This scheme will offer health cover of Rs 5 lakh per family per year to 10 crore families.
The cabinet on Wednesday approved the centrally-sponsored Ayushman Bharat-National Health Protection Mission (AB-NHPM), which will provide a health insurance cover of Rs 5 lakh per family per year.
The intended beneficiaries of the proposed scheme will be more than 10 crore poor and vulnerable families, based on the Socio Economic and Caste Census (SECC) database.
The existing Rashtriya Swasthya Bima Yojana (RSBY), which provided a health cover of Rs 30,000, and the Senior Citizen Health Insurance Scheme (SCHIS) will be subsumed into the new scheme.
Although the government has not specified an exact date for the introduction of the scheme, sources told Moneycontrol that a formal launch will be done on August 15.
The AB-NHPM was first announced by finance minister Arun Jaitley in his Union Budget speech this year.
A government statement said this cover will take care of almost all secondary care and most tertiary care procedures.
"To ensure that nobody is left out (especially women, children and elderly) there will be no cap on family size and age in the scheme. The benefit cover will also include pre and post-hospitalisation expenses. All pre-existing conditions will be covered from day one of the policy," the government said in the statement.
At present, most insurance policies exclude all pre-existing conditions of individuals in health insurance products.
The AB-NHPM will also have a defined transport allowance for every time a person is hospitalised, which will be paid to the beneficiary.
It is estimated that the government will need between Rs 20,000 crore and Rs 25,000 crore to implement the scheme.
AB-NHPM will be an entitlement-based scheme with entitlement decided on the basis of deprivation criteria in the SECC database.
The different categories in rural areas include families with only one room with kucha walls and kucha roofs, families having no adult member between age 16 to 59, and female-headed households with no adult male member between age 16 to 59, among others.
Also, families with disabled members and no able-bodied adult member, SC/ST households, and landless households deriving major part of their income from manual casual labour, will be entitled under the scheme.
For urban areas, 11 defined occupational categories are entitled under the scheme. The beneficiaries can avail benefits in both public and empanelled private facilities.
All public hospitals in the states implementing AB-NHPM will be deemed empanelled for the scheme. Hospitals belonging to Employee State Insurance Corporation (ESIC) may also be empanelled based on the bed occupancy ratio parameter.
As for private hospitals, they will be empanelled online based on defined criteria.
In terms of the mode of implementation, state governments will be allowed to expand AB-NHPM both horizontally and vertically. They can implement it through an insurance company or directly through a trust/society or a mixed model.
However, it is likely that most states will employ an insurance model wherein companies will be chosen through a process of tender.
To ensure that the funds reach state health agencies (SHAs) on time, the transfer of funds from the central government under AB-NHPMA to the SHAs will be done through an escrow account directly.
In partnership with NITI Aayog, an IT platform that will entail a paperless, cashless transaction will be made operational.
In the initial stages, outpatient expenses will not be covered under the scheme and only in-patient hospitalisation expenses will be covered.
Data showed that rural households primarily depended on their household income/savings (68 percent) and on borrowings (25 percent).
However, urban households relied much more on their income/saving (75 percent) for financing hospitalisation expenses, than on borrowings (18 percent).
Out of pocket (OOP) expenditure for healthcare in India is over 60 percent, which leads to nearly 6 million families slipping into poverty due to catastrophic health expenses. The AB-NHPM is expected to have an increased benefit cover for nearly 40 percent of the country's population.
