On August 15, when Prime Minister Narendra Modi will launch the Ayushman Bharat National Health Protection Mission (AB-NHPM), almost half of the states would not be part of it. So far 20 states have agreed to implement the scheme which is being termed 'Modicare' on the lines of 'Obamacare' of the US. But only 12-15 states will launch the scheme that day as the others are not prepared to roll it out on time, says Dr Vinod K Paul, the chief architect of the scheme who is also a member of Niti Aayog. States like UP and Bihar may take another 6 months or longer to launch Ayushman Bharat.
As for the states that are ready, patients will be able to walk into empanelled hospitals on the first day and receive cashless treatment upto Rs 5 lakh per annum for each family. Southern states such as Telangana, Andhra Pradesh and Karnataka which already have health insurance schemes in place are far better prepared to introduce Ayushman Bharat. In fact, the Centre is initially using Telangana's technology backbone to launch NHPM.
Announced in the 2018 Budget, the AB-NHPM was touted as the 'world's largest government funded health care programme'. While it might take a while, with participation at both the Centre and state levels, and a cover for 10.74 crore families, the scheme is set to meet expectations eventually.
As per the scheme, states will devise their own modes and adequate funds will be provided, though the ratio will differ from state to state. For most states, funding will be shared in the ratio of 60:40 with Centre contributing the majority. The North Eastern states, Himachal Pradesh, Uttarakhand and J&K, will however, enjoy 90:10 funding ratio.
Each state will need to create an apex body that will implement and monitor the scheme. The Centre's funding will be to this apex body. States like Telangana, MP, Assam, Sikkim and Andhra Pradesh and 8 others have opted for the trust model where the bills will be reimbursed directly by the government. Twelve states are expected to adopt the insurance model, where the government will pay an amount to an insurance company that in turn will pay the hospitals. Gujarat, Tamil Nadu, and 6 others, for instance, have chosen the 'mixed mode implementation'.
The government will also implement standard treatment guidelines to ensure that every patient receives quality treatment and nothing substandard. To make sure this is followed through, each empanelled hospital will have an 'Ayushman Mitra' to assist patients with the procedure. Moreover, there will be regular auditing and monitoring to keep the treatment meted out in check as well as a redressal mechanism will be in place.
While it might appear otherwise, private hospital chains have no reason to complain. Private hospitals could get up to 40 per cent higher rates for a procedure over rates prescribed by National Health Protection Scheme (NHPM) or Central Government Health Scheme (CGHS), provided they meet the following conditions:+ 10% for NABH accredited hospitals
+ 10% for hospitals providing PG courses
+ 10% for hospital in 115 backward districts
+ 10% if state offers additional top-up
Additionally, keeping in mind a key demand of the RSS and SJM, government insurance companies will be preferred over private or international players. States where government-owned insurance companies such as Life Insurance Corporation of India; General Insurance Corporation of India; National Insurance; Oriental Insurance; New India Assurance and United India Insurance will be allowed to match the bids of the private insurers. If they do agree to match the bids put forth by private insurance firms, the business will be divided 50:50 between them.
The government has been reaching out to beneficiaries since April this year through Panchayats and Gram Sabhas. Beneficiaries are being selected on the basis of the Socio Economic Caste Census (SECC) data of 2011. Initially, beneficiaries would be identified through their mobile numbers before a unique ID is issued.Total outlay of the scheme in terms of the premium to be paid by the government to insurance firms will be discovered when firms bid for the business. Cost to government is not known yet but it expected to be much higher than Rs 12,000 crore that has been estimated so far.