HIMACHAL HEALTH CARE SCHEME
PREAMBLE
The Governor, Himachal Pradesh is pleased to
notify a scheme to provide cashless treatment to the residents of Himachal
Pradesh namely 'The Himachal Health Care Scheme' in short HIMCARE as under:-
Scheme - 1. Short Title.
This policy shall be called 'The Himachal Health Care Scheme' in short
HIMCARE.
Scheme - 2. Commencement.
The scheme shall come into effect from the date of notification.
Scheme - 3. Benefit Package.
Cashless treatment coverage of Rs. 5.00 lakh per year per family will be
provided under the scheme on family floater basis subject to maximum of five
members per family unit. In case family size exceeds five members, the
remaining members can be enrolled as a separate unit subject to the capping of
five members for each such addition unit. The treatment will be provided on the
basis of pre-defined package rates in the empanelled hospitals for inpatient/
day care treatment.
Scheme - 4. Differential premium.
Following premium shall be collected from beneficiaries at the time of
enrollment under Him Health Care Scheme based on the categories defined below:
|
Category
|
Target
group
|
Premium
amount
|
|
I
|
BPL and
Registered Street Vendors (Not covered under Ayushman Bharat)
|
Zero
|
|
II
|
Ekal
Naaris
Disabled
>40% (At present >70% Disabled are covered and it is proposed to cover
>40% disabled under the new scheme)
Sr.
Citizens above 70 years of age (At present Sr. Citizens above 80 years are
covered and it is proposed to cover Sr. Citizens above 70 years of age under
new scheme)
|
Rs. 365
per year
|
|
|
Anganwari
Workers
Anganwari
Helpers
ASHA
workers (Category not included under MMSHCS and it is proposed to include
ASHA workers)
Mid-Day
meal workers
Daily Wage
Workers (Govt., Autonomous Bodies, Societies, Boards & Corporations
etc.),
Part Time
Workers (Govt., Autonomous Bodies, Societies, Boards & Corporations etc.)
Contractual
Employees (Govt., Autonomous Bodies, Societies, Boards & Corporations
etc.)
|
|
|
III
|
Beneficiaries
not covered under category-I and category-II or who are not govt. servants or
their dependent family members.
|
Rs. 1000
per year
|
The various beneficiaries shall give proof of concerned category through
uploading of relevant document at the time of enrolment and renewal as under:-
|
Category
|
Documents
required for authentication
|
|
BPL
|
Copy of
BPL certificate attested by the Panchayat Secretary within previous one
month.
|
|
Registered
Street Vendors
|
Registration
Certificate attested by the Executive Officer, MC/NP/NAC within previous one
month.
|
|
Ekal Naaris
|
Certificate
to be issued by Child Development Program Officer (CDPO) of the concerned
area and shall include Widows/Divorced/Legally Separated/ Unmarried more than
40 years.
|
|
Disabled
>40%
|
Medical
Disability Certificate showing permanent disability.
|
|
Sr.
Citizens above 70 years of age
|
Any valid
age proof
|
|
Anganwari
Workers/Helpers
|
Certificate
from Child Development Program Officer (CDPO) of the concerned area.
|
|
ASHA
workers
|
Certificate
from Block Medical Officer (BMO) of the concerned area.
|
|
Mid-Day
meal workers
|
Certificate
from Block Elementary Education Officer of the concerned area, if working in
Government Primary School. Certificate from concerned Head of Institution if
working in Government Middle/ High/Sr. Sec. School.
|
|
Contractual
Employees
|
Certification
from concerned Department
|
|
Daily Wage
Worker
|
Certification
from concerned Department
|
|
Part Time
Workers
|
Certification
from concerned Department
|
Scheme - 5. Enrolment & Renewal.
5.1 Enrolment:-
The scheme shall be implemented through e-cards. The enrolment shall be done in
a simple way through a user friendly web interface hosted on the website
www.hpsbys.in capturing Aadhar, Ration Card, Mobile Number and proof of
category. The beneficiary will apply through online system directly or through
Lok Mitra Kendra/Common Service Centres. He/she will make online payment of
premium by using online payment gateway. After the approval of enrolment from
back-end, the beneficiary will receive SMS regarding his enrolment and he/she
will be able to download/generate the E-Card under the scheme. The CSC/LMK will
collect Rs. 50/- per family from the beneficiaries for enrollment and uploading
the documents under the scheme. After the approval message is received, the
beneficiary can get his/her card printed from the concerned CSC/LMK within the
user fee of Rs. 50/- initially given to the CSC/LMK. Option to generate the
E-Card at hospital level shall also remain available. The enrollment/renewal
shall be open only for three months in a year i.e. from January to March to
avoid the issues of adverse selection. The policy period for individual
beneficiary household shall commence from the date of approval of
enrollment/renewal till the expiry of twelve months.
5.2 Existing Schemes:- This scheme shall subsume
Mukhya Mantri State Health Care Scheme (MMSHCS) and Himachal Pradesh Universal
Health Protection Scheme (HPUHPS). The existing beneficiaries under these
schemes will continue to avail benefits as per their applicable policy period
and the data of the existing beneficiaries shall be ported onto the new system
(unique ID will remain same) and they shall automatically receive link for
downloading of the e-card on their registered mobile numbers.
5.3 Renewal:- The beneficiary will be informed
through SMS on registered mobile alongwith policy renewal link for renewal of
policy 15 days before the expiry of policy period.
5.4 Addition/Deletion of family members:- Option
shall be given to add or delete family members in a particular beneficiary
family unit consequent upon the birth/marriage/adoption or death of a family
members for which relevant documents like birth certificate, marriage
certificate, adoption certificate, death certificate and ration card would be
required to be uploaded at the time of addition/deletion of family members.
Scheme - 6. Transaction Management System.
A Card less Transaction Management System will be used at the hospitals
for treatment of beneficiaries under the scheme. This system will be used for
authentication of beneficiary at hospital and online treatment entries of
beneficiaries. The claims will be checked by the support agency through online
system and recommended for payment/rejection. Thereafter the society will
reimburse the amount to the concerned hospitals through electronic
transfer/RTGS/NEFT etc.
Scheme - 7. Empanelment Process & Package rates.
The hospitals empanelled under Ayushman Bharat will stand automatically
empanelled for HIMCARE and package rates of Ayushman Bharat (customized for the
state by HPSBYS) will be adopted for this scheme.
Scheme - 8. Him Care Sathi.
Under Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna, the hospitals
have engaged Pradhan Mantri Arogya Mitra who are responsible for Beneficiary
Identification System (BIS) and working on Transaction Management System (TMS)
for implementation of Ayushman Bharat. These PMAM will also look after the work
of Him Health Care Scheme and they may be designated as HIMCARE SATHI for the
said scheme.