RSBY was launched to provide health coverage to all those living below the poverty line in India. Under the scheme, beneficiaries are entitled to hospitalization coverage of up to Rs. 30,000/- annually (approximately USD 700) for most diseases. Beneficiaries pay Rs. 30/- as a registration fee, while the central and state governments pay the premium to the insurer.
RSBY was launched to provide health coverage to all those living below the poverty line in India. Under the scheme, beneficiaries are entitled to hospitalization coverage of up to Rs. 30,000/- annually (approximately USD 700) for most diseases. Beneficiaries pay Rs. 30/- as a registration fee, while the central and state governments pay the premium to the insurer.
The objectives of RSBY are to:
- Provide financial protection from health care expenses on hospitalization
- Improve access to quality health care
- Provide beneficiaries the power to choose from a national network of providers
- Provide a scheme which even the illiterate can use easily
There are fixed package rates for a large number of surgical interventions. Pre-existing conditions are covered from day one and there is no age limit. Coverage extends to five members of the family, which includes the head of household, spouse, and up to three dependents. The central and state governments pay the premium to the insurer selected by the state government on the basis of a competitive bidding (the technically qualified lowest bid is selected).
Some of the most noteworthy aspects of RSBY include:
- Empowering beneficiaries: RSBY provides freedom of choice to the patient in the selection of hospitals: They can access any public or private provider in the network across the country.
- Business model for all stakeholders: The scheme is designed as a business model, with incentives built in for each stakeholder:
- Insurers: The insurer is paid a premium for each household enrolled in RSBY, therefore giving the insurer an incentive to enroll as many households as possible from the BPL list.
- Hospitals: A hospital has the incentive to provide treatment to large number of beneficiaries as it is paid per beneficiary treated. Even public hospitals have an incentive to treat beneficiaries under RSBY as money from the insurer will flow directly to the public hospital. Insurers, in contrast, will monitor participating hospitals in order to prevent unnecessary procedures or fraud resulting in excessive claims.
- Intermediaries: The inclusion of intermediaries, such as NGOs and MFIs, was intentional since they have a greater stake in assisting BPL households. Intermediaries will be paid for the services they render in reaching out to the beneficiaries.
- Government: Including public sector providers in the RSBY delivery network creates healthy competition between public and private providers which in turn provides incentives for public providers to improve their service delivery.
- SmartCard: Every beneficiary family is issued a biometric enabled SmartCard 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. The SmartCard also ensures that only true beneficiaries can use sevices, reducing fraud.
- Portability: One key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to use his/her SmartCard in any RSBY empanelled hospital across India. This makes the scheme beneficial to the many poor families that migrate from one place to the other.
- Cashless: RSBY transactions are completely cashless. Beneficiaries do not pay cash for any services unless they exceed the annual allowance of Rs. 30,000/-. Provider-to-insurer dealings are also paperless, as all claims are processed and paid electronically.
To date, RSBY has:
- Started in 23 States of India
- Issued SmartCards to 10 million families
- Covered 40 million people
- Empanelled over 2,500 hospitals
- Treated more than 350,000 hospitalization cases
RSBY
Program Summary
RSBY was launched to provide health coverage to all those living below the poverty line in India. Under the scheme, beneficiaries are entitled to hospitalization coverage of up to Rs. 30,000/- annually (approximately USD 700) for most diseases. Beneficiaries pay Rs. 30/- as a registration fee, while the central and state governments pay the premium to the insurer.
The objectives of RSBY are to:
- Provide financial protection from health care expenses on hospitalization
- Improve access to quality health care
- Provide beneficiaries the power to choose from a national network of providers
- Provide a scheme which even the illiterate can use easily
There are fixed package rates for a large number of surgical interventions. Pre-existing conditions are covered from day one and there is no age limit. Coverage extends to five members of the family, which includes the head of household, spouse, and up to three dependents. The central and state governments pay the premium to the insurer selected by the state government on the basis of a competitive bidding (the technically qualified lowest bid is selected).
Some of the most noteworthy aspects of RSBY include:
- Empowering beneficiaries: RSBY provides freedom of choice to the patient in the selection of hospitals: They can access any public or private provider in the network across the country.
- Business model for all stakeholders: The scheme is designed as a business model, with incentives built in for each stakeholder:
- Insurers: The insurer is paid a premium for each household enrolled in RSBY, therefore giving the insurer an incentive to enroll as many households as possible from the BPL list.
- Hospitals: A hospital has the incentive to provide treatment to large number of beneficiaries as it is paid per beneficiary treated. Even public hospitals have an incentive to treat beneficiaries under RSBY as money from the insurer will flow directly to the public hospital. Insurers, in contrast, will monitor participating hospitals in order to prevent unnecessary procedures or fraud resulting in excessive claims.
- Intermediaries: The inclusion of intermediaries, such as NGOs and MFIs, was intentional since they have a greater stake in assisting BPL households. Intermediaries will be paid for the services they render in reaching out to the beneficiaries.
- Government: Including public sector providers in the RSBY delivery network creates healthy competition between public and private providers which in turn provides incentives for public providers to improve their service delivery.
- SmartCard: Every beneficiary family is issued a biometric enabled SmartCard 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. The SmartCard also ensures that only true beneficiaries can use sevices, reducing fraud.
- Portability: One key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to use his/her SmartCard in any RSBY empanelled hospital across India. This makes the scheme beneficial to the many poor families that migrate from one place to the other.
- Cashless: RSBY transactions are completely cashless. Beneficiaries do not pay cash for any services unless they exceed the annual allowance of Rs. 30,000/-. Provider-to-insurer dealings are also paperless, as all claims are processed and paid electronically.
To date, RSBY has:
- Started in 23 States of India
- Issued SmartCards to 10 million families
- Covered 40 million people
- Empanelled over 2,500 hospitals
- Treated more than 350,000 hospitalization cases
RSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme.
RSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme.
Funding from central and state governments is divided as follows:
- 75% (90% in case of Jammu & Kashmir and North-eastern States) of the premium comes from the central government
- 25% (10% in case of Jammu & Kashmir and North-Eastern States) of the premium comes from the state government
The insurance premium is determined at the state-level based on an open tender process.
Indian Insurance Regulatory Development Authority (IRDA) registered insurers compete in competitive bidding; the organization that fulfils technical criteria and has the lowest premium is chosen. The state and central governments pay the agreed upon premium to the insurance company commensurate with the number of BPL families enrolled. The insurer bears all the risk of the scheme and though the state governments provide support to the insurer(s), it is the responsibility of the insurer to operationalize the scheme on the ground.
RSBY
Funding
RSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme.
Funding from central and state governments is divided as follows:
- 75% (90% in case of Jammu & Kashmir and North-eastern States) of the premium comes from the central government
- 25% (10% in case of Jammu & Kashmir and North-Eastern States) of the premium comes from the state government
The insurance premium is determined at the state-level based on an open tender process.
Indian Insurance Regulatory Development Authority (IRDA) registered insurers compete in competitive bidding; the organization that fulfils technical criteria and has the lowest premium is chosen. The state and central governments pay the agreed upon premium to the insurance company commensurate with the number of BPL families enrolled. The insurer bears all the risk of the scheme and though the state governments provide support to the insurer(s), it is the responsibility of the insurer to operationalize the scheme on the ground.
RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme.
RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme.
RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An enrollment schedule for each village, along with dates, is prepared by the insurance company with the help of district officials. The insurance companies are provided a maximum of four months to enroll BPL families in each district.
To communicate and market the RSBY scheme and enrollment camps, insurance companies are required to hire intermediaries to provide grassroots outreach prior to enrollment. (These organizations could also be used to provide assistance to members in utilizing services after enrollment.) In addition, the BPL list is posted in each village at the enrollment station and prominent places prior to the enrollment camp. The date/location of the enrollment camp are also publicized in advance.
Mobile enrollment stations are established at local centers (e.g., public schools) at each village at least once a year. These stations are equipped by the insurer with a printer to print SmartCards, as well as hardware to collect biometric information (fingerprints) and photographs of household members to be covered. A SmartCard is given to each BPL family at the time of enrollment in the scheme. Fingerprints of all beneficiaries are collected during enrollment at the village level. One thumb impression of each of the household beneficiaries is stored in the SmartCard. This fingerprint is used to verify the identity of the beneficiaries at the hospital.
The SmartCard is prepared and printed on-the-spot in the village by the insurer and handed over to the beneficiary. This SmartCard can be used by the beneficiary in any empanelled hospital across India to obtain treatment. The SmartCard given to each enrolled household also contains a new national unique ID for each family—a program the Government of India is implementing nationwide. The SmartCard, along with an information packet describing benefits, hospitals in network, and other relevant information is provided to all enrollees once they have paid the Rs. 30/- registration fee. The process normally takes less than 10 minutes.
Another unique feature of the scheme is its key management system which helps in reducing enrollment fraud and improves accountability. A government official from the district (field key officer—FKO) needs to be present at the camp and must insert his/her own government-issued SmartCard and provide his/her fingerprint to verify the legitimacy of the enrollment. This way each enrollee can be tracked to a particular government official. The details of each BPL family who is authenticated by the FKO gets transferred to the FKO’s SmartCard; the data is also transferred from the FKO’s card to the government server at the district level. In addition to the FKO, an insurance company/SmartCard agency rep is present at the enrollment camp.
At the end of the enrollment camp, a list of enrolled households is sent to the state nodal agency by the Insurer. The list of enrolled households is maintained centrally and the insurer is paid once data provided from the insurer and FKO card has been reconciled.
The aim of the scheme is to use technology not only for controlling fraud and monitoring utilization, but also to find innovative solutions to insurance-related problems. For example, enrollment software has been designed to ensure that male heads of households must insure their spouses. In addition, since the scheme aims to provide quality treatment to all beneficiaries, technology has been implemented to ensure that every beneficiary receives needed treatment. For example, if a patient is not in a condition to validate his/her identity at the hospital then any family member who is on the SmartCard can validate the identity of the patient by providing his/her fingerprint.
Currently, the Government of India is considering how the SmartCard can be used for other social sector schemes and how the RSBY technology platform can be used to provide other services to the below-the-poverty-line population.
RSBY
Population covered
RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme.
RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An enrollment schedule for each village, along with dates, is prepared by the insurance company with the help of district officials. The insurance companies are provided a maximum of four months to enroll BPL families in each district.
To communicate and market the RSBY scheme and enrollment camps, insurance companies are required to hire intermediaries to provide grassroots outreach prior to enrollment. (These organizations could also be used to provide assistance to members in utilizing services after enrollment.) In addition, the BPL list is posted in each village at the enrollment station and prominent places prior to the enrollment camp. The date/location of the enrollment camp are also publicized in advance.
Mobile enrollment stations are established at local centers (e.g., public schools) at each village at least once a year. These stations are equipped by the insurer with a printer to print SmartCards, as well as hardware to collect biometric information (fingerprints) and photographs of household members to be covered. A SmartCard is given to each BPL family at the time of enrollment in the scheme. Fingerprints of all beneficiaries are collected during enrollment at the village level. One thumb impression of each of the household beneficiaries is stored in the SmartCard. This fingerprint is used to verify the identity of the beneficiaries at the hospital.
The SmartCard is prepared and printed on-the-spot in the village by the insurer and handed over to the beneficiary. This SmartCard can be used by the beneficiary in any empanelled hospital across India to obtain treatment. The SmartCard given to each enrolled household also contains a new national unique ID for each family—a program the Government of India is implementing nationwide. The SmartCard, along with an information packet describing benefits, hospitals in network, and other relevant information is provided to all enrollees once they have paid the Rs. 30/- registration fee. The process normally takes less than 10 minutes.
Another unique feature of the scheme is its key management system which helps in reducing enrollment fraud and improves accountability. A government official from the district (field key officer—FKO) needs to be present at the camp and must insert his/her own government-issued SmartCard and provide his/her fingerprint to verify the legitimacy of the enrollment. This way each enrollee can be tracked to a particular government official. The details of each BPL family who is authenticated by the FKO gets transferred to the FKO’s SmartCard; the data is also transferred from the FKO’s card to the government server at the district level. In addition to the FKO, an insurance company/SmartCard agency rep is present at the enrollment camp.
At the end of the enrollment camp, a list of enrolled households is sent to the state nodal agency by the Insurer. The list of enrolled households is maintained centrally and the insurer is paid once data provided from the insurer and FKO card has been reconciled.
The aim of the scheme is to use technology not only for controlling fraud and monitoring utilization, but also to find innovative solutions to insurance-related problems. For example, enrollment software has been designed to ensure that male heads of households must insure their spouses. In addition, since the scheme aims to provide quality treatment to all beneficiaries, technology has been implemented to ensure that every beneficiary receives needed treatment. For example, if a patient is not in a condition to validate his/her identity at the hospital then any family member who is on the SmartCard can validate the identity of the patient by providing his/her fingerprint.
Currently, the Government of India is considering how the SmartCard can be used for other social sector schemes and how the RSBY technology platform can be used to provide other services to the below-the-poverty-line population.
RSBY covers all hospitalization expenses of up to Rs. 30,000/- (USD 600) per family per year and has established package rates for 727 inpatient surgical procedures, including maternity and newborn care. Benefits packages also provide beneficiaries with transportation assistance of up to Rs. 100/- (USD 2) per visit, though not exceeding Rs. 1,000/- (USD 20) per year.
RSBY covers all hospitalization expenses of up to Rs. 30,000/- (USD 600) per family per year and has established package rates for 727 inpatient surgical procedures, including maternity and newborn care. Benefits packages also provide beneficiaries with transportation assistance of up to Rs. 100/- (USD 2) per visit, though not exceeding Rs. 1,000/- (USD 20) per year.
A family covered by RSBY can include up to five members (including a husband, a wife, and three dependents). Most of the surgical and medical conditions for which hospitalization is necessary are covered in the scheme. In addition, beneficiaries are covered for outpatient surgeries which can be done on an outpatient basis. The benefit also includes one day pre- and five day post-hospitalization expenses.
All pre-existing diseases are covered from the first day of enrollment with some exclusions. RSBY does not cover:
- OPD expenses, or expenses in hospitals which do not lead to hospitalization
- Congenital external diseases
- Drug and alcohol induced illness
- Sterilization and fertility-related procedures
RSBY
Benefits package
RSBY covers all hospitalization expenses of up to Rs. 30,000/- (USD 600) per family per year and has established package rates for 727 inpatient surgical procedures, including maternity and newborn care. Benefits packages also provide beneficiaries with transportation assistance of up to Rs. 100/- (USD 2) per visit, though not exceeding Rs. 1,000/- (USD 20) per year.
A family covered by RSBY can include up to five members (including a husband, a wife, and three dependents). Most of the surgical and medical conditions for which hospitalization is necessary are covered in the scheme. In addition, beneficiaries are covered for outpatient surgeries which can be done on an outpatient basis. The benefit also includes one day pre- and five day post-hospitalization expenses.
All pre-existing diseases are covered from the first day of enrollment with some exclusions. RSBY does not cover:
- OPD expenses, or expenses in hospitals which do not lead to hospitalization
- Congenital external diseases
- Drug and alcohol induced illness
- Sterilization and fertility-related procedures
As of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers.
As of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers.
After an insurance company is selected by the state, the insurance company is tasked with empaneling/certifying both public and private care providers in the program. The process is based on prescribed criteria (e.g., the service providers should possess specified basic facilities, like: have at least 10 inpatient medical beds; have specified medical and surgical facilities and diagnostic facilities, etc.). In addition, hospitals must agree to need to install necessary hardware and software to be able to process beneficiaries’ SmartCard transactions. They must also set up a dedicated RSBY desk with trained staff.
The insurer must empanel enough hospitals in each district so that beneficiaries do not need to travel great distances to get to health care services. For empanelment of public hospitals, the insurer needs to coordinate with the respective health department of the state.
Once a hospital is empanelled, a nationally-unique hospital ID number is generated so that transactions can be tracked at each hospital. Each empanelled hospital is connected with the district server of the insurance company and thus able to transfer data related to hospitalization on a daily basis.
RSBY
Service delivery system
As of October 2009, the RSBY delivery network included 2,067 hospitals, 1,516 private and 551 public. Providers are empanelled by a state-selected insurance company based on specific structural, procedural and quality criteria, including the installation of SmartCard readers and all associated technology. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers.
After an insurance company is selected by the state, the insurance company is tasked with empaneling/certifying both public and private care providers in the program. The process is based on prescribed criteria (e.g., the service providers should possess specified basic facilities, like: have at least 10 inpatient medical beds; have specified medical and surgical facilities and diagnostic facilities, etc.). In addition, hospitals must agree to need to install necessary hardware and software to be able to process beneficiaries’ SmartCard transactions. They must also set up a dedicated RSBY desk with trained staff.
The insurer must empanel enough hospitals in each district so that beneficiaries do not need to travel great distances to get to health care services. For empanelment of public hospitals, the insurer needs to coordinate with the respective health department of the state.
Once a hospital is empanelled, a nationally-unique hospital ID number is generated so that transactions can be tracked at each hospital. Each empanelled hospital is connected with the district server of the insurance company and thus able to transfer data related to hospitalization on a daily basis.
Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment.
Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment.
Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household.
Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time.
The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals.
The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
- Operate a 24-hour toll free call center
- Manage district kiosks for post issuance modifications to SmartCards
- Management info system functions, including collecting, collating, and reporting data on a real time basis
- Generating reports, in predefined format, at periodic intervals, as decided between insurer and state nodal agency
- IT related functions which include running the local website/updating data regularly
- Pre-authorization function for non-package surgical interventions
- Claims settlement
- Organizing Health camps
- Publicity for enrollment and post-enrollment
- Grievance and dispute resolution
- Feedback functions
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states.
Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing.
The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
| Central Govt | State Nodal Agency | Insurer/TPA | NGOs/Other Partners | Providers of Care | |
|---|---|---|---|---|---|
| Oversight of scheme | X | X | |||
| Financing scheme | X | X | |||
| Setting parameters (benefits package, empanelment criteria, BPL criteria, etc.) | X | X | |||
| Hardware specifications (e.g, systems, SmartCard, etc.) | X | ||||
| Contract management with Insurer | X | ||||
| Accreditation/Empanelment of providers | X | ||||
| Collecting Registration Fees | X | ||||
| Enrollment | X | X | X | ||
| Financial management/planning | X | X | |||
| Actuarial analysis | X | ||||
| Setting rate schedules for services/reimbursement rates | X | X | |||
| Claims processing and payment | X | ||||
| Outreach, Marketing to beneficiaries | X | X | X | ||
| Service delivery | X | ||||
| Developing clinical information system for monitoring/eval | X | X | |||
| Monitoring state-level utilization and other patient information | X | X | X | ||
| Monitoring national RSBY information | X | ||||
| Customer service | X | X | X | ||
| Training | X | X | X |
RSBY
Institutional structures
Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment.
Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household.
Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time.
The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals.
The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
- Operate a 24-hour toll free call center
- Manage district kiosks for post issuance modifications to SmartCards
- Management info system functions, including collecting, collating, and reporting data on a real time basis
- Generating reports, in predefined format, at periodic intervals, as decided between insurer and state nodal agency
- IT related functions which include running the local website/updating data regularly
- Pre-authorization function for non-package surgical interventions
- Claims settlement
- Organizing Health camps
- Publicity for enrollment and post-enrollment
- Grievance and dispute resolution
- Feedback functions
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states.
Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing.
The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
| Central Govt | State Nodal Agency | Insurer/TPA | NGOs/Other Partners | Providers of Care | |
|---|---|---|---|---|---|
| Oversight of scheme | X | X | |||
| Financing scheme | X | X | |||
| Setting parameters (benefits package, empanelment criteria, BPL criteria, etc.) | X | X | |||
| Hardware specifications (e.g, systems, SmartCard, etc.) | X | ||||
| Contract management with Insurer | X | ||||
| Accreditation/Empanelment of providers | X | ||||
| Collecting Registration Fees | X | ||||
| Enrollment | X | X | X | ||
| Financial management/planning | X | X | |||
| Actuarial analysis | X | ||||
| Setting rate schedules for services/reimbursement rates | X | X | |||
| Claims processing and payment | X | ||||
| Outreach, Marketing to beneficiaries | X | X | X | ||
| Service delivery | X | ||||
| Developing clinical information system for monitoring/eval | X | X | |||
| Monitoring state-level utilization and other patient information | X | X | X | ||
| Monitoring national RSBY information | X | ||||
| Customer service | X | X | X | ||
| Training | X | X | X |
Providers are paid on a fee-for-service basis, with packages defined for each of the covered procedures and interventions. Claims submission and processing is cashless, allowing hospitals and insurers to submit claims and payments online.
Providers are paid on a fee-for-service basis, with packages defined for each of the covered procedures and interventions. Claims submission and processing is cashless, allowing hospitals and insurers to submit claims and payments online.
The process for reporting and paying claims is designed to be simple and cashless from the perspective of the provider and beneficiary. In general, the process looks as follows:
- A patient comes to a provider to receive care and goes straight to the RSBY help desk; the patient’s identity is verified via fingerprints
- The patient visits the doctor who assesses his/her health condition; doctor prescribes a treatment
- Assistant at RSBY help desk checks whether procedure is in the list of pre-specified packages. Procedures are priced/paid to the provider on a case-based payment system
- a. If procedure is on list, appropriate prescribed package is selected, patient is scheduled for procedure, and the amount to be paid out is blocked
- b. If not on list, help desk checks with insurer to price and get approval to conduct procedure, patient is scheduled for procedure, and the pre-determined amount to be paid is blocked
- In-patient treatment is provided to the beneficiary.
- Upon release of beneficiary from hospital, SmartCard is swiped again with fingerprint verification a. Beneficiary is paid by the hospital Rs. 100/- as transportation expense at time of discharge b. The pre-specified cost of procedure is deducted from the amount available on the card
- After rendering service to patient, hospital sends an electronic report and claim to the insurer/TPA
- The insurer/TPA reviews the records and information and makes payment to the hospital (electronically) within a specified time period (agreed upon between insurer/TPA and hospital)
At present there are no quality standards being utilized by RSBY, but the national team is working with states and insurers to develop an incentive based quality management system for providers (e.g., a system where hospitals are graded according specific quality parameters and hospitals with better quality are paid at a higher rate by insurers).
RSBY
Provider payment mechanisms
Providers are paid on a fee-for-service basis, with packages defined for each of the covered procedures and interventions. Claims submission and processing is cashless, allowing hospitals and insurers to submit claims and payments online.
The process for reporting and paying claims is designed to be simple and cashless from the perspective of the provider and beneficiary. In general, the process looks as follows:
- A patient comes to a provider to receive care and goes straight to the RSBY help desk; the patient’s identity is verified via fingerprints
- The patient visits the doctor who assesses his/her health condition; doctor prescribes a treatment
- Assistant at RSBY help desk checks whether procedure is in the list of pre-specified packages. Procedures are priced/paid to the provider on a case-based payment system
- a. If procedure is on list, appropriate prescribed package is selected, patient is scheduled for procedure, and the amount to be paid out is blocked
- b. If not on list, help desk checks with insurer to price and get approval to conduct procedure, patient is scheduled for procedure, and the pre-determined amount to be paid is blocked
- In-patient treatment is provided to the beneficiary.
- Upon release of beneficiary from hospital, SmartCard is swiped again with fingerprint verification a. Beneficiary is paid by the hospital Rs. 100/- as transportation expense at time of discharge b. The pre-specified cost of procedure is deducted from the amount available on the card
- After rendering service to patient, hospital sends an electronic report and claim to the insurer/TPA
- The insurer/TPA reviews the records and information and makes payment to the hospital (electronically) within a specified time period (agreed upon between insurer/TPA and hospital)
At present there are no quality standards being utilized by RSBY, but the national team is working with states and insurers to develop an incentive based quality management system for providers (e.g., a system where hospitals are graded according specific quality parameters and hospitals with better quality are paid at a higher rate by insurers).
One of the key strengths of the RSBY scheme is a real-time monitoring and evaluation system enabled by the program’s extensive technology backbone. RSBY's smartcard technology allows all patient data to be electronically recorded and sent to the central government at periodic intervals.
One of the key strengths of the RSBY scheme is a real-time monitoring and evaluation system enabled by the program’s extensive technology backbone. RSBY's smartcard technology allows all patient data to be electronically recorded and sent to the central government at periodic intervals.
One of the key strengths of the RSBY scheme is a real-time monitoring and evaluation system enabled by the program’s extensive technology backbone. SmartCard patient data allows insurers to track claims, transfer funds to providers, and investigate suspicious claims through on-site audits. Governments are able to monitor utilization of the scheme and, to some extent, begin to measure the impact of the program. Enrollment, hospitalization, and claims data are analyzed at the national level regularly and shared with state nodal agencies.
RSBY’s management information system collects data from all districts streamed to the central government at periodic intervals. This information is uploaded through an internet/phone line to a database on a district server. A separate set of pre-formatted tables are generated for the insurer and for the state and central government respectively. The central government posts much of the data on the program’s impact online on the RSBY website. Additionally, the government of India is planning to produce periodic reports on selected indicators to be shared with all the stakeholders in the near future.
RSBY is one of the few government sponsored schemes where a concurrent evaluation is being done by both central and state governments. The Government of India and a few state governments have already begun to conduct evaluations of RSBY and the results are positive. The World Bank and GTZ together are developing a survey instrument which will be prescribed by the Government of India for the evaluation of RSBY schemes across India. This is being done to improve comparability of studies across implementing states. The tender document of the scheme has a provision whereby each state government is required to evaluate the performance of its RSBY scheme.
RSBY
Monitoring and evaluation
One of the key strengths of the RSBY scheme is a real-time monitoring and evaluation system enabled by the program’s extensive technology backbone. RSBY's smartcard technology allows all patient data to be electronically recorded and sent to the central government at periodic intervals.
One of the key strengths of the RSBY scheme is a real-time monitoring and evaluation system enabled by the program’s extensive technology backbone. SmartCard patient data allows insurers to track claims, transfer funds to providers, and investigate suspicious claims through on-site audits. Governments are able to monitor utilization of the scheme and, to some extent, begin to measure the impact of the program. Enrollment, hospitalization, and claims data are analyzed at the national level regularly and shared with state nodal agencies.
RSBY’s management information system collects data from all districts streamed to the central government at periodic intervals. This information is uploaded through an internet/phone line to a database on a district server. A separate set of pre-formatted tables are generated for the insurer and for the state and central government respectively. The central government posts much of the data on the program’s impact online on the RSBY website. Additionally, the government of India is planning to produce periodic reports on selected indicators to be shared with all the stakeholders in the near future.
RSBY is one of the few government sponsored schemes where a concurrent evaluation is being done by both central and state governments. The Government of India and a few state governments have already begun to conduct evaluations of RSBY and the results are positive. The World Bank and GTZ together are developing a survey instrument which will be prescribed by the Government of India for the evaluation of RSBY schemes across India. This is being done to improve comparability of studies across implementing states. The tender document of the scheme has a provision whereby each state government is required to evaluate the performance of its RSBY scheme.