Model tender document lays down strict conditions, penalties for payment delays
National Health Protection Mission, commonly referred to as Modicare and touted as the largest government funded health insurance scheme in the world, will not cover OPD care.
The model tender document released by the ministry of health and family welfare on Tuesday evening says that NHPM will not cover conditions that do not require hospitalisation, dental procedures, congenital physical problems, vaccinations and fertility related procedures or the treatment of a person who has attempted suicide.
The model tender document which is only indicative and leaves room for the states to work their schemes the way they deem necessary, also has elaborate mechanism to control needless bleeding of the exchequer because of “moral hazard” procedures – treatments that only happen because they are paid for and are not really necessary to ensure the health of a beneficiary.
636 of the 1350 packages or 47% of all treatments covered under National Health Protection Mission (NHPM) will require pre-authorisation. This includes all packages for cardiology, oncology and ophthalmology. Emergency consultation for acute colic, high fever, cut, 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 only if treatment is availed in a government hospital.
There are also stiff penalty provisions both for delays in payment on the part of the insurer and the state
For a claim ratio of up to 120 percent states will not pay any additional premium. If the claim ratio is beyond 120% the state will pay 50% of the additional premium.
There are also stiff penalty provisions both for delays in payment on the part of the insurer and the state.
States have been divided into categories A and B. Category A states include Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi, Sikkim, Tripura, Uttarakhand and 6 Union Territories (Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep and Puducherry). Category B state includes Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh, West Bengal.
To be able to bid for the category A states, an insurance company will have to have a “Gross Direct Premium Income from Health business of at least Rs. 100 crores for Category A States and at least Rs. 200 crores for Category B States in India in each of the last three completed financial years.”
In category A States the administrative cost allowed is 10% if claim ratio less than 60%, 15% if claim ratio between 60-70% and 20% if claim ratio is between 70-80%. In Category B States administrative cost allowed will be 10% if claim ratio is less than 60%., 12% if claim ratio is between 60-70% and 15% if claim ratio is between 70-85%.
