2. MHIS 2015 - 2016

Contents

A. Project Report with Budgets and ApprovalsI. Megha Health Insurance Scheme Phase II: 1st August 2015 to 31st July 2016

i. Rectification done before enrollmentii. Enrollment Report on MHIS I May 2013 –July 2015.

iii. Enrollment Figures.iv. Challenges faced during enrolment.v. Comparison of MHIS I & MHIS II Enrollment throughout the years (2013 – 2016)

vi. Hospital Empanelment MHIS I May 2013 – July 2015.vii. Training & Capacity Building

viii. Some of the Challenges face by Public/Private Hospital.ix. MHIS’s cover consists of four components.x. Claims Utilization

xi. Claims Reports from Public and Private Hospitalsxii. Average Claims Size in Public and Private Hospital

II. IEC Activities

Megha Health Insurance Scheme - 1st August 2015 to 31st July 2016(Ongoing)

Enrollment Report on MHIS II August 2015 – July 2016 : Enrolment for the phase two of the Megha Health Insurance Scheme started in the month of June 2015. As the enrolment process rolls out in all district with a new data base of 762316 (Seven Lakhs Sixty Two Thousand Three Hundred and Sixteen) Household to enrol and following are the enrolment reports in all the eleven (11) districts of Meghalaya.

Here are some rectification done before enrollment:

Data inconsistency in the beneficiary list was one of the most important issues faced by the implementing agencies during the MHIS Phase I, the Govt of Meghalaya has decided to involve a Data Mining Agency to rectify the issue and Winnow Analytics Solutions Pvt Ltd was selected through a rigorous competitive bidding process as the data mining agency. All 30,00,000 Meghalaya residents eligible, including residents travelling or living outside the state.

After the involvement of the data Mining Agency, data mismatch in the state of Meghalaya has been reduced to a very large extent between 80% to 85%. This was achieved with the help of the State Election Department.

Sl. No.

District Total Data

Enrolled House-holds

Total Enrolled (%)

Total Enrolled HH (%) (minus 10% Govt

Employees)

1 EAST KHASI HILLS 2,22,695 73,251 32.9 36.52 WEST KHASI HILLS 58,909 27,352 46.4 51.6

3 SOUTH WEST KHASI HILLS

22,023 12,095 54.9 61

4 RI BHOI 64,961 23,158 35.6 39.65 EAST JAINTIA HILLS 36,374 20,970 57.7 64.16 WEST JAINTIA HILLS 68,286 42,579 62.4 69.37 WEST GARO HILLS 1,32,765 57,034 43 47.7

8 SOUTH WEST GARO HILLS

46,121 33,856 73.4 81.6

9 NORTH GARO HILLS 39,079 23,891 61.1 67.910 EAST GARO HILLS 40,958 13,940 34 37.811 SOUTH GARO HILLS 30,145 18,422 61.1 67.9

MEGHALAYA TOTAL 7,62,316 3,46,548 45.5 50.5

Here were some challenges faced during enrolment of MHIS II - August 2015 – July 2016,

Connectivity and Accessibility issue Manpower Issue

East Khasi Hills

West Khasi Hills

South West Khasi Hills

Ri Bhoi East Jaintia Hills

West Jaintia

Hills

West Garo Hills

South West Garo Hills

North Garo Hills

East Garo Hills

South Garo Hills

0

5

10

15

20

25

30 29

8

3

9

5

9

17

6 5 5 4

11

4 2

3 3

6 8

5 3

2 3

District - Total Data % and Total Data Enrolled %

Total Data % Total Enrolled Data %

The households were defined as per the house number, but often more than one family was staying in the same house.

Non- Motorable roads in remote areas made it necessary to carry 50-kilogram batteries along with the enrolment kits physically. During the rainy season, this became very difficult.

Power shortages is still an issue in many parts of the state. Because of unsatisfactory previous experiences with RSBY and MHIS I, some village headman did not allow

enrolment in their villages. Of the four months of the enrolment period, heavy rains stroll the enrolment process for three months at

stretch. Superstition beliefs still affects the enrolment process and numbers. Militancy issue still affects the enrolment process in some part of the State.

Comparison of MHIS I & MHIS II Enrollment throughout the years (2013 – 2016)

East Khasi

Hills

West Khasi

Hills

South West

Khasi Hills

Ri-Bhoi

East Jaintia Hills

West Jaintia Hills

West Garo Hills

South West

Garo Hills

North G

aro Hills

East Garo Hills

South Garo Hills

Meghalaya Total

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

38.00 44.00 46.00

54.00

63.00 61.00

37.00

56.00 48.00

38.00 39.00 46.00

36.50

51.60

61.00

39.60

64.10

69.30

47.70

81.60

67.90

37.80

67.90

50.50

Meghalaya Enrollment Report throughout the years

May 2013 - July 2015 August 2015 - July 2016

Hospital Empanelment for MHIS II Aug 2015 – July 2016:

New India Assurance Company Ltd, is the insurance company identified to implement the Megha Health Insurance Scheme Phase Two; it was selected through a rigorous competitive bidding process.

The State Nodal Agency along with the Insurance Company had empaneled 150 Public Hospitals, 1 Medical Institute and 15 Private Hospitals in Meghalaya.

The scheme provides to the residents of Meghalaya with a special focus on social protection by covering expensive diseases such as cancer, heart diseases, trauma, critical care, catastrophic hospitalization, OPD Treatments for different Groups and category. The team had identified more common and most visited hospitals by patients from Meghalaya across the country for the treatment of critical illness and a total of 37 Private Hospitals were empaneled with the Scheme.

111 PHCs (100 percent of total available in state) 28 CHCs (100 percent of total available in state) 12 District hospitals (100 percent of total available in state) 1 Medical Institute (100 percent of total available in state) 15 Private hospitals (100 percent of total available in state) 37 Private hospitals outside state for critical care (as against 13 before in MHIS I)

Training & Capacity Building:

Training to all Doctors and Medical Officer in Public and Private Hospitals about the scheme Staff Nurse Training Operators Field Key Officers (ASHA) PHC/CHC/DH Accountants

Some of the Challenges face by Public/Private Hospital:

Most of the Hospital are facing many hardware and software issue due to no system maintenance. Internet Connectivity is still an issue throughout the state. Power shortage is still an issue in most remote areas.

During the MHIS Phase I many Private Hospitals had complains about the Package rates which is very low and Packages rates is not as per the most prevailing diseases in Meghalaya. At the time of creation of MHIS II Aug 2015 – July 2016, the State Nodal Agency had involved Milliman, the world’s largest provider of actuarial services, set up a consultative group of industry experts to fill knowledge gaps and refine solutions. The team visited every Public and Private hospitals in the state and then designed the package rates based on a scientific study in these Public & Private Hospitals of the most prevailing and occurrence diseases and treatments in Meghalaya. A total of 1704 Packages with an increment of 64% including Outpatients Treatments, OPD Diagnostics and Follow up.

Rationalizing price structures: The team instituted a first of its kind pricing study to help rationalize rates at which hospitals would be encouraged to join the network.

Including primary care: An analysis of prior pilots indicated that longer-term systemic changes were required to fully roll out primary care. The team designed enhancements to introduce preventive, follow-up, and maternal care to address the most critical needs.

Under MHIS II Aug 2015 – July 2016 , a family of up to five members is entitled up to Rs. 200,000 coverage for fully cashless hospitalization across India and an additional of Rs 7500 for any OPD Treatment for Weavers and Artisan category only. The premium of Rs. 30 per family is paid by each family enrolled and is valid for a year. Cashless medical treatment is thus available for every Meghalaya resident at all public / private hospitals in the state, as well as empanelled private hospitals across the country. There is no age limit and pre-existing diseases are also covered under this insurance scheme.

MHIS’s cover consists of the following four components:

Base Cover (Rs 30,000): To meet hospitalization expenses for medical and surgical procedures. No pre-authorization needed. Claims processed online according to standard package rates pre-determined by the Government of India.

Replenishment Cover (Rs. 30,000): Additional cover to meet hospitalization expenses for medical and surgical procedures, once the base cover is fully utilized. Pre-authorization from the insurance company needed. Claims processed online according to standard package rates pre-determined by the Government of India.

Catastrophic Illness Cover (Rs. 140,000): Additional cover for treatment, procedure, or intervention for catastrophic illnesses, provided hospitalization expenses are over Rs. 30,000. Pre-authorization from the insurance company needed up to a maximum of Rs 170,000 (Replenishment Cover + Catastrophic Illness Cover).

MHIS II Aug 2015 – July 2016 covers 'end-to-end' hospitalization costs, including a day’s pre-hospitalization costs (15 days for catastrophic illnesses), post-hospitalization costs for 5 days (30 days for catastrophic illnesses), transport expenses of Rs. 100 per incidence, and economic loss compensation of Rs. 100 per incidence. For critical illness, transport expenses remains the same, but economic loss compensation is Rs. 900 per incidence.

Weavers & Artisan OPD Cover (Rs. 7500): Additional cover for the expenses for any OPD procedures limited to 10 visits per family and to a maximum of Rs 750 per Visit only for Weavers & Artisan category. Pre-authorization needed from the Insurance Company.

MHIS II Aug 2015 – July 2016 as the first Universal Health Insurance Scheme in the Country also covers several OPD Treatments so as to bridges the gap and reduce the MMR and IMR in the state of Meghalaya, this includes:-

Ante Natal Care Post Natal Care Targeted OPD Cover (Children between the age of 0 – 5 years old)

MHIS August 2015 – July 2016 also does includes OPD Preventive care (Cardiac and Diabetic Preventive Care), OPD Diagnostic Care (MRI & C.T Scan) and Follow up care (Medical and Surgical Follow up maximum up to 4 visits) as part of the MHIS packages.

Beneficiaries: MHIS II Aug 2015 – July 2016 database has been integrated with different marginalized categories namely MGREGA (Mahatma Gandhi National Rural Employment Guarantee Act), BoCW (Building other Construction Workers),

Weavers, Handicrafts and ASHA. Apart from the mentioned categories the database also includes Person with Disability (PwD) and Orphans from Orphanages in the state. Beneficiaries are identified on the basis of voter ID cards issued to heads of households.

Insurance cover: MHIS II Aug 2015 – July 2016 provides an effective cover up to Rs 200,000 per household (up to five members on a floater basis) through a professional insurance service provider. The cover is provided through a private insurance company identified after a competitive bidding process. New India Assurance Company Ltd. won the tender for the Second year.

Diseases covered: MHIS II Aug 2015 – July 2016 covers all diseases covered under RSBY. It also covers specific conditions that create tremendous pressure on family finances such as trauma, cancer, and heart disease. A total of 1704 Packages.

Relevance to beneficiaries: MHIS II Aug 2015 – July 2016 provides for effective treatment of frequently occurring diseases in Meghalaya, including cancer, heart diseases, trauma cases (catastrophic diseases) and OPD & Preventive Care.

Incentive for utilization: Incentive schemes for doctors and nurses ensure higher utilization of government health service centers (pull factor). Payments to patients for wages lost loss ensure higher utilization of cards (push factor).

MHIS August 2015 – July 2016 Claims Utilization:

The Policy Period for MHIS II starts from 1st August 2015 to 31st July 2016 (Ongoing)

Below is the claims reported of Beneficiaries claiming from all 11 Districts from 1st August 2015 to 15th June 2016:

Member Districts Female Male Total Total Claim Amount EAST GARO HILLS 1113 747 1860 1,71,80,151EAST JAINTIA HILLS 3233 1710 4943 2,42,01,907EAST KHASI HILLS 7132 3523 10655 8,93,74,649NORTH GARO HILLS 1909 1069 2978 2,06,41,066RI BHOI 2524 1370 3894 2,30,62,930SOUTH GARO HILLS 1642 986 2628 1,44,33,375SOUTH WEST GARO HILLS 2448 989 3437 1,83,74,701SOUTH WEST KHASI HILLS 865 512 1377 8,53,78,27WEST GARO HILLS 2495 1039 3534 2,43,26,076WEST JAINTIA HILLS 5764 2727 8491 5,08,19,634WEST KHASI HILLS 2974 1606 4580 2,95,60,090Grand Total 32099 16278 48377 32,05,12,406

EAST GARO HILLS

EAST JAINTIA

HILLS

EAST KHASI HILLS

NORTH GARO HILLS

RI BHOI SOUTH GARO HILLS

SOUTH WEST GARO HILLS

SOUTH WEST KHASI HILLS

WEST GARO HILLS

WEST JAINTIA

HILLS

WEST KHASI HILLS

0

5

10

15

20

25

30

5 8

28

6 7 5 6

3

8

16

9

District Members wise Claims %

The Number of beneficiaries claiming are more from East Khasi Hills District at 28% and West Jaintia Hills District at 16%.

Male & Female Claims % Utilization:

EAST GARO HILLS

EAST JAINTIA

HILLS

EAST KHASI HILLS

NORTH GARO HILLS

RI BHOI SOUTH GARO HILLS

SOUTH WEST GARO HILLS

SOUTH WEST KHASI HILLS

WEST GARO HILLS

WEST JAINTIA

HILLS

WEST KHASI HILLS

0

10

20

30

40

50

60

70

80

60 65 67 64 65 62

71 63

71 68 65

40 35 33 36 35 38

29 37

29 32 35

Male and Female Claims % Utilization DIstrict Wise

Female Male

The Claims portions of Male and Female shows that 66.35% of claims by number are from females, demonstrating higher utilization by females than males at 33.64%.

Claims by Private & Public Hospital: Average claim size similar across government and private hospitals in Meghalaya and Outside Meghalaya

55.25 % of claims by amount is from Public hospitals in Meghalaya 44.50 % of the claims by number is from Private hospitals in Meghalaya 0.25 % of the claims by numbers is from Private Hospitals o/s Meghalaya More than 98 government hospitals have raised claims as of 15th June 2016. Private Hospital Total Claims 21524 & Total Amount Claimed Rs 163048545 Public Hospital Total Claims 26733 & Total Amount Claimed Rs 151164641 Private Hospital Outside Meghalaya Total Claims 120 & Total Amount Claimed Rs 6299220 (Critical Illness

Treatment)

Female Male0

10203040506070

66.35

33.64

Total Male & Female Utilization %

*o/s Meghalaya

PRIVATE HOSPITAL in MEGHALAYA

PUBLIC HOSPITAL in MEGHALAYA

PRIVATE HOSPITAL o/s MEGHALAYA

0.00

10.00

20.00

30.00

40.00

50.00

60.00 44.50

55.25

0.25

% of Claims in Public and Private Hospitals

Patients District Wise

PHC CHC DH PVT PVT o/s MEGH

Female Male Total Amount Claimed Female Mal

e Total Amount Claimed

Female Male Total Amount

Claimed Female Male Total Amount Claimed Female Male Total Amount

ClaimedEAST GARO HILLS 63 41 104 1008200 89 48 137 1161625 922 637 1559 13882986 35 16 51 346750 4 5 9 780590EAST JAINTIA HILLS 194 92 286 746200 858 535 1393 4297550 655 319 974 3988400 1524 764 2288 15158757 2 0 2 11000

EAST KHASI HILLS 371 108 479 2127800 462 182 644 3937800 1302 614 1916 17976025 4985 2597 7582 64053974 12 22 34 1279050NORTH GARO HILLS 563 217 780 5398950 1093 691 1784 9917300 170 115 285 2363850 66 31 97 793837 17 15 32 2167129RI BHOI 180 86 266 972000 707 391 1098 3610650 520 274 794 4970175 1116 618 1734 13404046 1 1 2 106059SOUTH GARO HILLS 252 151 403 3334250 215 106 321 1605000 1074 690 1764 8460925 97 39 136 964950 4 0 4 68250SOUTH WEST GARO HILLS 285 78 363 1650975 1210 517 1727 6673125 554 279 833 5749562 396 108 504 3775950 3 7 10 525089SOUTH WEST KHASI HILLS 86 37 123 407000 347 247 594 2213500 168 78 246 1991250 264 150 414 3926077 0 0 0 0WEST GARO HILLS 361 110 471 3077350 82 16 98 418000 1286 614 1900 13026148 758 284 1042 6712525 8 15 23 1092053WEST JAINTIA HILLS 197 43 240 979000 467 193 660 3122150 1638 808 2446 10692795 3462 1682 5144 36018689 0 1 1 7000WEST KHASI HILLS 47 19 66 306750 28 19 47 122000 1349 583 1932 10975350 1549 983 2532 17892990 1 2 3 263000

Grand Total 2599 982 3581 20008475 5558 2945 8503 37078700 9638 5011 14649 94077466 14252 7272 2152416304854

5 52 68 120 6299220Claims Reports from PHC/CHC/District Hospitals/Private Hospitals in Meg/ Private Hospitals Outside Meghalaya: 1st Aug 2015 to 15th June 2016 (On Going)

Because of insurance payouts, government hospitals also charge beneficiaries for medical services via the smart card. This money is being ploughed back to improve hospital infrastructure, which again results in better quality healthcare. Since the entire scheme revolves around voter lists, in the long run this will lead to more robust voter registries and better participation in the democratic process. This also ensures that only bona-fide citizens of India avail benefits under MHIS.

Average Claims Size in Public and Private Hospital:

5654

7575

5249

Average Claims Size - MHIS II Aug 2015 - July 2016

Public Hospital Private Hospital

Private Hospital o/s Meghalaya

Budget & Approvals for MHIS 2013 - 2016:

Budget for MHIS is prepared on an annual basis only on the state share component only, since Central Share is paid to the State when requisition is made against the Invoice raised by the Insurance Company. State Share is budgeted on the 10% RSBY Component and 100% of the MHIS component. Budget is estimated only on the total Premium layout of the Scheme for a financial year of the State Share, taking into account all categories. The following is taken into consideration for budgeting.

• The Estimated percentage of enrollment.

• Rate of premium (which is estimated as per the current market trends)

The total budget is the total premium payable for the total estimated enrolled households. In order to run the scheme, the requirement for expenses like salary of staff, furniture & equipment, office supplies etc that are required to run the scheme on a day to day basis are sustained out of the ₹ 30/- (being the 1 st installment of premium) collected from beneficiaries at the time of enrollment.

Budget for MHIS II 2015 to 2016:- 145066025/-

IEC Activities