Rashtriya Swasthya Bima Yojana (RSBY)

The Rashtriya Swasthya Bima Yojana (RSBY) was introduced in 2008 by the Ministry of Labour and Employment to provide health insurance to unorganised workers. It aims to provide essential healthcare services and social security to families below the poverty line (BPL).

The scheme helps BPL families access quality medical facilities for health issues related to old age, maternity, disability, and general ailments. RSBY was later expanded to include unorganised workers just above the poverty line.

Eligibility Criteria for Rashtriya Swasthya Bima Yojana

To enroll in the Rashtriya Swasthya Bima Yojana, applicants must meet the following criteria:

• Must be an unorganised sector worker belonging to a household listed in the district's BPL list.
• Individuals just above the poverty line and those registered under welfare boards are also eligible.

Key Features of Rashtriya Swasthya Bima Yojana

Key features of the Rashtriya Swasthya Bima Yojana include:

• Coverage up to ₹30,000 for hospitalisation expenses for unorganised workers.
• Premiums are jointly paid by the central and respective state governments.
• No age limit for coverage.
• Beneficiaries pay ₹30 for registration.
• Reduces out-of-pocket expenses for BPL families during medical emergencies.
• Covers beneficiaries' pre-existing conditions.
• Offers family floater coverage for all family members.
• Provides incentives for stakeholders; insurers receive government incentives based on enrollment numbers.
• Insured families receive a smart card with biometric details.
• Supported by a robust data management system that tracks nationwide transactions and generates periodic reports.

Insurance Coverage under Rashtriya Swasthya Bima Yojana

Each enrolled family receives health insurance coverage up to ₹30,000. Includes transportation coverage of ₹100 per hospital visit, up to a maximum of ₹1,000.

Exclusions of Rashtriya Swasthya Bima Yojana

RSBY covers only medical emergencies. Cosmetic surgeries and treatments are excluded. Certain listed medical conditions are covered only in genuine emergencies.

Procedure for Claim Settlement

Treatment is cashless. Beneficiaries can avail medical treatment at any network hospital by presenting their government-issued smart card. Authorities verify biometrics to initiate treatment.

After treatment, the claim is sent electronically to the insurance service provider or Third-Party Administrator. Upon review, the insurer initiates payment within the agreed timeframe.

Selection of Health Insurance Provider

State governments select private or public insurance service providers through a competitive public bidding process. The chosen provider must be IRDAI-licensed and typically offers the lowest bid for RSBY.

How is RSBY Financed?

RSBY is primarily financed by the central government (75%) and respective state governments (25%). For North-Eastern states and J&K, the central government covers 90%, with the state funding the remaining 10%.

How to Enroll Beneficiaries in RSBY

An electronic list of BPL families from the district BPL list is sent to the insurance service provider. The provider then prepares and posts an enrollment schedule with specific dates for each village at the local enrollment station.

Biometrics and photographs of BPL family members are collected. Beneficiaries register by paying ₹30 and receive a smart card along with an information pamphlet listing network hospitals.

Enrollment legitimacy is authenticated by a Field Key Officer and a health insurance company representative. A consolidated list is then sent to the State Nodal Agency, which forms the basis for financial transfers from the central to the state government.

Preparation of Below Poverty Line Data

State governments prepare and submit electronic BPL data to the Government of India, including details like name, age, gender, head of household, and relationship. Scheme implementation in the district is based on this data.

Empanelment of Hospitals for RSBY

Hospitals are empanelled concurrently with the selection of the health insurance service provider. The provider ensures a sufficient network of hospitals in the district for easy cashless treatment access. Empanelled hospitals must have RSBY desks to address beneficiary inquiries.

Verification of Services Utilised by the Beneficiary

The procedure begins with the beneficiary visiting a network hospital for identity verification at the RSBY desk. For hospitalisation, hospital departments verify the price and procedure for the specific package.

Upon discharge, beneficiaries undergo biometric verification and swipe their smart card for the predetermined treatment cost deduction. They are also eligible for ₹100 towards transportation costs, with no proof required.

Evaluation of RSBY

Hospital transaction data is sent to the district server via phone line. This data is arranged in pre-formatted tables for both the insurance company and the government, facilitating claim tracking and fund transfers to hospitals by the insurance service provider.

Conclusion

RSBY is a unique cashless scheme providing medical treatment to unorganised workers and their BPL families. Its family floater coverage can be utilised for medical emergencies. The scheme is secured by a robust evaluation procedure that enables the insurance service provider to track claims and inspect patterns to prevent discrepancies.