MEGHA HEALTH INSURANCE SCHEMEI n su r i n g Peop l e E n su r i n g Hea l th

4th August 2016

RSBY to MHIS

RSBY

Launched in December 2009 with NRHM as the nodal agency

Coverage of INR 30,000 for only BPL households

MHIS I Launched in December 2012 Sum insured to INR 1.6 lakh on a floater basis for secondary and tertiary care including cancer specific coverUniversal Health Coverage - All residents of Meghalaya except for government employees coveredDedicated SNA created for implementation

MHIS IILaunched in May 2015, continuing with the success of the phase ICoverage increased to INR 2 lakh on a floater basis for preventive, secondary, tertiary and follow up care.Added benefits: Pre and post natal MCH. Cardiac, diabetes and other lifestyle diseases

WHY MHIS – A Situational Analysis

Tackling issues of health shocks: prominently diseases that require hospitalisation.

Decreasing the out of pocket (OOP) expenditure among the majority of households.

Decreasing the risk of households becoming impoverished.

To provide quality health care by regulating health cost

MHIS RSBY

Coverage of ₹ 30,000.

Coverage for BPL only.

Only Covers Medical and

Surgical Procedures.

Expansion of coverage

which includes primary,

secondary and tertiary care.

Preventive care for lifestyle disease

Universal Coverage

MHIS I: ₹ 1,60,000 MHIS II: ₹ 2,00,000

A robust IT framework to improve access to health care to all citizens

Dedicated person/organization

• From half FTE manpower to 18 FTE manpower leading to creation of substantial capacity in the SNA

Capacity Building of Stakeholders • Continuous capacity building of various stakeholders of the MHIS

Infrastructure set up • IT and other infrastructure set up with a dedicated server.

Organization Structure of Agency at State level Organization Structure of Agency at District level

CEO

Joint CEO

MHIS manager

Grievance Redressal

Enrollment manager

Finance manager

Monitoring and control

IT manager

Claims officer

Finance Director

MHIS: Snapshot of State Nodal Agency

MHIS: Enrolment ProcessPre-enrolment activities: Preparation of a data base for the scheme through a Data Analytics companyIEC/awareness activities – Workshops, Announcements, Meetings with Stake Holders, Health Camps, Programs with NGO’s, faith based institutes and educational institutesPreparation of Route Maps for all districts and others

Enrolment Process:• Enrolment Period: 4 months (as per RSBY guidelines)• Enrolment is done by a team of operators – village wise

functioning under the Insurance Provider (TPA)• Smart Card is handed over the counter (OTC) to Beneficiaries

after authentication by a Field Key Officer (FKO is a government field worker like ASHA/ANM belonging to the village/area)

• An FKO biometrically authenticates the enrolled households via a Master Issuance Card (MIC), after which the enrolled household is issued the smart card.

Enrolment Monitoring:

Infrastructure Monitoring : Regular checks on the number of enrolment kits being utilised by the Insurance Company/Third Party Administrator.

Card Issuance: Weekly checks on the number of cards issued and handed over to households. Monitoring and reporting of non- OTC cards.

Enrolment Station Assessment Forms: used to collect feedback from 3 parties – Enrolment Operators, Field Key Officers, Beneficiaries at enrolment stations.

MHIS: Enrolment Checks

Enrolment Reports: Field Reports on a daily basis (reports via SMS etc)

Weekly reports based on the field reports

Reports through MIC card( FKO)

Sign data submitted and uploaded to server,

SQL report from Insurance Company

MHIS: Enrolment Stakeholders

Beneficiary Household

Village Authorities

Block and District

government authorities

District Health

authorities and Doctors

FKO (ASHA) Operators/

Infrastructure

Enrolment Station

Faith Based

Institutes

NGO’s

Insurance Company

SNA (State and Central

Government)

Educational Institutes

Government Departments

No of Service Provider Number of service providers have increased substantially – from 65 in RSBY and 170

in MHIS I to 203 in MHIS II

Empanelment ofFacilities

All the government facilities have been Empanelled (100 % during MHIS I & II)Under MHIS II, all Private hospitals in the state have been empanelled

Super-specialty hospitals outside the state

37 multi specialty/ speciality hospitals including DHARAMSHILA CANCER HOSPITAL & RESEARCH CENTRE, CMC Vellore, GNRC HOSPITALS, NE CANCER HOSPITAL, APOLLO GLENEAGLE HOSPITAL, INDRAPRASTHA APOLLO HOSPITAL, MEDICA, AMERICAN ONCOLOGY INSTITUTE etc

• 109 PHCs (100%)• 28 CHCs (100%)• 12 District Hospitals (100%)• 1 Medical Institute• 15 private hospitals in

Meghalaya (100%)• 37 Private Hospitals outside

state for critical care

MHIS: Empanelment

34%

66%

Healthcare Facility

Private PublicMHIS I (2013 - 2015) MHIS II (Aug 1st 2015 - May

23rd 2016)

150160170180190200210

170

203

No of Service Providers Empaneled

84.5%

1036

RSBY (2010-11)

MHIS -1 MHIS 2

50% increase from RSBY

1704

MHIS: Package Rates

1142

COSTING COLLABORATIVE STUDYStudy was conducted by a consulting agency

Objective of the Costing Collaborative StudyRationalize and contain Health care services

Adequate financial and disease coverage

Making the market conducive for entry of quality health care for provision of health care services within the state

Additional coversCritical and Cancer care, OPD benefits for Maternal and Child Health, Cardiac and Diabetes Preventive care, OPD diagnostic benefits, Follow-Up for critical care

Claims Processing

Online Claims

Manual Claims

For all Treatments that are below Rs 30,000 via the Transaction Management

Software in Hospitals.

For all Treatments that are above Rs 30,000 including critical illness & zero/less Balance in

the smart card

Hospitals upload claims to 3 servers, vizState Server, Central Server and

Insurance Co.

Claims once verified/authenticatedby the Insurance Company are paid

within 30 days

Involves paperwork and for fluidity in Operations SNA is kept on the loop vis-à-

vis patient party

Claims• Online claims are monitored closely by

Insurance Company , State Nodal Agency and Central Govt.

• Off line claims are easier to monitor since SNA is the intermediary in all cases.

Upon satisfactory submission of all required Docs, such claims are settled within 30 days.

MHIS: Claims Processing

For primary and secondary health care centres in the peripheries, an alternate method for saving the Claims on a CD and submitted for upload on a weekly basis

TECH TEAM

Insurance Company

Claims Officer SNA

MHISDistrict Account

DPM

TPA Server

SNA Server

RSBY ServerConnection AvailableHospital Directly upload to Servers

Connection UnavailableData Email / Write on CD

Data Processing by TPA

Claims Settled/Rejected Details emailed

Manual Claim

Form em

ail to ILGIC

TPA

Inqu

ire a

bout

the

Man

ual C

laim

s

Dire

ct T

rans

fer o

f Mon

ey to

hos

pita

l ac

coun

t with

onl

ine

tran

sacti

on fa

ciliti

es

Claims Settled/Rejected Email to DPM

Dire

ct U

ploa

d of

dat

a to

Ser

vers

Settled Claims Report

and

appr

ove

or re

ject

the

clai

m

Clai

ms M

oney

tran

sfer

to D

istric

t Acc

ount

For h

ospi

tal w

ith o

ut o

nlin

e tr

ansa

ction

facil

ities

.

Cheque of Settled Claim

s

DPM

Sett

le C

laim

s to

PHC/

CHC

by C

hequ

e

Data for reports

State Nodal Agency Claims Report

MHIS smart card holder

MHIS: Utilization Stakeholders

MHIS Claims Audit/Monitoring ModelClaims Fraud Trigger

Audit/Monitoring TeamBaseline Quality Check Corrective Measures

State Level District Level Claims Auditing Process

Pre-Authorisation Claims POS Claims

Low Trigger of Fraud

• Benefit availed on approval by Insurer.

• SNAs intermediates on all pre authorisation proposed claims.

Medium to High level Trigger of

Fraud• POS Claims

complied by SNA from three Servers – RSBY, Insurer and SNA Server.

• Extraction of Triggered Claims by SNA.

Types of Claims Extracted

1. Errors while blocking/ using TMS software

2. Unusual trend of claims3. Mismatch with Medical

records• Visit to the Hospital and

investigation/audit is conducted by the District Key Manager/ District Programme Manager Monitoring and Control Officer.

• Filing of Reports

• Educating Hospitals• Issuance warnings/letters• Highlight such issues at the DGRC

meeting. • Periodical District/State Level

impartation of training to Doctors, MHIS operators and other stakeholders.

MHIS: Incentive Structure for stakeholders

Enrolment Incentives:For the Filed Key officers on the basis of the enrolment in their area

Doctors Incentive and Infrastructure fund:Public Health facilities participate in a revenue sharing modelIncentive and Infrastructure is divided in a 30% and 70% ratio respectively strengthening and improving health care access in Public health facilities

• Grievance Redressal Committee has been constituted in the State and District Level since the implementation of the Scheme.

• Meetings are regularly conducted to address the grievances of various state holders at the State and District Level.

State Grievance Redressal Committee membersChairman Addl.Chief Secretary/Principal Secretary/Commissioner & Secretary/Secretary H&FW Dept

Convener Chief Executive Officer /Joint CEO MHIS.

Other Members Director Health Service (MI) ,State Manager , Grievance Redressal Manager , Claims officer, MC&O - MHIS and representatives from Insurance Company.

District Grievance Redressal Committee membersChairman Deputy Commissioner

Convener District Key Manager

Other Members DM&HO , Block Development Officers, Insurance Company representatives, DPM MHIS

MHIS: Grievance Redressal

Future for MHIS

Sustainability of the scheme:

• Increase in the scope of cover and coverage

• A comprehensive selection process for the Insurance Provider

• A robust IT mechanism for the functioning of the scheme

• Addressing financial gaps

• Creation of a tangible database