Q. What is RSBY, MMSHCS, HPUHPS?
RSBY means “Rashtriya Swasthya Bima Yojna”, a health insurance scheme for Below Poverty Line families & other categories (building and other construction workers, licensed railway porters ,
street vendors ,MGNREGA workers, beedi workers , domestic workers , sanitation workers ,mine workers , rickshaw pullers , rag pickers , auto/taxi drivers). RSBY is being implemented in Himachal Pradesh since 2008-09.The health department is the nodal department implementing RSBY through Himachal Pradesh Swasthya Bima Yojna Society
MMSHCS means “Mukhya Mantri State Health Care Scheme”. The State Government has launched this scheme for ekal naaris, senior citizens more than 80 years of age, daily wage workers, part time workers, mid-day meal workers, anganwari workers/helpers, contractual workers and persons with more than 70% disability.
HPUHPS means “Himachal Pradesh Universal Health Protection Scheme”. It was launched by the State Government on 2nd August, 2017. HPUHPS is for those people who are not covered under other health insurance/protection schemes or any other medical reimbursement scheme.
Q. What is the insurance coverage under these schemes?
These schemes provide health insurance coverage upto Rs. 30,000/- per year on family floater basis for common ailments. For treatment of critical illnesses, additional benefit of Rs 1, 75,000/- is being provided. For cancer, the limit has been increased to Rs 2, 25,000/- per year.
Q. What is not covered under these schemes?
These schemes do not cover OPD expenses, or expenses in hospitals which do not lead to hospitalization (except some listed day care procedures). Other exclusions include:-
Note: Treatment under Ayurveda is covered
EXCLUSIONS UNDER MATERNITY BENEFIT CLAUSE:
The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of:
Q. Is OPD covered under these schemes?
OPD is not covered in these schemes (except some day care producers). Therefore, medicines and tests which are not related or do not lead to hospitalization need to be paid by the beneficiary.
Q. What is the concept of hospitalization?
Hospitalization means admission to hospital for 24 hours or more. These schemes refer to such hospitalizations. However, it includes such day care treatments entailing less than 24 hours as are listed out below:-
Day care services under which benefits are provided include:
How are day care surgeries different from hospitalization of less than 24 hours?
Hospitalization can be for both medical and surgical procedures. Therefore, in all the surgical cases, whether there is a need for hospitalization or can be handled on a day care basis, are covered but medical procedures which need hospitalization for more than 24 hours are covered.
Are maternity benefits covered?
Yes
What is covered under maternity expenses?
All expenses related to the delivery of the baby in the hospital are covered and hospital will be reimbursed by the insurer.
What all types of deliveries are covered?
Both normal and caesarean deliveries are covered under these schemes. A hospital will be paid Rs. 2500 for normal and 4500 for caesarean delivery.
Is there any provision to take care of the new-born?
A new-born is covered under these schemes since birth automatically for the remaining period of the health insurance policy.
If there are five members already covered in a family under these schemes, will the new-born be covered?
Yes. Even if the new-born is sixth member, he/she will be covered.
For how long will the new-born be covered?
The new-born will be covered for the remaining policy period. However, at the time of renewal of the policy, the household will have to take a decision whether to include the new born next year.
Q. Is there any provision for payment of transportation charges?
Transportation charges are covered under these schemes. For every case of hospitalization, beneficiary is paid Rs. 100/- per hospitalization as the transportation charge subject to a maximum of Rs. 1000/- during the policy period under basic package. For hospitalization under critical care, beneficiary is paid Rs. 1000/- per hospitalization as the transportation charge subject to a maximum of Rs. 3000/-.
Q. Is there any proof, like ticket etc. required to claim transportation charges?
There is no proof required to claim transportation charge benefits.
Q. When will the beneficiary get the transportation charge, at the time of hospitalization or discharge?
The beneficiary will be paid transportation charge at the time of discharge.
Q. Who will give this Rs. 100/- or Rs 1000/- at the time of discharge?
The hospital which has provided the treatment will give this amount at the time of discharge to the beneficiary.
Q. If there are less than five people, will the coverage amount be reduced?
Coverage amount of is on a floater basis. Therefore, the total amount will remain same even if the family consists of only one member.
Q. Will each person in the household who is covered under these schemes get coverage of Rs. 30,000/- (or 1, 75,000 or 2, 25,000) separately or it is total for the family?
The policy is on a family floater basis. Therefore, total cover is Rs. 30,000/- (or 1,75,000 or 2,25,000) for a family and not for an individual.
Q. What is meant by on “floater basis”?
Floater basis means that total amount can be used by one person or jointly with other members of the family.
Q. What is a pre-existing disease?
Any disease that was present at any time in the past (including any disease, which the insured person may not have been aware of) is treated as pre-existing.
Q. Are pre-existing diseases covered under these schemes?
Yes, pre-existing diseases are covered under these schemes from day one itself. There is no discrimination with respect to the pre-existing diseases.
Q. Is there any age limit to get enrolled under these schemes?
No.
Q. What happens in case of any dispute?
If any dispute arises between the parties during the subsistence of the policy period or thereafter, in connection with the validity, interpretation, implementation or alleged breach of any provision of the scheme, it will be settled in the following way:
The parties shall refer such dispute to the redressal committee constituted at the District level under the chairmanship of concerned District magistrate and authorized representative of the insurance company/support agency as members. This committee will settle the dispute.
If either of the parties is not satisfied with the decision, they can go to the State level committee which will be Chaired by the Principal Secretary (Health) with representative of the Insurance Company/Support Agency as a member.
The parties shall refer such dispute to the redressal committee constituted at the District level under the chairmanship of concerned District magistrate, authorized representative of the insurance company and a representative of the health care providers as members. This committee will settle the dispute.
If either of the parties is not satisfied with the decision, they can go to the State level committee which will be chaired by the Principal Secretary (Health) with representative of the Insurance Company/Support Agency as a member.
A dispute between the State Government/Nodal Agency and Insurance Company/Support Agency shall be referred to the respective Chairmen/CEO’s/CMD’s of the Insurer for resolution.
In the event that the Chairmen/CEO’s /CMD’s are unable to resolve the dispute within {60} days of it being referred to them, then either Party may refer the dispute for resolution to a sole arbitrator who shall be jointly appointed by both parties, or, in the event that the parties are unable to agree on the person to act as the sole arbitrator within {30} days after any party has claimed for an arbitration in written form, by three arbitrators, one to be appointed by each party with power to the two arbitrators so appointed, to appoint a third arbitrator.
Q. How will the Communication for these schemes be done and who will do it?
Insurance Company/Support Agency in consultation with State Nodal Agency will prepare and implement a communication strategy for launching/ implementing these schemes. The objective of these interventions will be to inform the beneficiaries regarding enrolment and benefits of the scheme.
In addition to this State Government will also undertake communication activities, especially to improve the utilization of the scheme.
Q. What is Call Center Service and what it does?
The Insurer shall provide telephone services for the guidance and benefit of the beneficiaries whereby the Insured Persons shall receive guidance about various issues by dialing a State Toll free number. This service provided by the Insurer. These are:
Sr. Divisional Manager, The New India Assurance Company Limited, Block No. 7, SDA Complex, Kasumpti, Shimla-9. Toll Free Number 18001808003, Landline: 0177-2622398- Fax:-01772623294, Email: nia351400@rediffmail.com
Call Centre Information
For RSBY: The Insurer shall operate a call centre for the benefit of all Insured Persons. The Call Centre shall function for 24 hours a day, 7 days a week and round the year. As a part of the Call Centre Service the Insurer shall provide the following :
a) Answers to queries related to Coverage and Benefits under the Policy.
b) Information on Insurer’s office, procedures and products related to health.
C) General guidance on the Services.
D) For cashless treatment subject to the availability of medical details required by the medical team of the Insurer.
E) Information on Network Providers and contact numbers.
F) Benefit details under the policy and the balance available with the Beneficiaries. Claim status information.
G) Advising the hospital regarding the deficiencies in the documents for a full claim.
H) Any other relevant information/related service to the Beneficiaries.
I) Any of the required information available at the call centre to the Government/Nodal Agency.
J) Maintaining the data of receiving the calls and response on the system.
K) Any related service to the Government/Nodal Agency.
Language
The Insurer undertakes to provide services to the Insured Persons in English and local languages.
Toll Free Number
The Insurer will operate a state toll free number with a facility of a minimum of 5 lines. The cost of operating of the number shall be borne solely by the Insurer. The toll free numbers are: 18001808003 and 18001028181
Insurer to inform Beneficiaries
The Insurer will intimate the state toll free number to all beneficiaries along with addresses and other telephone numbers of the Insurer’s Project Office. Insurer may provide the details of the call center service with the technical proposal.
For MMSHCS: The support agency for MMSHCS is RTS Rural Technologies Private Limited. The call center number is 180030100334.
For HPUHPS: The support agency for HPUHPS is Smart Chip Private Limited. The call center number is 18002006544 and whatsapp number is +919711035378.
2. Enrolment Related Questions
Q. Who pays the premium for RSBY?
Government pays the premium for RSBY. Central Government pays 90% of the total premium while State Government pays the remaining 10% premium. MMSHCS and HPUHPS are State funded. Under HPUHPS, Rs 1 / day or Rs 365/ year has to be given at the time of enrollment.
Q. Will beneficiaries have to pay anything to get the policy?
Beneficiaries need to pay Rs. 30 per family at the time of enrollment for RSBY and MMSHCS .For HPUHPS, the premium is Rs 365 per family per year. In case the family has more than 5 members an additional card is issued.
Q. Whom do the beneficiaries need to pay the premium and when?
They need to pay at the time of enrollment to the representative of the insurer/support agency.
Q. Will the beneficiary get Rs. 30 or Rs 365 back at the end of the year if he/she does not use services during the year?
No money is returned at the end of the year even if services are not availed.
Q. Will this Rs. 30/- or Rs 365/- need to be paid again at the time of renewal of the policy by the beneficiary?
Yes. This amount is the yearly registration fee which the beneficiary will have to pay each time the policy is renewed.
Q. How many people can be enrolled in one family?
Under RSBY and MMSCHS, upto maximum of five members of a family can be enrolled i.e. head of the family, spouse and three dependents. Under HPUHPS, more than five members can be added by paying for an additional card.
Q. What is meant by dependents?
Dependents can be children, parents or any other family member.
Q. In case of children, till what age can they be insured?
Any child who is listed as dependent can be enrolled.
Q. What happens if there are more than three children?
In case of RSBY/MMSHCS smart card, if the family has more than three children, the head of the household will have to decide which three children should be insured. But in case of HPUHPS, all the members can be insured by making an additional card.
Q. Can only five children be enrolled without enrolling head of household?
The head of the household and the spouse need to be insured and then only dependents can be added.
Q. What is the enrollment process?
For RSBY: 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 centers (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.
For MMSHCS: The beneficiary has to download the form online, fill it and has to get the verification done from the concerned department. After this, he/she can come to the enrollment station to get the smart card.
For HPUHPS: The beneficiary can fill the form online and make the payment online or he/she can visit the nearby Lok Mitra Kentra and fill the form there. After this, they need to come to the enrollment station to get the smart card.
Q. When will be the smart card given to the beneficiary after the enrollment?
The authenticated smart card shall be handed over to the beneficiary at the enrollment station itself.
Q. Why is there a photograph on smart card?
The photograph of the head of the family on the smart card can be used for identification purpose in case biometric information fails.
Q. Why photograph of all family members is taken when there is photograph of only head of household on the card?
Although on the card the head of the family photograph is printed, the photograph of all family members is stored in the chip so that in case of need it can be used for verification.
Q. If other family members are not at present at the time of enrollment will the card issued?
If the listed head of the family is absent then the name at number two can be treated as head of the family and, being treated as head of the family, his/ her photo will be printed on the card. However, if both are absent, the card cannot be issued. But, if one of them is present the card can be issued even if some other listed members are absent. The details of other members can be added subsequently at the district kiosk.
Q. How does the Government ensure that the correct beneficiary is getting the Smart card?
Each enrolment team in the villages is accompanied by a Field Key Officer (FKO) who identifies the beneficiaries at the time of enrollment. FKO is also provided with a smart card and his job is to identify the beneficiary and authenticate their smart card by his FKO card and finger print. Without FKO’s authentication the smart card with the beneficiary will not work. The detail of each family which is authenticated by the FKO also gets copied in the FKO card and insurance company/support agency is paid based on the number of beneficiaries obtained from the FKO card.
Q. Who are these FKOs?
FKOs are representative of the Government. They can be different entities in different districts. For example Health Workers, Gram Vikas Adhikaris, Patwaris, etc. have been given the role of FKO by different State Governments.
Q. Can the enrollment be done if FKOs are not present at the enrollment station?
No. These schemes mandate the presence of FKOs at the enrollment station for the enrollment process.
Q. What is the purpose of smart card?
Smart card is used for various varieties of activities like identification of the beneficiary through photograph and fingerprints, records 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.
Q. What happens if the beneficiary loses the smart card?
If a smart card is lost, beneficiary can approach the district kiosk of Insurance company/support agency to get a new smart card.
Q. Will the beneficiary have to pay for the reissuance of smart card in case they lose the first one?
If a new second smart card is issued in case of loss, beneficiary will have to pay a fee, fixed by State Government to get the second card.
Q. What happens if the head of the household is travelling to a different district? Who will keep the card?
If one person from the household is travelling to another district, the beneficiary can get a split card at the time of enrolment or from the district kiosk, for use at different places. However, the total balance amount will also be split in both the cards. The family can retain one card and the other one can be carried by the member who is travelling.
Q. How is the splitting amount decided?
The amount will be decided by the beneficiary family and he can suggest this at the time of card splitting.
Q. How many splits are allowed of one card?
A card can be split in two parts only. A beneficiary can get only one additional card.
Q. Who will do the splitting and is there any charge for that?
Splitting will be done by authorized person who is issuing the cards. At a later date splitting can also be done at the district kiosk. The additional cost for the splitting card would be decided by the State Government and has to be borne by the beneficiary.
Q. Is the food for family members also covered?
Food only for the person who is hospitalized is covered in the package rate.
Q. Can the members who are enrolled be changed during the midway of year?
In case of death of an existing member on the card, another member can be enrolled in his/her place provided his/her name is there in the data base.
3. PROCEDURE AT EMPANELLED HOSPITAL WHEN A SMART CARD HOLDER COMES FOR TREATMENT
Package covered and sufficient funds available
Q. In case pre authorized package is not available for treatment required?
Hospital shall take authorization from Insurance Company/ Support Agency in case package is not covered under these schemes. In case the line of treatment prescribed is not covered under these schemes, the helpdesk shall advice the beneficiary accordingly and initiate approval from the insurance company/support agency manually (authorization request).
Request for hospitalization shall be forwarded by the provider after obtaining due details from the treating doctor in the prescribed format i.e. “request for authorization letter” (RAL).
The RAL needs to be faxed to the 24-hour authorization /cashless department at fax number of the insurer/support agency along with contact details of treating physician, as it would ease the process.
This process would be a manual process involving paper work.
Insurance company/ Support Agency shall either approve or reject the request within the time stipulated.
In case of approval Insurance Company/Support Agency needs to provide the approved package cost for the treatment.
On receipt of approval the RSBY/MMSHCS/HPUHPS helpdesk would manually enter the amount and package details (authorization ID).
Q. In case of insufficient funds?
If the card has been split and sufficient balance as required for package selected is available in total from both the cards the software should have provision to deduct balance amount from both cards. (Both cards would have to be present at the same time in card readers). Initially, transaction may be blocked with insufficient balance but at the time of discharge, both cards should be present. Amount shall be deducted first from the card on which blocking was done.
Balance amount would be deducted from the second card. Reference of blocked transaction has to be maintained on the split card as well. In case there is no split card or balance is not available on split card as well, the amount available on the card would be utilized and the balance package cost recovered in cash after conformation from beneficiary. (Or as is being done presently).
Q. Which hospitals can the beneficiaries visit for the treatment under these schemes?
A list of the hospitals (both public and private) will be provided at the time of enrollment.
Q. What kind of hospitals will be part of this list?
Based on the qualifying criteria, both public and private hospitals will be empanelled. The beneficiary will have the option to choose hospitals where they want to go.
Q. Which hospitals beneficiary can go to get the treatment?
At the time of issuance of the card, a list of hospitals will be provided to the beneficiaries. In case of need to go to hospital, beneficiary will have to go to one of these hospitals or such hospitals as are added to the list of empanelled hospitals subsequently.
Q. How will the beneficiary know which hospitals they can go for treatment under these schemes?
The list of the hospitals will be provided at the time of the card issuance. Information relating to these and other hospitals has been provided by the insurer/support agency at the time of enrolment and can also be obtained by calling the toll free helpline number provided by the insurer.
Q. Has any amount to be paid at the hospital for treatment?
No.
Q. What is meant by cashless service?
Cashless service means that 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/support agency.
Q. What is the role of Health Care Providers?
Q. Has any expenditure to be incurred by beneficiary on the medicine?
If the beneficiary is hospitalized, No.
Q. What if medicines or tests are not available in the hospital and that have to be done from somewhere else?
It is the responsibility of the hospitals to arrange for all the medicines and tests needed for the treatment.
Q. What if more than Rs. 100/- (in case of Basic Package) or Rs 1000/- (in case of Critical Care Package) per visit are spent on transport?
Payment for transport under these schemes is limited to Rs. 100/- or Rs 1000/- only per hospitalization.
Q. Will the beneficiary get transport allowance if they use their own transport?
Irrespective of the mode of transportation, the beneficiary will be paid Rs. 100/- or Rs 1000/- per hospitalization as transport assistance
Q. How is the balance amount ascertained in the smart card?
The Operator in the hospital can verify the smart card and can tell the balance.
Q. What is the need for finger print verification?
Fingerprint verification is to prevent fraud and misuse of the smart card.
Q. Whose fingerprint is needed when the beneficiary goes to hospital?
Fingerprint of any enrolled member of the family can be provided.
Q. What are pre hospitalization and post hospitalization expenses?
Pre-hospitalization expenses are such expenses which are incurred by the hospitals before taking a view with regards to hospitalization. Expenditure incurred by the beneficiary on tests/ medicines which lead to hospitalization are also covered for reimbursement subject to production of proof. The hospital will also provide medicines and other assistance which are needed for patient till five days after discharge from the hospital, under basic package and 60 days after discharge under critical care package.
Q. How will the beneficiary get those charges reimbursed?
Hospital will provide necessary medicines, tests etc. to the patient for this. These are the part of package.
Q. What is meant by package charges? What does it provide for?
A package charge means that all the expenses related to the treatment like medicine, tests, bed charges, other materials, food etc. will be part of package and hospital will not charge anything from the patient for these.
Q. What happens if the disease is not in package rate? How long the beneficiary will have to wait for that?
If the disease is not in the package rate, the nodal person will take consent from the insurance company before blocking the amount. This can take from 1-2 hours to one day depending on the type of disease.
Q. What will happen if the smart card machine is not working in the hospital?
It will be the responsibility of the hospital and the insurance company to provide for alternative arrangements if the smart card machine is not working. The beneficiary will not be denied treatment in any case if the identity of the beneficiary is established.
Q. Where will the beneficiary need to go once they reach an empanelled hospital?
In the hospital there will be a counter for RSBY/MMSHCS/HPUHPS to guide the beneficiary.
Q. Does the beneficiary need to take any document to hospital other than the smart card?
The beneficiary needs to take only smart card when they go to the hospital.
Q. What will happen if the beneficiary forgets to take the smart card to the hospital for the treatment? Will he get the services?
Smart Card is essential to get the service. However, in exceptional cases hospital can allow it after appropriate verification.
Q. Is consultation and medicine covered?
If the consultation and medicine lead to hospitalization, they are covered.
Q. Who will bear the cost of tests and medicine in case there is no hospitalization?
The beneficiary or Rogi Kalyan Smiti (RKS) as the case may be, will have to bear the cost.
Q. What should a beneficiary do if the hospital asks for any payment from the beneficiary in case of hospitalization?
The patient should immediately inform the insurance company/support agency through toll free number provided in the broacher given to him at the time of enrollment.
Q. What is meant by day care surgeries?
Day care surgeries are the procedures which require a surgical intervention but patient need not be admitted to hospital after the surgery.
ADDITIONAL BENEFIT FOR CRITICAL CARE BEING PROVIDED BY HIMACHAL PRADESH GOVERNMENT.
Q. What are the benefits under Critical Care?
Under Critical Care, an additional coverage of up to Rs. 1, 75,000 per year (for cancer it is Rs. 2, 25,000/-) are provided for meeting expenses of hospitalization and surgical procedures of beneficiaries for treatment of
Q. Whether all Pre-existing conditions/diseases under Critical Care are covered?
Yes, all Pre-existing conditions/diseases will be covered from day one.
Q. Is there any provision for payment of transportation charges?
Yes. In the case of Critical care, the package shall include a provision for transport allowance of Rs. 1000 per visit subject to an annual ceiling of Rs. 3000 per beneficiary family. Under Basic Package, Rs 100 transport allowance is given per visit, subject to an annual ceiling of Rs 1000 per beneficiary family.
Q. What are Pre and post hospitalization expenses?
Critical Illnesses: up to 15 days prior to hospitalization and up to 60 days from the date of discharge from the hospital shall be part of the package rates.
Basic Package: up to 1 day prior to hospitalization and up to 5 days from the date of discharge from the hospital shall be part of the package rates.