1 000 persons
Claims ratio 157% 69.6–128.3% (average 89%) About 80% in 2009–10 80%
449
Source: Adapted from PHFI, 2011.