National Health Authority, the top body governing Prime Minister Narendra Modi’s flagship health insurance scheme Ayushman Bharat, has given in-principle approval allowing out-of-pocket payments for packages costing beyond the scheme’s wallet limit of Rs 5 lakh, News18.com has learnt.
According to a senior official, the National Health Authority, the apex body responsible for the implementation of Ayushman Bharat, has briefed the governing board that many times, beneficiary families under the scheme are not able to use the full wallet amount due to limitations in the current policy.
The NHA is governed by a Board chaired by the Union Minister for Health and Family Welfare. The NHA informed the Governing Board that in case of insufficient balance in the wallet for a package listed under the scheme, the beneficiary may be allowed to utilise the leftover amount in the wallet if they are willing to co-pay the additional amount.
As per the current rule under the ‘Claims Adjudication Manual’ of NHA, the available sum insured in the beneficiary’s family wallet should be enough for payment of the current treatment.
“The Government of India is committed to provide a health cover of Rs 5 lakh for each beneficiary family and thus it is well within the rights of the beneficiary to avail the full cover in case the wallet is getting exhausted and other avenues of funding are available,” the source said, quoting the Governing Board’s decision.
However, to avoid any abuse of such provision, all such cases will first go through the mandatory audit.
For instance, consider a family that has utilised Rs 4 lakh given for treatment under the scheme. However, due to some other emergency, the family needs to go for another procedure and should be able to use the remaining Rs 1 lakh along with its own money.
Or, in case a package cost is higher than Rs 5 lakh such as for lung transplant, the beneficiary may be allowed to use their full wallet along with their self-contribution to avail such treatment under the scheme.
How The NHA Convinced the Governing Board
The NHA had told the Governing Board that with Ayushman Bharat already integrated with schemes such as Rashtriya Arogya Nidhi or Health Minister’s Discretionary Grant, this has created possibilities for funding of expensive treatment procedures.
Further, it said, several states and Union Territories have implemented schemes with provision for higher funding for rare or life threatening diseases.
“It was, therefore, proposed to provide the beneficiary with the option to use other sources of funding over and above the PM-JAY wallet, if required for availing healthcare services,” a senior government official said.
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