Rashtriya Swasthya Bima Yojana

✦Key Features

• Cashless hospitalization coverage up to a specified sum (e.g., Rs. 30,000 per family per year on a family floater basis).
• Smart card-based identification and transaction system for beneficiaries.
• Coverage for pre-existing diseases from day one of enrollment.
• Inclusion of both public and empaneled private hospitals.
• Provision for transport allowance (e.g., Rs. 100 per visit, up to a maximum of Rs. 1000 per year).
• Coverage for most common illnesses requiring hospitalization.

✓Eligibility Criteria

• Families identified as Below Poverty Line (BPL) by the respective State Governments.
• Unorganised sector workers and their families, as defined by the Ministry of Labour and Employment.
• Specific categories of workers such as domestic workers, construction workers, street vendors, and others, as notified by the government.

★Benefits

• Hospitalization expenses including surgeon and anaesthetist fees, diagnostic tests, medicines, and room charges.
• Pre-hospitalization expenses for one day and post-hospitalization expenses for five days.
• Maternity benefits (in some states, as per state-specific packages).
• Transport allowance for each hospitalization.

▶Application Process

• Enrollment camps are organized at the village or block level by the implementing agency.
• Eligible beneficiaries register at these camps by providing their demographic and biometric information.
• A smart card is issued on the spot after successful verification and payment of a nominal registration fee (e.g., Rs. 30).
• The smart card can then be used at empaneled hospitals for cashless treatment.
• Annual renewal of the smart card and coverage.

₹ Budget Allocation

227

Funding Ratio (Centre:State): 75:25 (Centre:State) for most states; 90:10 for NE and J&K.

Historical Context

Launched in 2008 by the Ministry of Labour and Employment to provide social security to workers in the unorganized sector. It was transferred to the Ministry of Health and Family Welfare in 2015.

Challenges

• Inadequate coverage limit of INR 30,000 per annum for a family of five.
• High transaction costs for insurance companies in rural areas.
• Exclusion of out-patient (OPD) expenses, which constitute the bulk of OOPE.
• Incidences of 'induced demand' where private hospitals performed unnecessary procedures.
• Lack of awareness among the migrant labor population about portability features.

Reforms & Recommendations

• Integration of OPD services to reduce overall medical costs.
• Stricter auditing of private hospitals to prevent fraud.
• Enhancing digital literacy among beneficiaries for better claim settlement.

Performance Statistics

SDG Linkages

Constitutional Backing

Technology Used

Success Stories

Key Takeaways

• First scheme to use biometric smart cards for the unorganized sector.
• Provided cashless insurance for secondary care.
• Portability allowed beneficiaries to use cards across India.
• Subsumed into PM-JAY in 2018.

Convergence Schemes

• Ayushman Bharat PM-JAY
• National Health Mission
• Aam Admi Bima Yojana

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