Aarogyasri Scheme boon to people of Telangana State

The role and responsibility of Health & Family Welfare is implementation of Maternal and Child Health Care and Family Welfare services in the State viz. Family Planning, Antenatal Care, Postnatal Care including Immunization services. The focus is mainly on promote and preventive care.

Family Welfare Programme is a Centrally Sponsored Programme with 100% financial assistance from Govt. of India from Ministry of Health & Family Welfare. Certain schemes are also assisted by State Government. External aided agencies are also assisting for the activities under National Health Mission.
Aarogyasri Scheme

Financing health care of persons living below poverty line, especially for the treatment of serious ailments such as cancer, kidney failure, heart diseases, is one of the key determinants that affects the poverty levels in Telangana.

Available network of government hospitals neither have the requisite infrastructure, manpower, resources and management autonomy nor the ability to satisfy the patients, in order to meet the tertiary care needs of the poor.

As a result, many such poor approach private hospitals and incur catastrophic expenditures leading to sale of assets, indebtedness and impoverishment. In many cases, patients die in harness unable to access medical treatment which is beyond their means. Medical expenses are identified as one of the causes driving the farming community into poverty.

Chief Ministers’ Relief Fund (CMRF) provides reimbursement of expenses for treatment of ailments. Though, a large number of poor patients request for assistance from CMRF, this was not helpful in meeting their total expenditure on treatment. Health insurance could be a way of removing the financial barriers and improving access of poor to quality medical care; of providing financial protection against high medical expenses; and negotiating with the providers for better quality care.

A budget of Rs.50 Crores was allocated during 2007-08 to implement this scheme. Aarogyasri Health Care Trust was set up in February 2007 to act as a state level nodal agency for the implementation of the Scheme. Rajiv Aarogyasri Community Health Insurance Scheme was launched in the three districts from 01-04-07, and later extended to all other districts of the State in five phases covering the entire poor population. ` 6 Coverage was given for 163 treatments including those for heart, cancer, Neuro-surgery, Renal procedures, Burns and Poly-trauma cases, etc. under the banner Aarogyasri-I.

Since coverage of treatments was limited, a large number of patients continued to seek assistance from CMRF for treatment of other ailments. The Trust therefore constituted 31 teams of specialist doctors from government and private hospitals, analyzed all diseases afflicting the poor and listed more than 1500 medical and surgical procedures. The selection was based on twin criteria of the procedure being life saving in nature, and secondly shortage of specialist doctors performing the procedure in government hospitals.
A list of 533(389 surgical and 144 medical) such procedures was identified for inclusion under the scheme. These procedures were covered under the banner Aarogyasri-II and launched in the State on 17th July 2008 in order to enable all BPL families avail cashless treatment for more procedures. 79 new procedures in the Specialities of Obstetrics, Eye, ENT, Cardiology, and Trauma and Critical care were further added in the Scheme with effect from 14th November, 2008, thus bringing the total procedures covered under the Scheme to 942.

Objectives

To improve equity of access to BPL families to quality tertiary medical care both by strengthening the Public Hospital infrastructure as well as through purchase of quality private medical services to provide financial support for catastrophic health needs. The treatment of diseases shall be by way of hospitalization, and surgeries or therapies through an identified network of health care providers. 2.3 Modes of implement- ation Name Rajiv Aarogyasri is being implemented by Aarogyasri Health Care Trust in the state to assist 233 lakh poor families. The name of the scheme is Rajiv Aarogyasri Scheme.

POPULATION COVERAGE
 
Beneficiaries
The Scheme intended to benefit 233 lakh.BPL families in the all the 10 districts of the state

Eligibility Definition

All poor families of the state, as defined by Civil Supplies Department of Government of Andhra Pradesh as BPL families, shall be eligible under this scheme.

Eligibility card 

The eligible families are provided with Below Poverty Line ration cards or Rajiv Aarogyasri Health Cards, herein after called eligibility cards. Eligibility card for this scheme means:
i.    White ration card;
ii.    Antyodaya Anna Yojana (AAY) card;
iii.    Annapurna card;
iv.    Rajiv Aarogyasri Health card
v.    TAP card
vi.    RAP Card

 Eligibility verification

The eligibility of beneficiary under the scheme shall be verified using Aarogyasri IT application or through any other means as decided by the Trust.

 Excluded beneficiaries

Such of the beneficiaries who are covered for the “listed therapies” by other insurance scheme such as CGHS, ESIS, Railways, RTC etc., shall not be eligible for any benefit under this scheme.

Family

Family means members as enumerated and photographed on the Rajiv Aarogyasri Health Card or BPL Ration Card. The photograph or name indicated in the Health Card or BPL Ration Card will be taken as the proof for determining the eligibility of the beneficiary

Enrolment process

Trust will provide the details of each eligible family covered under the scheme through the eligibility card. This eligibility card shall be considered as the result of an enrolment and identification process for availing the health insurance facility. The BPL database of the Civil Supplies Department of Govt. of Andhra Pradesh shall be the sole basis for determining the eligibility.

BENEFIT COVERAGE 
 
Out-Patient
No out-patient services are covered as part of “Listed Therapies”

In-patient
The scheme shall provide coverage for the 938 “Listed Therapies” for identified diseases in the 31 categories.

Pre-existing diseases
All diseases under the scheme shall be covered from day one. A person suffering from any disease prior to the inception of the scheme shall also be covered

Pre and Post hospitalisation requirement

i. From date of reporting to hospital up to 10 days from the date of discharge from the hospital shall be part of the package rates.

ii. In case of Kidney Transplantation the postoperative care under package has to extend to 1 year.
Follow-up Services

Network Hospitals will provide free follow-up services to the patients under 125 follow-up packages.

Preauthorisation

The prior authorization shall be as specified at Term.

FINANCIAL COVERAGE

Collection Fund

The Trust has allocated an amount as specified in scheme budget. This fund has been mobilized through tax revenues of the GoAP and allocated to the Trust. GoAP being the agency who is collecting the prepayment from the beneficiaries through taxes, the GoAP/Trust will be the insurer for this scheme.

 Fund

The collected fund is transferred to AHCT which in turn manages it.

Risk Identification and Transfer if Any

In case the Trust transfers the risk of actual expenditure of the scheme exceeding the collected amount, an insurer will be identified. This firm is expected to arrive at the risk of actual expenditure under the scheme exceeding the budget and quote the premium for covering this risk. The Trust shall pay the insurance premium to the Insurer directly in instalments as specified in the contract for purchase of risk coverage.
In case of engagement of an insurer:

i.    Administrative cost: The admissible administrative cost ceiling under the scheme shall be as specified in the contract. Any administrative charges in excess of the admissible administrative costs shall not be allowed.

ii.    Refund The insurance cover shall be triggered the moment expenditure under the scheme exceeds the budget. Any premium paid to the insurer which remains nutilized due to the actual expenditure incurred being less than the sum of budget and premium shall be refunded to the Trust as specified in the contract.
Financial cover

The financial entitlements of the beneficiary shall be as follows:

i.    Coverage limit : The scheme shall provide coverage for the services to the beneficiaries up to Rs.1.50 lakh per family per annum on floater basis. And 0.50 lakh through buffer, thus total coverage is for Rs.2.0 lakhs

ii.    Floater Basis : The coverage limit on a beneficiary family shall be on floater basis. The beneficiary family shall have the ability to avail of the total coverage limit either individually by one member or collectively by two or more members of the family.

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