Health Sector – UHC, National Health Policy, Family Planning, Health Insurance, etc.

Pre-authorization must for nearly half of all treatments under NHPM


Mains Paper 2: Governance | Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

From UPSC perspective, the following things are important:

Prelims level: Particulars of the Ayushman Bharat Programme

Mains level: Universal health coverage and associated Moral hazard


Ayushman Bharat operational details

  1. Pre-authorisation will be mandatory for 636 of the 1,350 packages – or 47 per cent of all treatments covered under the National Health Protection Mission (NHPM), including all packages for cardiology, ophthalmology and oncology.
  2. The NHPM will not cover conditions that do not require hospitalization, dental procedures, congenital physical problems, vaccinations and fertility-related procedures, and will also not cover treatment of a person who has attempted suicide.
  3. The document also lays down that for a claim ratio of up to 120 percent, states will not pay any additional premium.

Pre-authorisation is essential to keep a check on “moral hazard” procedures

  1. “Moral hazard” in health insurance parlance is the tendency of people who are insured to buy/be sold additional healthcare interventions, irrespective of their actual needs
  2. This leads to expenses that do not necessarily add to their own health or well being but bleeds the insurer
  3. For this procedures such as emergency consultation for acute colic, high fever, cuts, stitches, soft tissue injury, single-bone fracture plaster, nebulization for asthmatic attack, moderate dehydration, hypoglycaemia in a diabetic, dengue without complication, and food poisoning will be covered in the scheme only if the treatment is availed in a government hospital
  4. For some specified conditions, pre-authorisation will be required for hospitalization beyond 10 days

A penalty for Delay in Premium

  1. The penalty provisions are stiff for any delays on the part of the insurer or the state health agency (SHA) either in paying the premium or in processing claims or refunds to the state.
  2. If claim payment to the hospital is delayed beyond 15 days, insurers will have to pay an interest of 1 percent for every seven days of delay.
  3. If the premium refund is not made by the insurer to SHA within 30 days of the communication for the refund, there will be 1 percent interest for every week of delay.
  4. If the premium is not paid to the insurer by the SHA within six months of the commencement of the AB-NHPM, insurers will get an interest of 1 percent of the premium amount for every seven days’ delay.

Administration of the Scheme

  1. For the purpose of administration of the scheme, states have been divided into two categories.
  2. Category A states include Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi, Sikkim, Tripura, Uttarakhand, and six Union Territories: Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep and Puducherry.
  3. States in Category B are Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh, and West Bengal.

Admin Cost Sharing

  1. In category A states, the administrative cost allowed is 10 percent if claim ratio less than 60 percent, 15 percent if claim ratio is between 60 percent and 70 percent and 20 percent if claim ratio is between 70 percent and 80 percent.
  2. In Category B states, administrative cost allowed will be 10 percent if claim ratio is less than 60 percent, 12 percent if claim ratio is between 60 percent and 70 percent, and 15 percent if claim ratio is between 70 percent and 85 percent
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