Scheme_Coverage

OBJECTIVE

Employees Health Scheme is formulated to provide cashless treatment to the employees, pensioners of the State Government and their dependent family members, which will ipso facto replace the existing medical reimbursement system under the 'Andhra Pradesh Integrated medical Attendance Rules, 1972 (APIMA Rules, 1972)', with additional benefits such as post-operative care and treatment of Chronic diseases, which do not require hospitalization and treatment in empanelled Hospitals.

IMPORTANT STAKEHOLDERS IN THE SCHEME

Beneficiaries:

The Scheme is intended to benefit Serving employees and Retired employees of the state.

Dr.YSR Aarogyasri Health Care Trust:

1. Dr.YSR Aarogyasri Health Care Trust will implement the Scheme under the supervision of Government of Andhra Pradesh.
2. Steering Committee under the chairmanship of Chief Secretary to Government will review the implementation of the Scheme from time to time. The Steering Committee will meet as frequently as required, discuss, monitor and review the Scheme, benefit packages, grievances, quality of medical care including the modalities of an Employees Health Trust. The General Administration (Services & HRM) Department will issue orders forming the Steering Committee with 40% members from employees and pensioners associations, and 60% members from Government.

Network Hospitals - Service Providers:

A health care provider shall be a hospital or nursing home in Andhra Pradesh established for indoor medical care and treatment of disease and injuries and should be registered under Andhra Pradesh Private Allopathic Medical Establishments (Registration & Regulation) Act and Pre-Conception and Pre-Natal Diagnostic Techniques Act (Wherever Applicable).

Software Company - Technology Solutions:

A dedicated real-time online workflow system was designed by the Trust in order to bring dynamism and decentralization of work like Online processing of the cases starting from registration of case at network hospital, pre-authorization, treatment and other services at the hospital, discharge and post treatment follow-up, claim settlement, payment gateway, accounting system, TDS deductions, e-office solutions etc. The maintenance of the workflow is done round the clock.

POPULATION COVERAGE

Eligible beneficiaries:

1. Serving Employees:
   1. All regular State Government Employees. A State Government Employee will have the meaning as defined under Fundamental Rules.
   2. Provincialized Employees of local bodies.
2. Retired Employees:
   1. All service pensioners
   2. Family pensioners without dependents
   3. Re-employed Service Pensioners

Beneficiaries not covered:

1. Those who are covered under other insurance schemes such as CGHS,
2. ESIS, Railways, RTC., Aarogya Bhadratha of Police Department and Aarogya Sahayatha of Prohibition & Excise Department;
3. Law officers (Advocate General, State Prosecutors, State Counsels, Government Pleaders and Public Prosecutors);
4. Casual and Daily paid workers;
5. Biological parents if adopted parents exist;
6. All independent children; and
7. AIS officers and AIS pensioners.

Family:

The following will constitute the family:

1. Dependent Parents (either adoptive or biological, but not both).
2. One legally wedded wife in case of a male employee/ service pensioner.
3. Husband in case of a female employee/ service pensioner.
4. Wholly dependent legitimate children (including step children and adopted children); and
5. Dependents of family pensioners shall also be eligible as in the case of Service Pensioners.

Dependency:

1. In case of parents, those who are dependent on the employee for their livelihood.
2. In case of unemployed daughters, those who are unmarried or widowed or divorced or deserted.
3. In case of unemployed sons, those who are below the age of 25 years
4. Disabled children with a disability which renders them unfit for employment.

Authentication:

The eligible beneficiaries will be provided with health cards also called eligibility cards.

The procedure of verification of eligibility of beneficiary under the scheme shall be by online authentication of the Health Card details. The beneficiary shall provide either the eligibility card or the card number in case the card is unavailable. The staff at the kiosk in the Network Hospital shall verify the details online by accessing the database. Once the authentication is complete, the eligibility verification ends.

Penal actions:

Any irregularities or misuse committed by the beneficiaries coming to the notice of Government or Dr. YSR AHCT will entail disciplinary action as per A.P. C.S. (CCA) Rules, 1991 and may attract penal action as per law.

BENEFIT COVERAGE

In-Patient Treatment:

1. The scheme will provide Inpatient treatment for the listed therapies for identified diseases under all specialties in the empanelled hospitals. List of IP therapies
2. Package includes the following services:
   1. End-to-end cashless service offered through a NWH from the time of reporting of a patient till ten days post discharge medication, including complications if any up to thirty (30) days post-discharge, for those patients who undergo a "listed therapy(ies);
   2. Free OP evaluation of patients for listed therapies who may not undergo IP treatment including consultation and investigations

Follow-up Services:

Follow-up services are provided for a period of one year through fixed packages to the patients whoever requires long term follow-up therapy in order to get optimum benefit from the procedure and avoid complications. Follow-up package includes consultation, investigations, drugs etc., for one year for listed therapies. List of IP therapies

Outpatient Treatment for identified chronic diseases:

OP treatment for pre-defined long-term (chronic) diseases will be provided in notified hospitals. Orders on the modalities and provision of budget to the notified hospitals will be issued separately.

Hospital Stay:

The eligibility for Slab-A (consisting of employees with Pay Grades from I to IV), and Slab B (consisting of employees with Pay Grades from V to XVII) will be semi-private ward, and for Slab- C (consisting of employees with Pay Grades from XVIII to XXXII) will be private ward.

FINANCIAL COVERAGE

1. The employees, pensioners and their dependent family members will be eligible for a sum of Rs.2.00 lakhs (Rupees two lakhs only) per episode of illness with no limit on the number of episodes as existing in APIMA Rules, 1972. However, in the cases where the cost of treatment exceeds Rs.2.00 lakhs, cashless treatment will continue. No network hospital shall deny the treatment in such cases.
2. The limit of Rs.2.00 lakhs will not apply in cases where predetermined package rates are above Rs.2.00 lakhs.
3. Chief Executive Officer, Dr.YSR Aarogyasri Health Care Trust will settle the claims which exceed Rs.2.00 lakhs, following the standard claims settlement process after obtaining the approval of the Technical Committee constituted by the Government.

Financing:

1. 60% of total amount will be borne by Government and 40% by the employee / pensioner contribution.
2. The monthly contribution will be Rs.90/- (for Slab A consisting of employees with Pay Grades from I to IV, and Slab B consisting of employees with Pay Grades from V to XVII) and Rs.120/- (for Slab C consisting of employees with Pay Grades from XVIII to XXXII). The Pay Grades for the three Slabs under other Pay Scales, such as University Grants Commission Pay Scales, will be those equivalents to the corresponding Pay Grades under the State Government. The contribution for service pensioners or family pensioners will be according to the present Pay Grade of the post from which the pensioner retired from service.
3. If both of the spouses are Government employees or Service Pensioners, contribution by any one of the spouses is sufficient. In such a case, the applicant shall give a declaration to the effect that the other spouse is a Government employee / Service Pensioner, duly indicating the Employee Code / Pensioner Code of the other spouse.
4. The expenditure in running the Scheme and Scheme experience will be reviewed at the end of six months and revision of contribution effected accordingly.

NETWORK HOSPITALS

Empanelment:

1. Guidelines for empanelment of hospitals within the State and outside, preauthorization and other modalities while implementing the scheme will be in conformity with the existing standard procedures being followed by Dr.YSR Aarogyasri Health Care Trust. The list of empanelled hospitals will be made available in the official website www.ehs.ap.gov.in

Hospital Payments:

Payments under the scheme will be based on approved package prices.

Penal actions:

1. Empanelled hospitals resorting to irregularities or misuse shall be blacklisted and entire amount recovered besides launching criminal action.

Patient Process Flow

Mode of OP capture

A beneficiary suffering from an ailment can approach any of the following ‘first point of contact' for registration under the scheme. The mode of OP capture is directly at the NWH in case of emergencies or through referral.

OP Process flow at the NWH

1. Arrival: The beneficiary arrives at the NWH kiosk either with a referral card or with a complaint for registration.
2. Registration: NAM first mandatorily registers the patient. In case the patient is a child, the patient's Identity and Complaint are registered. OP is registered and OP ticket issued.
3. OP Consultation: Patient is forwarded to the OP and gets counselled to ascertain the eligibility under Scheme. Investigations are prescribed if required.
4. Investigations: He thereafter moves to the Investigation facilities if required, gets tested and returns to the doctor. If he can be treated as an OP case, prescription is given. The Diagnosis and prescription are entered in the system by NAM and case disposed.
5. Uncovered OP Procedure: If the patient's treatment warrants use of any of the uncovered OP, the MEDCO enters the details in the system and refers the case to Government Hospital.
6. IP registration: If the patient's treatment warrants use of any of the Listed Therapies, the MEDCO enters the details of Procedure and Investigations in the system, converts the case to IP, sent to the ward concerned (semi-private or private based on the eligibility) and raises preauthorisation.

Evaluation and Admission

After the initial evaluation of the patient, the patient is admitted if needed and evaluated further. The patient may be evaluated as an out-patient initially and after ascertaining the diagnosis and finalization treatment mode admitted and converted as "in-patient" in the online workflow.

Final diagnosis and categorization

After the evaluation of the patient:

1. If the patient is found to be suffering from listed therapies, MEDCO shall submit the pre-authorisation through the Trust portal within 24 hours.
2. If the patient is found to be suffering from diseases other than those that cannot be managed in the NWH or not covered in the Listed therapies, he shall be counselled and referred to nearest suitable Hospital for further management.

Pre-authorisation

MEDCO shall upload all the relevant documents and send the case for pre-authorization.

Treatment

The NWH shall render complete treatment to the patient after obtaining pre-authorization. Any complications arising during the course of hospitalization shall also be attended to.

Discharge

The patient is discharged after complete recovery. The NWH shall issue discharge summary, 10 days post-discharge medication, counsel the patient for follow-up. A letter of satisfactory services shall be obtained from the beneficiary at the time of discharge.

MEDCO shall upload the documents.

Follow-up

Patient shall be provided follow-up services as per the standard medical norms duly counselling and recording the same in the discharge summary.

The follow-up packages provided under the scheme shall be utilized for this purpose to provide cashless follow-up services.

Claim submission

The NWH will raise the claim after the 10 days of satisfactory discharge of the patient.

Emergency Registration and Admission

All the beneficiaries shall be admitted by a NWH and treated immediately. MEDCO or treating doctor shall obtain emergency telephonic pre-authrorisation through dedicated round the clock telephone lines of the Trust, if the patient is suffering from listed therapies.

If the patient is suffering from diseases other than listed therapies he must be counselled and facilitated safe transportation to the nearest Government Hospital.

If the patient's condition warrants shifting him to a higher centre, safe transport shall be facilitated to other NWH if suffering from listed therapies.