The government has decided to revise the ceiling rate of premium paid to insurance companies by states and Union Territories (UTs) under India’s flagship health insurance scheme, Ayushman Bharat, from Rs 1,052 per year by each family to Rs 1,500, News18 has learnt.
Ayushman Bharat, formally known as Pradhan Mantri Jan Arogya Yojana (PMJAY), provides an annual health cover of Rs 5 lakh per family to more than 10 crore poor and vulnerable people (around 50 crore beneficiaries) for secondary and tertiary care hospitalisation.
The National Health Authority (NHA), which is responsible for the implementation of the scheme, had proposed the revision highlighting that per family utilisation under the Ayushman Bharat in a few states and UTs has already breached the ceiling limit of Rs 1,052.
The NHA explained to its governing board, headed by Union health minister Mansukh Mandaviya, that in a few states and UTs while the contribution of the central government has been capped between 60% and 100% of Rs 1,052 per family, the outgo of these states and UTs has increased substantially.
“It has increased so much that the state contribution has not only breached the sharing guidelines but has also exceeded the central contribution,” a government source explained. The source further said this makes the scheme unattractive for states.
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“This has limited NHA’s institutional capacity to guide and direct the implementation of the scheme on state UTs with high utilisation under the scheme,” the source added.
The government official said NITI Aayog CEO Amitabh Kant quoted a study to the governing board that “the per family premium or expenditure for providing healthcare services similar to that of Ayushman Bharat was around Rs 2,800.”
“Kant told the board that in light of the same, increasing the per family expenditure ceiling to Rs 1,500 was within reasonable limits,” the source said.
As Ayushman Bharat is touted to be the world’s largest health insurance scheme, the premium paid to insurance companies varies state to state. The insurance companies decide premiums based on the number of beneficiaries in the state. Where beneficiaries are less and the premium is high.
According to the NHA, the ceiling limit of Rs 1,052 was last revised in September 2018.
The NHA also convinced the board to approve the proposal by explaining that apart from “the general inflation in prices there has been a spiralling increase in the costs of medical treatment following the onset of Covid-19”.
“As a result, this ceiling limit was no longer reflective of the on ground scenario.”
New Ceiling to Bring More States/UTs to Adopt Scheme
The upward revision of ceiling limits is likely to encourage many states, UTs to adopt the recently notified health benefit packages under Ayushman Bharat.
Benefitting hospitals, the treatment rates for more than 400 procedures have increased, in some cases by as much as 100% in anticipation of widespread adoption and higher utilisation of the scheme by the states across India.
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