Ayushman bharath

1. Dr.Vidhyashree M.D

2.  Chief Minister’s Comprehensive Health
Insurance Scheme (CMCHIS)
 Launched by the Govt of Tamil Nadu through
United India Insurance Company Ltd
 Total number of families benefited under this
Scheme so far - 1.57 crore families

3.  Every member of a family whose annual family income is
less than Rs.72,000/-
 Sum insured – The coverage is Rs.1 lakh per year per
family with a provision of Rs.2 lakh for certain specialized
procedures.
 Legal spouse of the eligible person;
 Children of the eligible person till they get employed or
married or attain the age of 25 years, whichever is earlier,
and who are dependent on the eligible person;
 Dependent parents of the eligible person.
 Migrant labourers who resided for more than six months in
the state as certified by suitable authority are included
after the payment of premium for migrant employees by
the Labour department.
 Orphans as defined by the State Government are covered
under the scheme and given single card.

4.  Totally, 881 hospitals - 224 Government Hospitals and
657 Private Hospitals
 In the scheme from 11.01.2012 to 10.01.2017 (5
years), 17.30 lakh beneficiaries are benefitted for
insurance coverage of Rs.3398.66 crore.
 Cost of specialized surgery will be borne by the
insurance Company upto Rs.2.00 lakh and the
remaining amounts are met from the Corpus Fund.
 Totally 6119 beneficiaries have been approved for the
high end surgeries by an Expert Committee as per the
following details:

5.  On September 23rd 2018, the Prime Minister
Narendra Modi launched Pradhan Mantri Jan
Arogya Yojana (PMJAY), under Ayushman
Bharat umbrella at Ranchi, Jharkhand.
 According to Socio-Economic Caste Census
(SECC) 2011 data, 8.03 crore families in rural
and 2.33 crore in urban areas will be entitled
to be covered under these scheme, i.e., it
will cover around 50 crore people.

6.  A cover of Rs. 5 Lakhs per family per year for secondary and tertiary
care
 There is no restriction on family size, age or gender
 All members of eligible families as present in SECC database are
automatically covered
 No money needs to be paid by the family for treatment in case of
hospitalization
 All pre-existing conditions are covered from day one of the policy. The
benefit cover will include pre & post hospitalization
 You can go to public or empanelled private hospitals across the
country and get free treatment
 You need to carry any prescribed ID to receive treatment at the
hospital

9.  High end procedures on this scheme are
being done at Private Hospitals.
 Cochlear Implant Surgery
 Renal Transplantation Surgery
 Bone Marrow Transplantation
 Stem Cell Transplantation
 Liver Transplantation

10.  Go to NHA portal and Log in to mera.pmjay.gov.in
 Enter your mobile number and captcha code.
 A one-time password will be sent to your mobile
number. After entering the OTP, you will be taken to
this screen.
 Select the state: Fill all the fields like name, mobile
number, ration card number, or Rashtriya Swasthya
Bima Yojna URN number.
 If your name is there in the list, it will show up on
the right-hand side of the page. Click on 'Family
Members' tab to find the beneficiary details

11. Required documents
 Respective special category certificates
 Age proof documents
 Family structure
 Identification details
 Contact information
 Scanned copy of Aadhar
 Income certificate
 Caste certificate

13.  AB-NHPM should envision strengthening
of primary care, inclusion of out-patient
treatment and a public healthcare delivery
system, and expanding the scope of
coverage to the entire population in order
to make the government’s transition from
provider to payer a successful one and
achieve Universal Health Coverage in the
true sense.

14. Ayushman Bharat – National Health Protection Mission 15
Standardisedtreatment
guidelines(STGs)
Mandate adoption of STGs for
standardised treatment and billing.
EnrichmentofNationalHealth
ResourceRepository(NHRR)
Generation of repositories on
hospitals, providers and other
human resources for health.
Standardised
packagerates
The scheme identifies approximately
1,350 treatment/surgical procedures for
which package rates will be fixed.
ITintegrationand
datageneration
Will create data for improved
operational, financial and medical
management effectiveness via IT-
enabled systems.
Updating
ROHINI
Itwill benefit the healthinsurance
sector in the management of claim
costs through reduction in
fraudulent claims.
Employment
generation
The scheme will have a multiplier
effect on the Indian economy
through employment generation
and promoting the healthcare
industry in tier 3 and 4 cities.

15. Identificationand verification
ofbeneficiaries
Pre-authorisation and
claimsprocessing
Hospital
empanelment
Fraud
Treatment
availed
Complaints
• Families eligible in SECC
• Beneficiaries identified via valid
Government ID
• Household covered
• Families migrated
• Families found with no change
• Families that could not
be contacted
• Families currently enrolled
in RSBY
• Families enrolled in state health
insurance schemes
• Percentage of pre-authorisationraised
• Percentage of pre-authorisation
approved Percentage of pre-
authorisation declined
• Time to pay hospitals after submission of
claims
• Percentage of pre-authorisation
settled within TAT
• Percentage of re-imbursement
claims reported
• Percentage of claims paid/rejected
• Percentage of claims paid within
30 days
• Hospital registered but application
submission pending
• Application submitted with
documents verified andunder
scrutiny by DEC/SEC
• Application sent for
field inspection
• Application approved and
contract pending
• Beneficiary fraud: Enrolment of in
genuine/ghost beneficiaries
• Beneficiary fraud: Impersonation in
connivance with cardholders and
hospital, leading to fraudulent
admissions
• Hospital fraud conversion ofOPD
patient into an IPDpatient
• Hospital fraud: Showingmedical
management cases as day
care procedures
• Qualified staff missing
• OT notes and daily monitoring
chart not available
• Proof of payment of transportation
charges missing
• Help desk missing
• Patients presenting complaints that
do not match withpackage blocked
• Treating doctor’s details not
shared
• Package blocked without
patient being admitted
• Qualified staff missing
• OT notes and daily monitoring
chart not available
• Indoor case papersincomplete
• Proof of payment of
transportation charges missing
• Help desk missing
• Patients presenting complaints
that do not match with package
blocked
• Treating doctor’s details
not shared
• Package clocked without patient
being admitted

16.  "e-India Jury Award" 2012 for the best
Practices in Health Insurance with IT enabled
solutions
 Chief Minister Recognition Award to Project
Director - CMCHIS scheme on 19th Dec 2012
 Any Enquiries / grievances contact :
cmchis@uiic.co.in and tncmchis@gmail.com