Based on a high-level review of the Ayushman Bharat Arogya Karnataka (AB-ArK) health scheme, the State Health Department is now weighing the pros and cons of adopting the insurance mode of the health scheme over the existing assurance mode.
To study the functioning of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY)/State health scheme on insurance mode and the relative advantages of insurance mode over assurance mode, the department is sending a team of four officials to Rajasthan and Tamil Nadu.
The team comprising officials from the Health Department and Suvarna Arogya Suraksha Trust (SAST), the nodal agency implementing the health scheme, will visit Rajasthan from June 27 to June 28 and Tamil Nadu from July 6 to July 7. The team includes Bhanumurthy, Joint Director (Medical); Suresh Shastri, Director (Medical Management), SAST; Roopa, Director (Operations) SAST, and Arun Kumar T., Assistant Director Finance, SAST.
Report by July 10
State Health Commissioner Randeep D. said the team would study the advantages of both the models and submit a report by July 10.
“Both Rajasthan and Tamil Nadu are running their health schemes on insurance mode. The Chief Minister and the Health Minister wanted us to study that (insurance) mode and suggest if it is better than the existing assurance mode implemented through SAST,” he said.
Flexibility
Since the launch of the AB-PMJAY in September 2018, States have been given the flexibility to adopt the trust, insurance or a combination of both, termed the hybrid mode of implementation. The trust mode indicates that a government-registered trust, also termed the State Health Authority (SHA), purchases services directly from empanelled providers (in Karnataka, the SAST is the SHA). Third-party administrators (TPAs), referred to as implementation support agencies (ISAs), may be contracted to support the scheme administration functions of the trust.
In the insurance mode, the SHA contracts an insurance company (IC) to insure beneficiaries and pay providers for the services included in the benefits package at fixed bundled rates in return for a fixed premium per beneficiary family unit covered. Here, insurers are responsible for authorising treatments, processing claims, and paying providers.
Consequently, the insurance company performs fraud detection and overall financial risk management. So far, 24 States and six Union Territories have adopted the trust mode and insurance mode, respectively, while three States have adopted the hybrid mode in the country.
