28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

JAGADISH S

Regional Manager

Medi Assist

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

a) YCFHCS is a successful micro insurance scheme in Karnataka (PPP). Started in the year 2003 with 1.6 million lives.

b) The amazing success is possible through a tight partnership with the following stake holders

c) Stake Holder : Govt. of Karnataka, Service providers ( Hospitals, Bank & TPA), Trust

d) This scheme provides cashless facility to eligible Yeshasvini card holders across 484 hospitals in Karnataka for nearly 1600 identified surgeries

e) Apart from the above - medical emergencies like snake bite, dog bite, bull gore, electric shock, insect bite is covered.

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

OMM: Operations, Maintenance & Management

Operations: Carried out by private viz TPA and Hospitals

Maintenance: Govt. of Karnataka

Management: Yeshasvini Trust, managed by Trustees representing Public and Private.

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

Trustees:1. The Principal Secretary to Govt. Co-operation Department (Chairman)

2. The Registrar of Co-operative Societies,

3. The Managing Director, KSC Apex Bank Ltd

4. Additional Registrar of Co-operative Societies (C&M),

5. The Managing Director, Karnataka State Milk Producers Federation,

6. Dr. C.N.Manjunath (Director) Jayadeva Institute of Cardiology,

7. Dr. Devi Prasad Shetty, Chairman, Narayana Hrudayalaya,

8. Dr. M.D Dixit, Director, KLE Heart Hospital,

9. Dr. Guru Dev, Nephrologist, Vikram Hospital,

10. Dr. L.H. Bidri, Dr. Bidri's Ashwini Hospital.

TPA: Hospitals:

Media Assist India TPA Pvt Ltd Govt (25%) Private (75%) – Total 484

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

To deliver quality healthcare to the organized sector

(Cooperative members) through minimum contribution.

To extend cashless facility (less paper transactions)

No reimbursement under the scheme.

Capacity utilization Govt. Setups

VAS – Discount for Investigations and free OPD

checkups at all network Hospitals.

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

07/05/10 Medi Assist India TPA Pvt. Ltd.

Enrollment Payment

• Pre- authorization• Query response • Enhancement

• Workflow management• Reports, Document, Billing

• Claim submission• Claim query response• Claim authorization

• Payment reconciliation

• Pre-authorization approval • Pre-authorization/ enhancement authorization

• Claim query & processing

• Payment Processing• Payment disbursement / EFT

1 432

Electronic Platform

Hospital

T P A

Pre-Care Treatment

Claim Management

Payment Management

Govt / Trust

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

•Increasing the number enrolled members from 16 Lakhs to 30 Lakhs in six years is a big achievement.•The PA process has slowly evolved from the fax based processing to 100% electronic.•Introduction of EFT for payment to Hospitals. •Inclusion of stree  shakthi groups (Self Help Group )in to the coverage since year 2011•Maintaining margins / administrative cost positively over the last three years.

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

Retention of enrolled beneficiaries

Make it self reliant

Increase scale

Extend to other self help groups

Revision of package rates

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

Year

Members Enrolled    ( ` in

lakh)

Members Contribution ( ` in Crores)

Govt. Contribution (` in Crores)

No. of Free OPD availed

No. of Surgeries

availed

Surgery Amount

Reimbursed to Hospital (` in

Crores)

2003-04 16.01 9.49 4.5 35814 9047 10.65

2004-05 21.05 12.87 3.57 50174 15236 18.47

2005-06 14.73 16.94 11 52892 19677 26.16

2006-07 18.54 21.56 19.85 206977 39602 38.51

2007-08 23.18 27.75 25 155572 60668 54.09

2008-09 30.47 36.1 30 191109 75053 61.03

2009-10 30.69 41.36 30 134534 66796 55.08

2010-11 30.47 41.68 30 157480 73963 57.23

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

Enrollment and data entry to NIC site:

The enrolled data takes at least  4 months to be entered in to the NIC site. In this window period members to avail treatment have to ascertain their identity with a letter from the society. This can be avoided if the enrollment goes online or other methods of enrollment are introduced such as smart cards, biometric cards etc. This make the process more efficient and transparent.

 Waiting period:

As in any mass Health insurance schemes moral hazards also happen in Yeshasvini as there the no waiting period. A waiting period of at least 30 days for all surgeries (except emergencies) may be suggested.

Entire family enrollment:

By waiving the minimum 4 member family concept for enrollment, it has made it convenient for the members to enroll only those individuals who are  likely to avail treatment / fall sick. This is not in the interest of the community as a whole (risk pooling?)

28 – 29 September 2011Vedic Village Spa Resort Kolkata, India.

Thank You

http://www.yeshasvini.kar.nic.in/