Transcript Rashtriya Swasthya Bima Yojna – Important Points

Rashtriya Swasthya Bima Yojna –
State Review Workshop
Dr. Nishant Jain
www.rsby.gov.in
13.04.2015
Seite 1
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
www.rsby.gov.in
13.04.2015
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Setting Up of Nodal Agency
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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
www.rsby.gov.in
13.04.2015
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Beneficiary Data Preparation

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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
www.rsby.gov.in
13.04.2015
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
Empanelment of Hospitals
Role of District Key Manager

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Role of SNA

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Provide New 64kb Master Hospital Card (MHC) after receiving
from SNA
Provide the New format in which Hospital data will be collected
Approve the list of hospitals through RSBY Website
Role of Insurance Company

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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
www.rsby.gov.in
13.04.2015
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Training

Role of SNA
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Role of District Key Manager/ DPM
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Organise training of DKMs at State level
Get FKO training organised at Block level with the help of
Insurance Company
Role of Insurance Company/ TPA

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
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
www.rsby.gov.in
13.04.2015
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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
www.rsby.gov.in
13.04.2015
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
Role of SNA


Enrolment
Send request for FKO, District Kiosk card online to MoLE
Role of District Key Manager

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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
www.rsby.gov.in
13.04.2015
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Enrolment

Insurance Company/ TPA
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Prepare a brochure to be given at the time of enrolment with
following details:
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List of hospitals empanelled
Details of the scheme
Details of the district kiosk and call centre
SCSP
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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
www.rsby.gov.in
13.04.2015
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Enrolment
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FKO
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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
www.rsby.gov.in
13.04.2015
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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
www.rsby.gov.in
13.04.2015
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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
www.rsby.gov.in
13.04.2015
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Transaction at Hospitals
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Role of Hospital
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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
www.rsby.gov.in
13.04.2015
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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
www.rsby.gov.in
13.04.2015
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Awareness Activities
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Role of Insurance Company
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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
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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
www.rsby.gov.in
13.04.2015
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Claim Process
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Role of Insurance Company
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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
www.rsby.gov.in
13.04.2015
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State Server
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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
www.rsby.gov.in
13.04.2015
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Data Analysis

State Nodal Agency
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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

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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
Analyse Hospitalisation data
 Disease pattern
 Hospitalisation pattern
www.rsby.gov.in
13.04.2015
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Fraud Detection and Control
Insurance Company
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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
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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

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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
www.rsby.gov.in
13.04.2015
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Administrative Activities
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State Nodal Agency
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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
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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
www.rsby.gov.in
13.04.2015
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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
www.rsby.gov.in
13.04.2015
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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:

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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
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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
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13.04.2015
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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.
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13.04.2015
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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
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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.
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www.rsby.gov.in
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
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13.04.2015
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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
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13.04.2015
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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
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13.04.2015
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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
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Few Important Documents
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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
www.rsby.gov.in
13.04.2015
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Thank You
[email protected]
[email protected]
[email protected]
www.rsby.gov.in
13.04.2015
Seite 30
www.rsby.in
4. Selection through tendering
Government
of India
State Nodal
Agency
9. Submission of data and bill
Insurance
Company
10. Payment to Insurer
BPL Data
FKO
Health Care
Call
Centre
Awareness
Health
Camps
BPL
Beneficiaries
6. Issuance of
FKO Card
District
Kiosk
8. Download of FKO
Data at DKM server
Providers
DKM
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