Pre-authorisation will be mandatory for 636 of the 1,350 packages – or 47 per cent of all treatments covered under the National Health Protection Mission (NHPM), including all packages for cardiology, ophthalmology and oncology.
The NHPM will not cover conditions that do not require hospitalisation, dental procedures, congenital physical problems, vaccinations and fertility related procedures, and will also not cover treatment of a person who has attempted suicide.
The Ayushman Bharat secretariat on Tuesday released the model tender documents for the scheme, which lays down every detail from the medical audits that are a mandatory part of the mission, the provision for interests to be paid by insurers in case of delays in payment, and the “administrative costs” allowed for insurers.
The document also lays down that for a claim ratio of up to 120 per cent, states will not pay any additional premium. If the claim ratio is beyond 120 per cent, the state will pay 50 per cent of the additional premium. The remainder will have to be borne by insurance companies.
Ayushman Bharat (AB)-NHPM will target about 10.74 crore poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data, both rural and urban. The tender documents released are model with flexibility for states both on the mode of implementation and the rates.
Pre-authorisation is essential to keep a check on “moral hazard” procedures. “Moral hazard” in health insurance parlance is the tendency of people who are insured to buy/be sold additional healthcare interventions, irrespective of their actual needs, leading to expenses that do not necessarily add to their own health or well being but bleeds the insurer.
For this reason, procedures such as emergency consultation for acute colic, high fever, cuts, stitches, soft tissue injury, single-bone fracture plaster, nebulization for asthmatic attack, moderate dehydration, hypoglycaemia in a diabetic, dengue without complication, and food poisoning will be covered in the scheme only if the treatment is availed in a government hospital.
For some specified conditions, pre-authorisation will be required for hospitalisation beyond 10 days.
The penalty provisions are stiff for any delays on the part of insurer or the state health agency (SHA) either in paying premium or in processing claims or refunds to the state. If claim payment to the hospital is delayed beyond 15 days, insurers will have to pay an interest of 1 per cent for every seven days of delay.
If premium refund is not made by the insurer to SHA within 30 days of the communication for refund, there will be 1 per cent interest for every week of delay. If the premium is not paid to the insurer by the SHA within six months of the commencement of the AB-NHPM, insurers will get an interest of 1 per cent of the premium amount for every seven days’ delay.
For the purpose of administration of the scheme, states have been divided into two categories. Category A states includes Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi, Sikkim, Tripura, Uttarakhand, and six Union Territories: Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep and Puducherry.
States in Category B are Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh, and West Bengal.
To be able to bid for the category A states, an insurance company will have to have a “Gross Direct Premium Income from Health business of at least Rs 100 crore (experience of handling 25000 claims), and at least Rs 200 crore (experience of handling 50,000 claims) for Category B states in each of the last three completed financial years”, according to the document.
In category A states, the administrative cost allowed is 10 per cent if claim ratio less than 60 per cent, 15 per cent if claim ratio is between 60 per cent and 70 per cent and 20 per cent if claim ratio is between 70 per cent and 80 per cent.
In Category B states, administrative cost allowed will be 10 per cent if claim ratio is less than 60 per cent, 12 per cent if claim ratio is between 60 per cent and 70 per cent, and 15 per cent if claim ratio is between 70 per cent and 85 per cent.