Scheme Details :

OBJECTIVE: To improve access of Below Poverty Line (BPL) and Above Poverty Line (APL) families (excluding White Card Holders as defined by Civil Supplies Department)to quality medical care for identified specialty services requiring hospitalizationfor surgeries and therapies or consultations through an identified Network of health care providers

SCHEME: Gandhi Jeevandayee Arogya Yojana (RGJAY) would be implementedthroughout the state of Maharashtra in phased manner for a period of 3 years.The insurance policy/coverage under the RGJAY for the eligible beneficiaryfamilies in 8 districts: Gadchiroli, Amravati, Nanded, Sholapur  ,Dhule, Raigad, Mumbai and Suburbs

BENEFITS: scheme would provide 972 surgeries/therapies/procedures along with121 follow up packages in following 30 identified specialized categories:

1 GENERAL SURGERY
2 ENT SURGERY
3 OPHTHALMOLOGY SURGERY
4 GYNAECOLOGY AND OBSTETRICS SURGERY
5 ORTHOPEDIC SURGERY AND PROCEDURES
6 SURGICAL GASTRO ENTEROLOGY
7 CARDIAC AND CARDIOTHORACIC SURGERY
8 PEDIATRIC SURGERY
9 GENITOURINARY SYSTEM
10 NEUROSURGERY
11 SURGICAL ONCOLOGY
12 MEDICAL ONCOLOGY
13 RADIATION ONCOLOGY
14 PLASTIC SURGERY
15 BURNS
16 POLY TRAUMA
17 PROSTHESES
18 CRITICAL CARE
19 GENERAL MEDICINE
20 INFECTIOUS DISEASES
21 PEDIATRICS MEDICAL MANAGEMENT
22 CARDIOLOGY
23 NEPHROLOGY
24 NEUROLOGY
25 PULMONOLOGY
26 DERMATOLOGY
27 RHEUMATOLOGY
28 ENDOCRINOLOGY
29 GASTROENTEROLOGY
30 INTERVENTIONAL RADIOLOGY

BENEFICIARY FAMILIES: holding yellow ration card, Antyodaya Anna Yojana card (AAY), Annapurna card and orange ration card from eight districts viz. Gadchiroli, Amravati, Nanded, Sholapur, Dhule, Raigad, Mumbai city and Suburban Mumbai. The families with white ration card holding would not be covered under the scheme. The beneficiary families would be identified through the “ Rajiv Gandhi Jeevandayee Health Card ” issued by the Government of Maharashtra or based on the Yellow and Orange ration card issued by Civil Supplies Department.

HEALTH CARDS: eligible families in these districts shall be provided with Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards in due course of time. This Health Cards will be used for identification of Beneficiary families in the family under the Scheme. Family Health Cards will be prepared by using data from valid Yellow or orange ration cards coupled with Aadhaar numbers issued by UID authorities. As an interim measure till the issuance of health cards, the valid Orange/Yellow Ration Card with Aadhaar number or in case Aadhaar number not available, any Photo ID card of beneficiary issued by Govt. agencies (Driving License, Election ID,) to correlate the patient name and photograph would be accepted in lieu of health card.

FAMILY: Family means members as listed on the Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards or holding valid Orange/Yellow Ration Card.

IDENTIFICATION: Health card issued by Govt. of Maharashtra/Rajiv Gandhi Jeevandayee Arogya Yojana Society or valid Orange/Yellow Ration Card with Aadhaar number if Health card is not issued would act as a tool for beneficiary identification for availing the health insurance facility. The following actions would be undertaken by Network hospitals in case of the possible exceptional situations:

Situation Validations / Check

No Health Card with beneficiary,
but Valid Yellow or Orange
Ration Card with name of
beneficiary is available
Aadhaar

Aadhaar number and in case Aadhaar
number not taken any Photo Health Card issued by Govt. (Driving license, election identity card with photograph, school ID, certificate issued by authorized office.) to correlate the patient name & photograph (In instance of emergency admission, provisional preauthorization may be given subject to confirmation of it against submission of valid photo identity card issued by Govt. before discharge.)

Children born after issue of card
i.e. name and photo not available
on health card or on valid yellow/Orange ration card

Photograph of child with either parent along with Health card/ valid Yellow or Orange ration card of parent and Birth certificate issued by authorized office.

PRE EXISTING DISEASES: All Diseases under the proposed scheme shall be covered from day one. A person suffering from disease prior to the inception of the policy shall also be covered under approved procedures for that disease

SUM INSURED ON FLOATER BASIS & PERIOD OF INSURANCE: The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary up to Rs. 1, 50,000/- per family per year in any of the Empanelled Hospital subject to Package Rates on cashless basis through Health cards or valid Orange/Yellow Ration Card. The benefit shall be available to each and every member of the family on floater basis i.e. the total annual coverage of Rs. 1.5 lakh can be availed by one individual or collectively by all members of the family. In case of renal transplant surgery, the immunosuppressive therapy is required for a period of 1 year. So the upper ceiling for Renal Transplant would be Rs. 2, 50,000 per operation as an exceptional package exclusively for this procedure. The cases are likely to be very few and well controlled by Human Organ Transplant Act 1994. The claims related to this have to be settled by Insurer. The insurance coverage under the scheme for the beneficiary families shall be in force for an initial period of one year from the date of commencement of the policy

RUN OFF PERIOD: A “ Run Off period ” of one month will be allowed after the expiry of the policy period i.e. till one month after the date of policy period for 8 districts Phase-I. This means that pre-authorizations can be done till the end of policy period and surgeries for such pre-authorizations can be done up to one month after the expiry of policy period and such claim will be honored by the Insurance Company

PACKAGE: The insurer should ensure that the Network hospitals follow the packages worked out by Rajiv Gandhi Jeevandayee Society. The package rates will include bed charges in General ward, Nursing and boarding charges, Surgeons, Anesthetists, Medical Practitioner, Consultants fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines and Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests, food to inpatient, one time transport cost by State Transport or second class rail fare (from Hospital to residence of patient only) etc. In other words the package should cover the entire cost of treatment of patient from date of reporting to his discharge from hospital including complications if any, making the transaction truly cashless to the patient. In instance of death, the carriage of dead body from network hospital to the village/township would also be part of package. The planned procedures like hernia, vaginal or abdominal hysterectomy, appendicectomy, cholecystectomy, Discectomy, etc. would preferably be performed in empaneled public hospitals, subject to service availability therein. The rates for each procedure are indicative and represent upper ceiling and the Insurer may negotiate with the given empanelled hospitals to bring them down amicably without compromising quality.

CASHLESS TRANSACTION: It is envisaged that for each hospitalization the transaction shall be cashless for covered procedures. Enrolled beneficiary will go to hospital and come out without making payment to the hospital subject to procedure covered under the scheme. When the beneficiary visits the selected network hospital and services of selected network hospital should be made available (Subject to availability of beds). In instance of non- availability of beds at network hospital, the facility of cross referral to nearest another Network hospital is to be made available and Arogyamitra will also provide the beneficiary with the list of nearby network hospitals.

ONLINE CLAIM SETTLEMENT: The Insurance Company shall settle the claims of the hospitals online within 7 working days of receipt of the Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The online progress of claim settlement will be scrutinized and reviewed by Rajiv Gandhi Jeevandayee Arogya Yojana Society.

Steps for Treatment in the Network Hospital

STEP 01: Beneficiary families shall approach nearby PHC/Rural, Sub district, General, Women/District Hospital/Network Hospital .Arogyamitra placed in the above hospitals shall facilitate the beneficiary. If beneficiary visits Government Health Facility other than the Network Hospital, he/she will be given a referral card to the Network Hospital with preliminary diagnosis by the doctors. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the Villages and can get that referral card based on the diagnosis. The information on the outpatient and referred cases in the PHC/Rural, Sub district, General, Women/DH and the camps will be collected from all Arogyamitra /Hospitals on regular basis and captured in the dedicated database through a well-established call center

STEP 02: The Arogyamitra at the Network Hospital examine the referral card and health card or Yellow/Orange Ration Card, register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. The information like admission notes, test done will be captured in the dedicated database by the Medical Coordinator of the Network Hospital as per the requirement of the Rajiv Gandhi Jeevandayee Arogya Yojana Society.

STEP 03: The Network Hospital, based on the diagnosis, admits the patient and sends E-preauthorization request to the insurer, same can be reviewed by Rajiv Gandhi Jeevandayee Arogya Yojana Society.

STEP 04: Recognized Medical Specialists of the Insurer and Rajiv Gandhi Jeevandayee Arogya Yojana Society examine the preauthorization request and approve preauthorization, if, all the conditions are satisfied. This will be done within 12 working hours and immediately in case of emergency wherein e-preauthorization is marked as “ EM ” . The validity of preauthorization would be for 7 days.

STEP 05: The Network Hospital extends cashless treatment and surgery to the beneficiary. The Postoperative notes of the Network Hospitals will be updated on the website by the medical coordinator of the Network Hospital

STEP 06: Network Hospital after performing the covered surgery/ therapy/ procedure forwards the Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The Discharge Summary and follow-up details will be part of the Rajiv Gandhi Jeevandayee Arogya Yojana Society portal.

STEP 07: Insurer scrutinizes the bills and gives approval for the sanction of the bill and shall make the payment within agreed period as per agreed package rates. The claim settlement module along with electronic clearance and payment gateway will be part of the workflow in Rajiv Gandhi Jeevandayee Arogya Yojana Society portal and will be operated by the Insurer. The reports will be available for scrutiny on the Rajiv Gandhi Jeevandayee Arogya Yojana Society login.

STEP 08 : The Network Hospital will provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge.

HEALTH CAMPS: Health Camps are to be conducted in Taluka Head Quarters, Major Gram Panchayat and Municipalities. Minimum of one camp per week per empanelled hospital has to be held in the eight districts in the policy year. The insurer shall ensure that at least one free medical camp is conducted by each network hospital per week at the place suggested by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The Rajiv Gandhi Jeevandayee Medical Camp Coordinator MCCOs of the hospital shall coordinate the entire activity. Network hospital shall carry necessary screening equipment along with specialists (as suggested by the Rajiv Gandhi Jeevandayee Arogya Yojana Society) and other Para-medical staff. The Insurer shall put in the minimum requirements as regards the health camp in the MOU with the hospitals. The empanelled hospital shall work in close liaison with district coordinator of the Insurance Company, Civil Surgeon/District Health Officer in consultation with District Collector. Hospital shall follow the Camp policy of Rajiv Gandhi Jeevandayee Arogya Yojana Society.