Rashtriya Swasthya Bima Yojana (RSBY) ₹ – The Rashtriya Swasthya Bima Yojana is a government-sponsored health insurance programme that provides coverage to families living below the poverty line. The scheme’s benefits can be obtained by paying a reasonable premium. Furthermore, there is no upper age limit for participation in this programme. Individuals and families living below the poverty line, as well as those in unorganized industries, are covered by the Rashtriya Swasthya Bima Yojana. On a floater basis, the policy offers an amount insured of Rs.30,000.
This is accomplished through providing health insurance coverage to low-income families (BPL). The plan offers financial protection against any financial obligations that may develop as a result of healthcare-related expenses, such as planned or unplanned hospitalizations. As a result, families can rest assured that their healthcare will be taken care of without being risked by financial difficulties.
Rashtriya Swasthya Bima Yojana Benefits and Features
Features and Benefits of Rashtriya Swasthya Bima Yojana RSBY( for Beneficiaries):
The RSBY includes various characteristics that aid low-income people, including:
- A total annual sum insured of Rs.30,000 per family
- The beneficiary is not required to pay anything to the hospital for any treatment up to Rs.30,000.
- The amount insured is based on a family floater.
- The government pays the premiums.
- The registration or renewal fee is Rs.30.
- There is no need to wait.
- There are only a few exceptions.
- The cost of hospitalization is included.
- There is coverage for all pre-existing conditions.
- The unorganized sector is taken into account.
- A five-member family unit is covered.
- All ailments are covered with a cashless service.
- The cost of transportation is paid up to Rs.1,000 (maximum per visit is Rs.100)
- a lengthy list
- A comprehensive list of public and private hospitals that are affiliated with the programme is available.
- The programme is transferable, allowing beneficiaries to use any empaneled hospital in any state, which is advantageous to migrant employees.
- Beneficiaries can choose from a list of accredited hospitals.
- There is no upper age limit for becoming a beneficiary.
Beneficiaries are also eligible for other inpatient insurance benefits as designed by their respective state governments.
Features and Benefits of RSBY(for Stakeholders):
Insurers, hospitals, intermediaries such as NGOs and Microfinance Institutions (MFIs), as well as state and federal governments, are all players in the RSBY. Significant benefits are also available to these stakeholders, including:
- Each household enrolled pays a premium to the insurer.
- Hospitals get compensated for each patient they serve.
- Hospitals can submit claims to their insurance companies electronically, saving time and effort.
- The insurance pays hospitals electronically, allowing for faster and better payment processing.
- The hospitals receive money straight from the insurance.
- Intermediaries are compensated for their efforts in promoting the plan.
- Increased competition between public and private hospitals will improve the efficiency of public health care providers.
- The government can provide healthcare coverage to those living below the poverty line without excluding anyone.
- Increased reach, exposure, and enrollment as a result of all stakeholders working together.
- IT service providers are also being sought for the biometric-enabled smart card and the district-level connection of empaneled hospitals to the government server.
- Periodic analytical reports are generated to aid in the scheme’s improvement.
What Does the RSBY Cover?
The Rashtriya Swasthya Bima Yojana is a unique health insurance plan that offers additional benefits over a commercial plan. The following are the RSBY insurance coverages:
- Hospitalization Expenses: The RSBY will reimburse expenses associated with hospitalization for the treatment of a sickness, illness, or accident. This coverage will also include the policyholder’s family. However, therapy and hospitalization must be provided by a trained Physician/Medical Specialist/Medical Practitioner at a Nursing Home/Hospital. The insurance company will reimburse expenses linked to the following (but not limited to):
- Nursing & Boarding Charges
- Bed charges (General Ward)
- Surgeons charges
- Doctor visits
- Consultation fee
- OT Charges
- Expenses related to the use of Surgical Appliances
- Prosthetic Devices
- X-Ray and Diagnostic Test
- Food (patient only)
2. Pre-Hospitalization: Up to one day before a patient is admitted to the hospital, the plan will cover the cost of diagnostic tests and medicines.
3. Post-Hospitalization: Expenses associated with an illness or surgery for which the patient was admitted are reimbursed for five days following release.
4. Transportation Expenses: A maximum of Rs.100/- per visit can be claimed under transportation. This fee is limited to one thousand rupees each year.
5. Dental Treatment: The Rashtriya Swasthya Bima Yojana will cover the cost of dental procedures required as a result of an accident.
6. Daycare Treatments: A daycare treatment is a surgical procedure that does not necessitate a lengthy stay in the hospital. Outpatient therapies are another term for these.
The following (not limited to) list of daycare treatments is covered under RSBY:
- Contracture release of a tissue
- Dental surgery following an accident
- Ear surgery
- Eye Surgery
- Gastrointestinal surgeries
- Genital surgery
- Hydrocele surgery
- Identified surgeries under general anesthesia
- Laparoscopic therapeutic surgeries allowed under daycare
- Minor reconstructive procedures of limbs
- Nose surgery
- Parenteral Chemotherapy
- Prostate surgery
- Surgery of urinary system
- Throat surgery
- Treatment of fractures/dislocation
Screening and follow up care including medicine cost with and without diagnostic tests. Any procedure covered by the insurance company
7. Maternity Benefit: This plan covers both natural and cesarean deliveries. The policyholder can receive Rs. 2500 for a natural birth and Rs. 4500 for a cesarean birth. Any issues that arise prior to delivery are also covered.
The expense of an involuntary pregnancy termination caused by an accident or in a case when saving the mother’s life is required will be paid.
8. Newborn Coverage: Even if the number of beneficiaries has been surpassed, the new-born baby will be automatically added to the RSBY insurance. This coverage will be in effect until the policy period ends. The policyholder has the option of including the baby in the policy when it is renewed.
What Is Not Covered Under RSBY
The Rashtriya Swasthya Bima Yojana helps poor individuals get the treatment they need in an emergency. As a result, the following situations are not covered by the plan:
- Any hospitalization claim that is not covered by the plan will be denied.
- Unless prescribed by a licensed medical practitioner as part of a treatment plan, the cost of vitamins or tonics.
- Dental procedures that are purely cosmetic or remedial will not be covered. Also excluded are root canals, cavity fillings, and operations associated with wear and tear.
- External congenital diseases
- Any sickness resulting from excessive use of alcohol, narcotics, or any other intoxicating substance is not covered.
- Fertility, infertility, and assisted conception procedures are all options.
- Physical transformations to resemble the other sex
- Replacement hormone therapy
- Plastic/cosmetic surgery is not recommended unless it is required as a result of an accident or a sickness.
- An act of a foreign enemy, invasion, or warlike operations using nuclear materials are all examples of war.
- Treatments received in a convalescent hospital, health hydro, convalescent home, nature care clinic, and other locations as specified in the policy documents.
- Maternity Benefit Exclusions include:
- Prenatal care costs
- The cost of a voluntary pregnancy termination
- The hospitalization lasted 48 hours following the delivery and other procedures.
Eligibility for RSBY – Rashtriya Swasthya Bima Yojana Eligibility
Only families who meet the RSBY’s qualifying requirements are eligible to participate in the programme. The following are the requirements for RSBY:
- This scheme is open to members of a family who are listed on the State government’s Below Poverty Line list.
- A worker in any unorganized sector could be the applicant.
- Member of a registered welfare board
Rashtriya Swasthya Bima Yojana Enrollment Process
- The RSBY enrolment process begins with the insurance companies authorised to offer the scheme receiving an electronic list of eligible BPL homes in a pre-specified data format. The insurance firms develop an enrollment calendar for each town with the cooperation of district officials.
- According to the schedule, the BPL list is placed at the enrollment station in every hamlet, and the date and site of enrollment are announced in advance. At significant locations such as public schools, mobile enrollment stations are set up. The insurance firm provides the stations with hardware that allows them to capture biometric data and images of the families that are covered. They also have a printer that can produce smart cards with photograph.
- After paying a Rs. 30 registration fee, the recipients are given a smart card as well as an information brochure with all the details regarding the scheme, including a list of network hospitals. The cards come with a plastic cover. The procedure is straightforward and quick. The entire procedure will take only ten minutes to finish.
Rashtriya Swasthya Bima Yojana Smart Card
Smart cards are necessary since they enable cashless purchases at network hospitals. The insured can also benefit from portability benefits across India using a RSBY smart card. Patient information, beneficiary identification by fingerprints, photos, and other functions are all possible with a smart card. In the event that the biometric information fails, the smart card’s photograph can be utilized for identification. The Rashtriya Swasthya Bima Yojana smart card will be given to the beneficiary at the enrollment station.
Process For Filing A Claim Under The Rashtriya Swasthya Bima Yojana
The majority of RSBY claims are cashless in nature.
- The Smart card must be presented at the hospital by the policyholder.
- Only a hospital that has been approved by the RSBY can settle cashless claims.
- The hospital will transmit the appropriate information to the insurance company or the Third Party Administrator (TPA).
- After the verification process is completed, the claim will be resolved between the hospital and the insurance company/TPA. At the moment of claim settlement, no paperwork is necessary.