Chief Minister’s Comprehensive Health Insurance Scheme, Government of Tamil Nadu

  • Written by eINDIA
  • October 16, 2012 at 9:12 am
  • Project Category : Health :: Health Insurance Initiative of the Year

    Details of the Applicant:

    Name: Dr.T.S.Selvevinayagam
    Designation: Joint Director
    Organization: Chief Minister’s Comprehensive Health Insurance Scheme.
    Address: State Health Insurance Unit, Tamil Nadu Health Systems Project, DMS Annexe, Teynampet, Chennai.
    City: Chennai
    State: 
    Tamil Nadu
    Country:
     India
    Postal Code : 600006
    Organization Website: www.cmchistn.com

    Details of the Agency implementing the Project/Initiative:

    Name of the Organization: Chief Minister’s Comprehensive Health Insurance Scheme
    Address: 
    State Health Insurance Unit, Tamil Nadu Health Systems Project, DMS Annexe, Teynampet, Chennai.
    City: 
    Chennai
    State: 
    Tamil Nadu
    Country:
     
    India
    Postal Code : 600006
    Head of Organization: Thiru.Pankaj Kumar Bansal,I.A.S.
    Project Website: www.jklu.edu.in

    Details of Programme /Project/Initiative:

    Brief Description:

    This is a lofty Insurance Scheme launched by the Tamil Nadu State Government through the United India Insurance Company Ltd (a Public Sector Insurer headquartered at Chennai) to provide free medical and surgical treatment in Government and Private hospitals to the members of any family whose annual family income is less than Rs.72,000/- (as certified by the Village Administrative Officers) .The Scheme provides coverage for meeting all expenses relating to hospitalization of beneficiary as defined in the Scope of the Scheme.

    Why was the project started:

    The main objective of the Scheme is to provide free medical and surgical treatment & Quality care in Government and Private hospitals to the members of eligible families

    Objective:

    To achieve the objective of Universal Health Care, To provide quality health care and easy access to the multi-specialty hospitals by the members of the scheme which was previously provided services for only the highly affordable society.

    Target Group: Every member of a family whose annual family income is less than Rs.72,000/- as certified by Village Administrative Officer and such other person who may be declared to be eligible for coverage under the ‘Chief Minister’s Comprehensive Health Insurance Scheme’ by the Government will be ‘Eligible Persons’ under the Scheme. Around 1.34 corers of family are covered under the scheme. In addition to this Widowers, Old age pensioners, People in old age homes, children’s in orphanages

    Geographical Reach within India: Tamil Nadu

    Geographical Reach outside India: No

    Date From which the Project became Operational: 11-1-2012

    Is the Project still operational?: Yes


    List 5 Innovations of programme/project/initiative:
    1. Online Empanelment of Hospitals –Done in a Transparent manner
    2. The scheme is entirely managed through user friendly web portal
    3. Members of the scheme can undergo Stand alone Diagnostic Procedures even if it doesn’t leads to approved Medical or Surgical procedures
    4. Moving towards Go green Concepts- entirely paperless transactions
    5. Using Smart card to identify our scheme members – already 1.07 crores of card are distributed.

    List 5 achievements of the programme/project/initiative:
    1. Around 77 high end procedure are covered like Liver Transplant, Renal Transplant, Bone Marrow Transplant etc.,
    2. More than 1.34 crores are Family are covered that is more than 50% population of Tamil Nadu are covered
    3. Entire process starting from pre-auth to claims amount settlement is through the Scheme ICT portal. Because the ICT we are able to process pre-auth approval within 24hrs and claims settlement in 7 days
    4. So far 1,55,599 Beneficiaries amounting to Rs: 361,32,69,680 pre-auth approved for their treatment under the CMCHIS in an entirely cashless basis. Within a period of 9 months form the inception
    5. Mobilizing patients through the mandatory Screening camps and also online tracking of referred patients form the camp site to the outcome of treatment at any of the network hospitals.

     

    List 5 Key challenges faced while implementing the project/programme/initiative and how they were overcome:

    1. Initially, we had problems with the server due to over-usage and immediately we have transferred data to cloud computing especially during the period of Online Empanelment. Because of this problem, we have extended the deadline for submission of online application document by the hospitals to enroll in the scheme as a NWH. Email option to apply is also kept as stand by.
    2. There were multiple entries made by the hospitals during empanelment through our Scheme ICT, which may be due to anxiety or it may be because of server down they have applied again & again, Due to this our software vendor has to do lot of back end operations to remove the repeated entries as well as incomplete/ ineligible entries based on the minimum criteria for empanelment of hospitals under CMCHIS.
    3. Previously it was very difficult to monitor the insurance company whether they are processing pre-auth & claims at the prescribed timeline, to over-come the issues we have include TAT concept because of this the time taken to process will be reflected in every individual pre-auth & claim’s.
    4. Initially the claims amount are settled to the hospitals by the insurance company through bulk cheque which is against the concept of transparency so the ICT is customized in such a way once the claims is approved the amount beneficiary wise is transferred through EFT creation and its through our ICT portal. Now money are transferred also through BULK EFT by simply authorizing the transaction through VASCO token provided to the Insurance company/TPA heads and the entire process can be Observed/Monitored through the ICT.
    5. Misuse/ abuse or overuse of certain procedures by the service provides are observed especially in specialties like ENT, O.G, Ortho, Opthal etc even if it’s not warranted. So we have taken high level policy decision & reserved the procedures only to Public sector Hospitals in order to curtail this kind of fraudulent activities.

    List 5 points on how the Project/Programme/Initiative can serve as a model that can be replicated or adapted by others?
    1. Reserving certain procedures to Government sector to prevent abuse/fraudulent/over-use of unwarranted procedures in the system.
    2. Online tracking of patients referred form the health camps to hospital for further management.
    3. Entire process like Empanelment of hospitals, enrollment of beneficiaries under the scheme, processing of pre-auth & claims, transfer of amount to the hospitals are through the Scheme web portal and its paperless.
    4. This scheme is entirely cashless, and the premium is paid by the Govt. of Tamil Nadu in behalf of beneficiaries through the SHIU,TNHSP to the Insurance Company and the scheme covers around 1016 medical & surgical procedures which includes 77 High end procedures. One more highlight in the scheme is that we are providing 23 Stand alone Diagnostic Procedures & 113 Follow up procedure free of cost for the scheme members and their families.

    List 5 points to elaborate on the scalability of the programme/project/initiative?
    1. Any organization-private or Govt /Individual member/society can join and get all benefits from the scheme with Govt. approval in future.
    2. We are having plans in improving the functionality of the scheme by innovating new things through our ICT, like establishing our own INHOUSE Server in future based on the growing needs.
    3. Scheme Smart Card can be integrated with other health programs and also it may be used to co-ordinate other programs like RSBY,NRHM related programs etc.,
    4. Newly emerging diseases can be added based on the disease load & severity in the population.
    5. The Sum assured or the coverage amount for a procedure may be increased in future based on the type of intervention and the severity of the diseases.






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