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Rashtriya Swasthya Bima Yojna – State Review Workshop

Rashtriya Swasthya Bima Yojna – State Review Workshop. Dr. Nishant Jain. Current Status of RSBY Implementation in India. Cards issued – App. 33.5 million People enrolled – App. 114 million Number of People benefitted till now – App. 4.6 million

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Rashtriya Swasthya Bima Yojna – State Review Workshop

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  1. Rashtriya Swasthya Bima Yojna – State Review Workshop Dr. Nishant Jain

  2. Current Status of RSBY Implementation in India Cards issued – App. 33.5 million People enrolled – App. 114 million Number of People benefitted till now – App. 4.6 million Number of Hospitals Empanelled – App. 11,000 States where Service delivery has started – Twenty Seven Number of Insurance Companies Involved – Fifteen

  3. Setting Up of Nodal Agency • State Nodal Agency • Develop a full time team for State Nodal Agency with some experts in • IEC • Data Analysis • IT etc • Strengthen capacity of SNA • Organise training for DKMs and other district level officials • Hire District Coordinators for RSBY and Train them in different aspects of RSBY

  4. Beneficiary Data Preparation • Role of State Nodal Agency • Get the data of BPL and eligible NREGS families from Rural Development Department • Receive data of other eligible categories from respective departments • Convert the beneficiary data in the RSBY specified format • Send this data to MoLE for verification and URN generation • Role of MoLE • Verify the data • Encrypt the data • Generate URN for each family • Upload the data on website

  5. Empanelment of Hospitals • Role of District Key Manager • Provide New 64kb Master Hospital Card (MHC) after receiving from SNA • Role of SNA • Provide the New format in which Hospital data will be collected • Approve the list of hospitals through RSBY Website • Role of Insurance Company • Upload the details of empanelled hospitals in specified 55 column format • Empanel the New hospitals and sign MoU • Train ALL empanelled hospitals in RSBY and New Transaction Software

  6. Training • Role of SNA • Organisetraining of DKMs at State level • Role of District Key Manager/ DPM • Get FKO training organised at Block level with the help of Insurance Company • Role of Insurance Company/ TPA • Organise training for hospitals in New Transaction Software • Organise training of enrolment teams • Organise training of the district officials Advanced Intimation of All trainings to be organised by the Insurance Company/ TPA to be provided to SNA and MoLE

  7. New Smart Card for 64kb • New 64kb smart cards will be issued now • All the existing 32kb smart cards will need to be replaced • For visual differentiation, change in artwork of Smart Cards also

  8. Enrolment • Role of SNA • Send request for FKO, District Kiosk card online to MoLE • Role of District Key Manager • Get FKO training organised at Block level • Provide support to the IC/ TPA in making the route chart for enrolment through block officials • Get DKM Computer operator trained in using New DKM Software • Receive FKO cards from SNA and Issue them to FKOs • Provide FKO Undertaking to FKOs and collect it when they return Visit Enrolment Stations on a random basis and use checklist • Receive back FKO card from FKOs, download the data on computer and issue card to new FKO if needed

  9. Enrolment • Insurance Company/ TPA • Prepare a brochure to be given at the time of enrolment with following details: • List of hospitals empanelled • Details of the scheme • Details of the district kiosk and call centre • SCSP • Organise number of Enrolment kits as per the Tender conditions • Awareness exercise in the villages as per the route plan before the enrolment date • Visit the villages as per the route plan with the enrolment kit • Enroll the beneficiaries as per the guidelines and provide smart card on the spot alongwith the brochure Evaluations have revealed that in a lot of cases Brochure was not provided to beneficiaries so this needs to be ensured

  10. Enrolment • FKO • Receive the FKO card alongwith undertaking • Be present at the enrolment station as per the route plan intimated • Identify the beneficiaries and verify them on the spot through its fingerprint and smart card • After the enrolment process is over give back the FKO card to the DKM alongwith the filled undertaking Without Presence of FKOs Smart Card Cannot be Printed now FKOs shall fill the undertaking and provide back after the Enrolment

  11. New KMS Cards in 64kb • New KMS to be rolled out along with the 64KB rollout • For visual impact, change in artwork of key cards also

  12. Enrollment Process Highlights • SCSP certification at QCI mandatory • Only SCSP which are accredited by QCI can be hired by Insurance Companies/ TPAs • Enrollment & card Issuance • Beneficiary Data will be encrypted by MoLE and can only be downloaded and decrypted by certified SCSP as per information provided by Insurance Company • At the enrollment station Smart card cannot be Printed until it is personalised by FKOs • The smart card will be reverified after printing through fingerprint of the beneficiary • SCSP will need to Provide encrypted enrollment data on a WEEKLY basis to DKM and SNA Server

  13. Transaction at Hospitals • Role of Hospital • Receive the New MHC card from Insurer • Admit the patient in case hospitalisation is needed • Enter the AGE and GENDER of the Patient at the time of admission • Provide cashless treatment to the beneficiary • Do not charge any money from the patient for anything related to the treatment • Provide food free of cost for the patient • Evaluations have shown that in some cases patients had to pay and we need to ensure that Patients shall not pay in the hospital after they are admitted

  14. Highlights of Transaction Software • Transaction Software • Transaction Software is installed at each empanelled hospital • Software prepared by MoLE would be available to all SCSPs at no cost • Hospitals will not be charged for the new Transaction Software • Policy extension and Business Continuity Plan in built into the system • Date of admission can be entered manually also in case beneficiary bring smart card later • Data would be transferred to Insurance server and simultaneously the State server from the hospital • Trainers of Hospital will be trained in the Beginning and they in turn will train hospitals in the districts

  15. Awareness Activities • Role of Insurance Company • Organise awareness activities before the enrollment process in all the villages • Organise chit/ slip distribution to each targeted beneficiary • Prepare a communication strategy and plan • Role of State Nodal Agency • Responsible for all the post-enrollment IEC activities • Organise health camps based on utilisation pattern • Organise different IEC activities so as to improve utilisation • Involve field level Government functionaries and incentivise them for doing these activities Evaluations have shows that awareness about the scheme is limited and therefore, awareness activities, especially after enrolment shall be the focus now

  16. Claim Process • Role of Insurance Company • Analyse the claim, take a decision and settle the claim or reject within ONE MONTH • Each claim going beyond ONE MONTH shall be explained to SNA • A timeline shall be followed for transferring inter-insurance company claims data between Insurers • Claims should be settled through electronic bank transfer • Claim should mention the details of cases for which it is paid In case of rejection of claim, alongwith rejection details of the District Grievance Committee shall be provided

  17. State Server • State Server will need to be installed in the State by State Nodal Agency • The State server shall house enrollment data of the State for each beneficiary family • Transaction data from each hospital will flow directly to the State server • The software for State server to receive the data from hospitals is being prepared Centrally • A Fraud detection and control module for this software is also being prepared with in-built triggers • State server will be connected directly to the National server and data will be sent every day from State server to the National Server

  18. Data Analysis • State Nodal Agency • Receive enrolment data from Insurer and hospitalisation data directly from the hospitals • Analyse this data on a regular basis • Prepare monthly report based on data analysis and share with other SNAs and MoLE • Insurance Company • Analyse Enrolment data in comparison to the Beneficiary data on a regular basis during the enrolment • e.g. Villagewise enrolment data with Zero enrolment • Average family size in enrolled families • AnalyseHospitalisation data • Disease pattern • Hospitalisation pattern

  19. Fraud Detection and Control • Insurance Company • Daily transaction data from hospitals should be monitored very closely to identify patterns/ trends • Triggers/ filters etc. shall be built into software for early detection • Strict action should be taken against errant hospitals however, good hospitals should be nurtured • Steps to be taken after de-empanelment are defined in revised advisory for de-empanelment • SNA should be kept in confidence for actions against hospitals • State Nodal Agency • Analyse the data on a regular basis • Visit to the hospitals based on data analysis • Provide support to the Insurance Company as and when needed for this purpose

  20. Administrative Activities • State Nodal Agency • Provide premium payment to Insurance Companies on time • Organise regular review meetings at district and State level • Monitor Claims settlement including Inter-insurance company through a monthly meeting organised by SNA • Utilise Premium Fund Flow application of website to enter data • Insurance Company • Submit bills to the SNA on a monthly basis • Organise review meetings at the district level • Use RSBY website to enter all the relevant data • Provide all the data to SNA and MoLE • Disseminate Information provided at National and State level to field level people who are involved in implementation

  21. New Complaint and Grievance System • A Revised version of Complaint and Grievance Redressal system has been prepared which will be used in all the districts • All the complaints and grievance shall flow through a web based format which is being designed now • All complaints and grievances will be updated in the web page by the by the receiving agency/ designated person • A unique number will be generated for each grievance • For all complaints and grievances timelines have been defined clearly for redressal • A day and time every month shall be fixed for meeting of Grievance Redressal Committee at District and State levels

  22. District Grievance Redressal Committee (DGRC) • This will be constituted by the State Nodal Agency in each district within 15 days of signing of MoU with the Insurance Company. The District Grievance Redressal Committee will be as follows: • District Magistrate or an officer of the rank of Addl. Magistrate/ Chief Medical Officer: Chairman • District Key Manager: Convenor • Representative of the Insurance Company: Member • District Level Grievances • Grievances from various Stakeholders such as Hospital/ Beneficiary/ IC/ TPA/ DKM would be received at district level. • These will be taken up at the DKM level and put up to the District Grievance Redressal Committee. • If either parties are not satisfied with the decision they can appeal to the SGRC

  23. State Grievance Redressal Committee (SGRC) • This will be constituted by the State Nodal Agency within 15 days of signing of MoU with the Insurance Company. • State Principal Secretary/Secretary of Nodal Department RSBY: Chairman • State Nodal Officer for RSBY: Convenor • State Representative of the Insurance Company • State Level Grievances • Grievances coming as appeal with respect to the decision of DGRC will be received at State level. • Some grievances can come directly at State Level • All these grievances will be taken up at the SNA level and put up to the State Grievance Redressal Committee.

  24. National Grievance Redressal Committee (NGRC) • This has been formed by the Ministry of Labour and Employment at National level. The National Grievance Redressal Committee will be as follows: • Deputy Director General, GoI/Director in the DGLW: Chairperson • National Nodal Officer of the concerned Insurance Company: Member • Director/Under Secretary, MoLE, GoI: Convenor • National Level Grievances • Grievances coming as appeal with respect to the decision of SGRC will be received at National level. • Some grievances can come directly at National Level as an appeal • Grievances directly being received at National level will be forwarded to SNA for necessary action • All the grievances will be taken up at the National level and put up to the National Grievance Redressal Committee.

  25. Role of DKM – Pre enrolment Receive DKMA card from State Nodal agency Issue three authority cards: (a) FKO (b) Hospital and (c) District Kiosk. Ensure safe upkeep of Cards, Keep PIN in safe custody. Set up DKM Computer with necessary hardware and software in own office Ensure Training of FKOs, IT, other support staff Issue FKO Cards according to the specified schedule. Issue Hospital Card and Kiosk Card to the Insurer/ TPA. Ensure Insurance company organize District Workshop at least 7 days before commencement of enrolment Facilitate the Route Plan with the insurance company/its intermediaries for effective coverage of beneficiaries

  26. Role of DKM – Pre Enrolment Verify insurance enrolment manpower and machines/kits status as per tender document Ensure effective IEC by the insurance company and lend all possible support Ensure empanelment of optimum number of eligible hospitals – public and private Ensure that hospitals are functional before enrolment Ensure hospital training workshop is conducted by the insurance company and be present during that Allocate space for setting up of district kiosk by insurance company free of cost or at. Ensure that district kiosk is functional before the enrolment starts

  27. Role of DKM – During Enrolment Monitor the participation, timely attendance, presence and role fulfillment of FKOs in the enrollment process Keep few extra FKOs as stand by Provide support to the Insurance Company Field visit to the enrollment stations and record observations in the prescribed format Review the performance of Insurance Company as regards the enrolment status, review meeting format attached

  28. Role of DKM – Post Enrolment Get the enrollment data downloaded from FKO cards to the DKMA computer and collect FKO Undertaking Reissue FKO cards to new FKOs after personalizing again Ensure submissionof enrolment data from Insurer/ TPA Coordinate with district administration to organize health camps for building awareness about RSBY Visit empanelled hospitals to check beneficiary facilitation Hold grievance committee meetings on pre-scheduled days Ensure that necessary entries are made on the website regarding all the complaints/grievances received 24 Hour helpline – check the functioning of Helpline Communicate with SNA in case of any problem related to DKMA software, authority cards

  29. Few Important Documents Snapshot of Role of Enrollment Team Snapshot of Role of FKOs Snapshot of Role of DKMs FKO Undertaking Task to be performed at District Kiosk State Workshop District Workshop Revised Package Rates Hospital Manual Empanelled Hospital Template Poster for the Hospitals

  30. Thank You nishant.jain@giz.de urmila.goswami@nic.in sumita.rsby@gmail.com

  31. 13. Submission of Data to State and Central Govt. www.rsby.in 3. Upload on website after verification 4. Selection through tendering Government of India State Nodal Agency Insurance Company 9. Submission of data and bill 10. Payment to Insurer 1. Prepare in given format BPL Data 2. Send for verification 12. Claim Process 5. Empanelment Health Care Providers FKO 7. Enrollment of Beneficiaries Setting-up BPL Beneficiaries 5. Setting-up 7. Verification of Smart Card District Kiosk Call Centre 8. Download of FKO Data at DKM server 6. Issuance of FKO Card Awareness Health Camps 11. Utilisation of Services DKM

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