medical insurance scheme for the poor - Aarogyasri

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RAJIV AAROGYASRI COMMUNITY HEALTH INSURANCE SCHEME - PHASE I (RENEWAL) FOR BPL POPULATION IN 3 DISTRICTS OF ANDHRA PRADESH

There is a felt need in the State to provide financial protection to families living below poverty line for the treatment of major ailments such as cancer, kidney failure, heart and neurosurgical diseases etc., requiring hospitalization and surgery. Government hospitals lack the requisite facility and the specialist pool of doctors to meet the statewide requirement for the treatment of such diseases. Large proportions of people, especially below poverty line borrow money or sell assets to pay for the treatment in private hospitals. Health Insurance could be a way of removing the financial barriers and improving access of poor to quality medical care; of providing financial protection against high medical expenses; and negotiating with the providers for better quality care. Government of Andhra Pradesh has accordingly implemented a Community Health Insurance Scheme by name Rajiv Aarogyasri in the three districts of Mahabubnagar, Anantapur, Srikakulam districts of Andhra Pradesh from 01-04-07 on pilot basis. Since the policy of phase-I will come to an end on 31.03.2008,Government has decided to renew the scheme in these 3 districts under Phase-I renewal with modifications.

In order to operate the scheme professionally in a cost effective manner, public private partnership is envisaged between the Insurance Company, the private sector hospitals and the State agencies. State government/ Trust will guide the Insurance Company in establishing network of hospitals, fixing of treatment protocol and costs, treatment authorization, claims scrutiny and any other related work, such that the cost of administering the scheme is kept at the lowest, while making full use of the resources available in the Government system. Private hospitals fulfilling minimum qualifications in terms of availability of inpatient medical beds, laboratory, equipments, operation theatres etc. and a track record in the treatment of the specified diseases can be enlisted for providing treatment to the BPL families under the scheme. List of such specialty hospitals already under empanelment for pilot scheme is enclosed as Annexure-5. Premium under this scheme will be borne by the Government / Trust.

1

Salient Features of the Scheme proposed for implementation in the 3 districts of Mahabubnagar, Anantapur and Srikakulam

1.0

Name:

The name of the scheme is Rajiv Aarogyasri Community Health Insurance Scheme-Phase I (Renewal).

2.0

Objective:

To improve access of BPL families to quality medical care for treatment of identified diseases involving hospitalization, surgeries and therapies, through an identified network of health care providers. The scheme would provide coverage for the following systems. i)

Heart

ii)

Lung

iii)

Liver

iv)

Pancreas

v)

Renal diseases

vi)

Neuro-Surgery

vii)

Pediatric Congenital Malformations

viii)

Burns

ix)

Post -Burn Contracture Surgeries for Functional Improvement.

x)

Cancer treatment a. Surgery b. Chemo Therapy c. Radio Therapy

xi)

Polytrauma (Coverage Recovery: The factor of recovery from the insurer insuring the vehicle for liability to the public arising out of the use of the vehicle and falling under MV Act, shall also be considered for pricing by the bidder.)

xii)

Cochlear Implant Surgery with Auditory-Verbal Therapy for Children below 6 years (costs to be reimbursed by the Trust on

2

case to case basis and hence not to be taken in to account for calculating the premium) Detailed list of surgeries and therapies falling in the identified groups is given at Annexure - 6.

3.0

Beneficiaries: The scheme is intended to benefit below poverty line (BPL) population in

the 3 districts of the State viz. Mahabubnagar, Anantapur and Srikakulam. There are 25.27 lakh BPL families in the five districts comprising of a population of 0.94 crores. Database and photograph of these families is available in „Health Cards‟ to be issued by the Trust based on the BPL ration card issued by the Civil Supplies Department. District wise profile of the BPL families is given below: BPL PHASE

Districts

BPL Cards

population

From

Mahabubnagar

9.32

35.49

Anantapur

9.31

35.70

Srikakulam

6.64

22.85

TOTAL

25.27

94.04

Phase-I (Renewal)

05-04-2008

(lakhs)

Note: Such of the „Health Card‟ holders who are covered for the specified diseases by other insurance scheme such as CGHS, ESIS, Railway, RTC etc., will not be eligible for any benefit under the scheme.

3

4.0

Health Cards: All eligible families in these districts will be provided with Rajiv

Aarogyasri Bhima Health Cards. These Health Cards/ BPL Ration card will be basis for identification of Beneficiary under the scheme. 4.1

Family: Means members as enumerated and photographed on the

Rajiv

Aarogyasri Health Card/ BPL Ration Card. The photograph indicated in the Health Card/ BPL Ration Card will be taken as the proof for determining the eligibility of the beneficiary.

4.2

Enrollment: GOAP / Trust will provide the details of each BPL family covered under

the Scheme through the Health Card.

This Health Card will be a part of

enrollment / identification for availing the health insurance facility

5.0

Sum Insured on Floater Basis: The scheme shall provide coverage for meeting expenses of

hospitalization and surgical procedures of beneficiary members up to Rs.1.50 lakhs per family per year subject to limits, in any of the network hospitals. The benefit on family will be on floater basis i.e. the total reimbursement of Rs.1.50 lakhs can be availed of individually or collectively by members of the family. Cost for cochlear Implant Surgery with Auditory –Verbal Therapy will be reimbursed by the Trust to the Insurance Company on actual basis up to a maximum of Rs.6.50 lakhs for each case. 6.0

Buffer / Corporate Sum Insured: An additional sum of Rs 7 crores shall be provided as Buffer / corporate

floater to take care of expenses; if it exceeds the original sum i.e. Rs 1.50 lakhs per Individual/family. In such cases an amount unto Rs. 50000/- per individual/family shall be additionally provided on the recommendation of the committee set up by the trust.

4

7.0

Cash less Transaction It is envisaged that for each hospitalization the transaction shall be

cashless for covered procedures. Enrolled BPL beneficiary will go to hospital and come out without making any payment to the hospital subject to procedure covered under the scheme. The same is the case for diagnostics if eventually the patient does not end up in doing the surgery or therapy. 8.0

Pre existing diseases All diseases under the proposed scheme shall be covered from day one.

A person suffering from any disease prior to the inception of the policy shall also be covered. 9.0

Pre and Post hospitalization 9.1

From date of reporting to hospital up to 10 days from the

date of discharge from the hospital shall be part of the package rates. In case of Kidney Transplantation the postoperative care have to extend to 1 year. 9.2

Network hospital will provide follow-up free consultation

and medicines supplied by the Trust wherever required for the patients undergoing treatment under the scheme for a period of up to one year from eleventh day of discharge. Commonly used follow-up medicines will be supplied to the network hospitals by the Trust from time-to-time.

10.0

Procedure for enrollment of Hospitals: The hospitals shall be separately empanelled for phase I (Renewal) of

the scheme. HOSPITAL / NURSING HOME: means any institution in Andhra Pradesh established for indoor medical care and treatment of disease and injuries and the networked hospital should comply with minimum criteria as under:

a) It should have at least 50 inpatient medical beds with adequate spacing and supporting staff as per norms. b) Fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and Xray, E.C.G. etc for the care and treatment of injured or sick persons as in-patient. 5

c) Fully equipped Operation Theatre of its own wherever surgical operations are carried out d) Fully qualified nursing staff under its employment round the clock. e) Fully qualified doctor(s) should be physically in charge round the clock. f) Maintaining complete record as required on day-to-day basis and is able to provide necessary records of the insured patient to the Insurer or his representative as and when required. g) Using ICD and OPQS codes for Drugs, Diagnosis, Surgical procedures etc. h) Having sufficient experience in the specific identified field. i) Should have infrastructure for Radiotherapy with Services of Radiation Oncologist and Medical Oncologist must be available in the hospital for empanelment for Chemo-Therapy And RadioTherapy. j) Should have Services of Trained ENT Surgeon for Cochlear Implant Surgery and Auditory –Verbal Therapist for empanelment for Cochlear Implant Surgery.

And

Hospital should be in a position to provide following additional benefit to the BPL beneficiaries related to identified systems: a. Provide space and separate Rajiv Aarogyasri counter/kiosk as per the design for Aarogyamithras (Health Coordinators) b. Provide a doctor as Medical Coordinator for Rajiv Aarogyasri. c. Provide Computer with networking (dedicated broadband with minimum 1mbps speed), printer, scanner and digital camera. d. Provide free food for the patient e. Provide transport/transportation charges for patient. f. Free OPD consultation. g. Free diagnostic tests and medical treatment required for beneficiaries irrespective of surgery.

6

h. Minimum one free Health Camp in village in a week for the screening of the BPL patient suffering from the identified ailments. Hospital may have a mobile team with diagnostic equipments and team of doctors as specified by the Trust for this purpose. Villages shall be identified by the trust in consultation with district administration and communicated to the hospitals/insurance company.

MoU with network Hospital: The insurance company shall sign MoU with all the hospitals to be empanelled under the scheme. This MoU is subject to the approval of the Trust. Empanelled medical institutions are supposed to extend medical aids to the beneficiary under the scheme. A provision will be made in MOU of non-compliance clause while signing them. Such matter shall be looked in to by the Trust 11.0

Payment of Premium: The Trust / Government will pay the insurance premium on behalf of the

BPL beneficiaries to the Insurance Company directly in installments as agreed up on in the MoU.

12.0

Period Of Insurance The insurance coverage under the scheme shall be in force for a period

of one year from the date of commencement of the policy (say from 00:00 hours of 05.04.2008 to midnight of 04.04.2009) 13. 0 Refund If there is a surplus after the pure claims experience on the premium (excluding Service Tax) at the end of the policy period, after providing 20% of the premium paid towards the Company‟s administrative cost, in the balance 80% after providing for claims payment and outstanding claims, 90% of the left over surplus will be refunded to the Government/Trust with in 30 days after the expiry of the policy period.

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14.0

MOU The insurer is required to enter into a MOU for implementation of the

scheme with GoAP/ Trust. 15.0

Penalty clause Failure to abide with the terms will attract penalty as suggested by the

GoAP / Trust at the time of finalizing the terms. 16.0

Standardisation of formats The Insurance Company shall standardise various formats used for

cashless transactions, discharge summary, billing pattern and other reports in consultation with the Trust.

17.0

Claim settlement The Insurance Company shall settle the claims of the hospitals within 7

days of receipt of the bills along with the discharge summary and satisfaction letter of the patient. The claim settlement progress will be scrutinized and reviewed by the Trust. 18.0

Implementation procedure: The entire scheme is intended to be implemented as cashless

hospitalization arranged by the Insurance Company. The following table represents the process flow of treatment to the beneficiary A). Process Flow of the Beneficiary Treatment in the Network Hospital Step 1 Beneficiaries approach nearby PHC/Area Hospitals/District Hospital/Network Hospital. Aarogya Mithras placed in the above hospitals facilitate the beneficiary. If beneficiary visits any other PHC/Government hospital other than the Network Hospital, the doctors will give him a referral card to the Network Hospital after preliminary diagnosis. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the Villages and can get

8

the referral card based on the diagnosis. Step 2 The Aarogya mithras at the Network Hospital examines the referral card and BPL ration card and facilitates the beneficiary to undergo preliminary diagnosis and basic tests. Step 3 The Network Hospital, based on the diagnosis, admits the patient and sends preauthorization request to the Insurance company and the Aarogyasri Health Care Trust. Step 4 Specialists

of

the

Insurance

Company and

the

Trust

examine

the

preauthorization request and approve preauthorization if all the conditions are satisfied. Step 5 The Network Hospital extends cashless treatment and surgery to the beneficiary.

Step 6 Network Hospital after discharge forwards the original bill, discharge summary with signature of the patient and other relevant documents to Insurance Company for settlement of the claim. Step 7 Insurance Company scrutinize the bills and gives approval for the sanction of the bill. Step 8 Network hospital will provide follow-up free consultation and medicines supplied by the Trust for the patients undergoing treatment under the scheme for a period of up to one year from eleventh day of discharge.

9

B). New empanelment The insurer needs to empanel the hospitals separately for Phase III for specialty services based on infrastructure available and as per the conditions laid down below: 

For cancer treatment, hospitals having fully qualified professionals (Medical Oncologist, Radiation Oncologist and Surgical Oncologist – all or either) and equipment (Cobalt therapy Unit, Linear accelerator and Brachy therapy unit – all or either) need to be empanelled. A combination of both professional and the equipment is essential.



Economy protocols with packages devised by the Trust should be adhered to.



Deviations in protocol for high cost therapy beyond package will be allowed only after scrutiny by a technical committee.



The hospital shall follow the mechanism devised to ensure that chemotherapy drugs are physically administered, by quoting batch no., labeling of the drugs and attaching empty vials to the bills.



The hospital should have Services of Trained ENT Surgeon for Cochlear Implant Surgery and Auditory –Verbal Therapist for empanelment for Cochlear Implant Surgery. Separate guidelines issued in this regard by the Trust shall be strictly adhered to.



The hospital should have full time services of qualified plastic surgeon with requisite infrastructure for corrective surgeries for post-burn contractures.



The hospital should have full time services of Pediatric Surgeons for surgeries for congenital malformations in children

The conditions laid down at para 10.0 above are common for all hospitals and shall be strictly adhered to while empanelling the hospitals. C).

Packages The insurer should ensure that the empanelled hospitals follow the

packages worked out by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital charges etc. In other words the package should cover the entire cost of patient from

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date of reporting to his discharge from hospital 10 days after surgery, making the transaction truly cashless to the patient.

D)

Camps Health Camps are to be conducted in all Mandal Head Quarters, Major

panchayats and municipalities. The insurer should ensure that at least one free medical camp is conducted by each network hospital in a week at the place suggested by the trust. They should carry necessary screening equipment along with specialists (as suggested by the Trust) and other para-medical staff. They should also work in close liaison with district co-coordinator, DM&HO in consultation with district collector.

E)

District Level Co-ordination District level offices with necessary infrastructure have to be set-up by

the Insurance Company. The Insurer needs to have district level monitoring staff with district coordinators and regional coordinators (in charge of a group of mandals within the district). Area Managers/District coordinators/ District level doctors/Regional coordinators of the insurance company should monitor Aarogyamithras, co-ordinate with network hospital, district administration and people‟s representatives for effective implementation of programme. They should ensure that camps are held as per schedule, arrange for canvassing for the camp, mobilize patients and follow up the beneficiaries. He/She should work in close liaison with district administration under the supervision of district collector. He should also ensure proper flow of MIS and report to trust on dayto-day basis about the progress of the scheme in the district. The company should ensure that dedicated staff is made available for the scheme. There shall be at least one doctor to be placed in each district. Further wherever the concentration of the network hospitals is more additional doctors need to be placed. The Insurance Company shall follow the instructions of the Trust in this regard.

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19.0

Aarogyamithras a. Aarogyamithras

in

PHCs/

CHCs/

Area

Hospitals/

Government Hospitals etc: The unique nature of the scheme demands the insurance company to appoint Aarogyamithras in consultation with the trust in all PHCs, CHCs, Area Hospitals and District Hospitals for propagating the scheme, mobilizing people for health camps, counseling beneficiaries, facilitating the referral/treatment of these patients and follow-up. For effective and instant communication all the Aarogyamithras will have to be provided with cell phone CUG connectivity by the Insurance Company. b. Aarogyamithras in Network Hospitals: The Insurance company also needs to appoint at least two Aarogyamithras at all network hospitals to facilitate admission, treatment and cashless transaction of patient round the clock. The Aarogyamithras should also help hospitals in pre-auth, claim settlement and follow-up. They should also ensure proper reception and care in the hospital and send regular MIS. Insurance Company shall provide all Aarogyamithras with cell phone having CUG connectivity with SMS based reporting framework for effective and instant communication. The insurance

company

shall

ensure

that

prefabricated

Aarogyamithra kiosks with all additional requirements as per the design approved by the Trust is put up in all hospitals. The role of Aarogyamithra can be modified by the Trust from timeto-time. The insurer will provide uniform and arrange the workshops/training sessions for the Aarogyamithras on the guidelines specified by the Trust. The detailed note on Aarogyamithras and their role is enclosed (Annexure B)

20.0

Online MIS and 24 Hour E-Preauthorisation. The Insurance Company should post enough dedicated staff, so as to

ensure free flow of daily MIS and ensure that progress of scheme is reported to trust in the desired format on a real-time basis. The company should establish 12

proper networking for quick and error-free processing of preauthorisations. This will be done through the existing dedicated website of the Trust, the up gradation and maintenance cost of the software, hardware, connectivity and data center will be borne by the Insurance Company. The preauthorisation has to be done round- the-clock in co-ordination with trust i.e., by a team of doctors from the Trust and the Insurance Company. The preauthorization team shall have all the specialists concerned with the systems covered in the scheme on a permanent basis. The trust will provide necessary specialists and technical committees to evaluate special cases from time-to-time. The website will be a repository of information and will have the following features: 

General Information on the scheme.



Details of patients reporting in the PHC/CHC/Government Hospitals/ District hospitals on daily basis

21.0



Details of Health Camps and daily reporting of health camps



Details of patients getting referred from the health camps.



Details of in-patients and out patients in the network hospitals



Costing of the Tests done in the network hospitals



E-preauthorisation.



Surgery details.



Discharge details.



Real-time reporting



Claim settlement



Electronic clearance of bills with payment gateway



Follow-up of patient after surgery



Distribution of Follow-up medicines.

Medical Auditors The company should appoint enough number of medical officers who

does pre-authorization in consultation with trust. The Company shall also recruit specialized doctors for regular inspection of hospitals, attend to complaints from beneficiaries directly or through Aarogyamithras for any deficiency in services by the hospitals and also to ensure proper care and counseling for the patient

13

at network hospital by coordinating with Aarogyamithras and hospital authorities.

22.0

In-House System The Insurance Company has to establish in-house system to

provide all facilities elaborated under the scheme.

23.0

Publicity The insurance company on its part should ensure that proper publicity is

given to the scheme. It should print brochures, banners, display boards in public places and highways. They should effectively use services of Aarogyamithras and district coordinators for this purpose. 24.0

State Level Co-Ordination The company should nominate responsible officer/ officers to properly

coordinate above work and ensure proper implementation of scheme up to the satisfaction of trust. They should review the progress with trust on day-to-day basis and be responsible to implement the suggestions of trust for effectively running the scheme. The Project Office of the Insurance Company shall be separately established at a place desired by the Trust for better coordination. The project office shall report to the CEO of the Trust on a daily basis. The following departments shall be established by the Insurance Company in the Project Office: i)

24 hour call center with toll free help line

ii)

MIS Department to collect, collate and report data on a real-time basis. This department will also have a subunit with operators who collect hourly information from the Aarogyamithras, regional co-coordinators, district coordinators etc. Based on this the reverse flow of dissemination of information shall also take place. There shall be subunits for each district. The MIS department shall also follow-up the cases at all levels. The department shall also generate reports as desired by the Trust.

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iii)

IT Department to ensure that the website with e-preauthorisation, claim settlement and real-time follow-up is maintained and updated on a 24-hour basis.

iv)

Round-the-Clock Pre-authorisation Department with specialist doctors for each category of diseases shall work round the clock along with the Trust doctors to process the preauthorization within 12 working hours. The doctors shall also undertake inspection of hospitals.

v)

Claims

settlement

Department

with

electronic clearance

facilities vi)

Health Camp Department to plan, intimate, implement and follow-up the camps as per the directions of the Trust.

vii)

Publicity Department to undertake all the publicity activities as specified by the Trust

viii)

Grievance Department to be manned by doctors and other staff to address the grievances from time to time as per the instructions of the Trust.

ix)

Follow-up Department to coordinate the follow-up consultation and distribution of drugs as per the instructions of the Trust.

x)

Hospital-Networking department to empanel the hospitals in the network as per the guidelines given by the Trust and monitor the compliance.

xi)

Feedback Department to send feedback formats, collect and analyse feedback of the patients as per the directions of the Trust. The department will also document each case and upload the same in the Trust portal.

25.0

xii)

Legal Department exclusively for the project.

xiii)

Other departments required for Office work.

Capacity Building The insurer will arrange the workshops/training sessions for the capacity

building of the insured, their representatives and other stakeholders in respect of specific field of insurance at each district on the convenience of the insured.

15

26.0

Criteria for Evaluating Bids / Proposals The Technical Proposals will be evaluated by a panel of officials

nominated by the Government of Andhra Pradesh. Once the technical bids have been evaluated, the successful bidders will be informed about the date of opening of financial bids. Financial bids of only those bidders will be opened who are declared successful in the technical Bid Evaluation stage. Financial bids will be opened in presence of the representatives of insurance companies that have been declared successful in the technical bid evaluation stage. 27.0 Award of Contract Government of Andhra Pradesh/Trust shall award the contract to the successful bidder/s whose Bid has/ have been determined to be substantially responsive, lowest evaluated bid, provided further that the bidder has been determined by the Government of Andhra Pradesh/Trust to be qualified to perform the contract satisfactorily. 28.0 Right to negotiate at the time of Award Government of Andhra Pradesh/Trust reserves the right to negotiate starting with lowest bidder after opening the Price Bid. 29.0

Government of Andhra Pradesh /Trust’s Right to Accept or Reject any or all Bids: Government of Andhra Pradesh/Trust reserves the right to accept or

reject any Bid or annul the Bidding process and reject all Bids at any time prior to award of contract, without thereby incurring any liability to the affected Bidder or Bidders. Government of Andhra Pradesh/Trust is not bound to accept the lowest or any bid. Incomplete bids and financial bids with extra attachments are liable to be disqualified. 30.0

Notification of Award and Signing Of MOU: The Notification of Award will be issued with the approval of the Tender

Accepting Authority. The terms of MOU will be discussed with the representatives of the successful insurance company and the company is 16

expected to furnish a duly signing MOU proposed by GoAP/Trust in duplicate within 7 days of declaration of „award of contract‟, failing which the contract may be offered to the next bidder in order of merit. Once the MOU is signed, the insurer will have no right to cancel the MOU signed between the GoAP /Trust and insurer. 31.0

Canvassing Bidders are hereby warned that canvassing in any form for influencing

the process of notification of award would result in disqualification of the Bidder. 32.0

Signature in each page of document The competent authority of the Bidder must sign each paper of Bid

Document. Any document / sheet not signed may lead to rejection of Bid. 33.0

Submission of Proposals:

The bidder must submit the proposal in both hard and soft copies as per the details mentioned below: i. Technical proposal in both hard and soft format should be sealed in a separate envelop clearly marked in BOLD “SECTION A – TECHNICAL PROPOSAL ” and “TECHNICAL PROPOSAL FOR IMPLEMENTING “RAJIV AAROGYASRI HEALTH INSURANCE SCHEME PHASEI(RENEWAL)” written on the top of the envelope. ii. Financial proposal in both hard and soft format should be sealed in another envelop clearly marked in BOLD “SECTION B – FINANCIAL PROPOSAL” and “FINANCIAL PROPOSAL FOR IMPLEMENTING “RAJIV AAROGYASRI HEALTH INSURANCE SCHEME PHASEI(RENEWAL)” written on the top of the envelope. iii. Both envelop should have the bidders Name and Address clearly written at the Left Bottom Corner of the envelope.

iv. Both envelops should be put in a larger cover / envelop, sealed and clearly marked in BOLD have “SECTION A – TECHNICAL PROPOSAL” for “Rajiv Aarogyasri Health Insurance Scheme Phase-I (Renewal)”. “SECTION B – FINANCIAL PROPOSAL” for “Rajiv Aarogyasri Health Insurance Scheme Phase-I (Renewal)” written on envelop and have the

17

bidders Name and Address clearly written in BOLD at the Left Bottom Corner. v. The bids may be cancelled and not evaluated if the bidder fails to: a. Clearly mention Technical / Financial Proposal on the respective envelops b. To seal the envelope properly with sealing tape c. Submit both envelops i.e. financial proposal and Technical Proposal together keeping in large envelop. d. Give complete bids in all aspects. e. Submit financial bids in the specified performa (Annexure 12) f. To submit soft copies of financial proposal and Technical Proposal in respective covers. 34.0

Deadline for Submission Bids / Proposals:

Complete bid documents should be received at the address mentioned below not later than 15.00 hours on 28th day, February 2008. Bid documents received later than the prescribed date and time will not be entertained under any circumstances. Address: Chief Executive Officer Aarogyasri Health Care Trust 3rd Floor, Municipal Complex Besides Koti Maternity Hospital Sultan Bazar, Koti, Hyderabad – 500 095 Phone: Fax: E-mail:

040 – 24652478 040 - 24657715 [email protected]

18

Working Pattern

Annexure A

19

Annexure B

AAROGYAMITHRA

Aarogyamithra is Friend of Health. Aarogyamithra is a concept unique to Rajiv Aarogyasri Community Health Insurance Scheme. Aarogyamithras act as facilitators for the patients. In fact they form face of this insurance scheme. Aarogyamithras are to be selected by the stakeholders of Self Help Group (SHG) movement/ Indira Kranthi Patham from local area of each PHC / Government Hospital in order to ensure performance efficiency and acceptability among local communities. The following qualifications are prescribed. i)

Graduate

ii)

Native & Resident of the same PHC area

iii)

Good communication skills

iv)

Prefers to move around the villages

v)

Functional knowledge of computers

The Mandal and Zilla Samakhya are the nodal agencies that select the Health Coordinators (Aarogyamithras). Insurance company has to enter into an MOU with the Zilla Samakhya to hire the services of local persons in each PHC/CHC/Area Hospital/Government Hospital. The Insurance Company will make a consolidated payment for the Health Coordinators through the Zilla Samakhya. The working of the Aarogyamithras will be monitored on a daily basis by the regional coordinators and district coordinators of the Insurance Company in coordination with the Zilla/Mandal samakhyas, District rural Development Agency, DM&HO, District Administration etc. All the Aarogyamithras are to be provided with cell phones (CUG connection) by the Insurance Company for instant communication and networking. The Insurance Company shall also provide uniforms (Aprons compulsorily) for all Aarogyamithras. 20

The following table shows the indicative number of PHC‟s / Government Hospitals where Aarogyamithras are to be placed: Phase I (Renewal) Anantapur Mahboobnagar Srikakulam Total

No. of PHCs

76

86

73

235

No. of CHCs

11

08

12

31

No. of Area Hospitals

03

04

02

09

No. of District Hospitals

01

01

01

03

Total

91

99

88

278

In addition to the above the Insurance Company have to select and post at least two Aarogyamithras in each Network Hospitals for round the clock monitoring of the patients. The total number will depend up on the exact number of the Network Hospitals. The Insurance Company shall follow the instructions of the Trust in this regard. Training of Aarogyamithras Training for Aarogyamithras shall be done by the Insurance Company on the instructions of the trust. Role of Aarogyamithras in PHC/CHC/Government / District hospitals 1)

ROLE OF PHC AAROGYAMITHRAS a)

IN THE HOSPITAL



Publicity and awareness.



Maintain helpdesk at hospital.



Receive the beneficiary.



Verify the Beneficiary criteria. (Eligibility Criteria)



Facilitate consultation with Doctor (PHC Doctor/Nearest Govt. Hospital Doctor) 21



Fill up the referral card.



Guide the patient to the next center.



To counsel the patients who may require any one of the listed surgeries.



To facilitate either to a Government Hospital for further tests or to a Network Hospital depending upon the advice of the doctor.



To guide the patient to Network Hospital.



Follow-up the referred cases.



In effect to act as, a guide and friend for the prospective beneficiaries under the Aarogya Sri scheme.

b) OUTSIDE THE HOSPITAL

 To send daily MIS of the patients  To spread the awareness of the scheme in the villages.  To spread the awareness about the scheduled camps by network hospitals in the villages.  To coordinate with network hospitals and help conduct camps.  Mobilize the patients for camps  Follow up the patients identified in the camp to report to network hospital.  Coordinate with local PR Bodies, Village organizations (VOs), Samakhyas, ANMs, Women Health Volunteers and Self-Help Groups for effective implementation of the scheme.  Move around the villages and encourage patients to come to avail the benefits of the scheme.  Educate villagers about the scheme and distribute brochures and other material.  Keep in touch with the District Coordinator  Follow up the Beneficiaries before and after Surgery.

22

2)

ROLE OF AREA HOSPITAL/DISTRICT HOSPITAL AAROGYAMITHRAS

Apart from the duties enlisted above the Aarogyamithras in Area Hospital and District Hospitals will 

Facilitate the Patient for specialist consultation and tests



Fill up the referral card (part-B) properly

 Counsel the patient

3)

ROLE OF AAROGYAMITHRAS AT NETWORK HOSPITALS

 Maintain Help Desk at Reception of the Hospital.  Receive the patient referred from (PHC or Network)  Verify the documents of the patients.  Obtain digital photograph of the patient.  Facilitate the Patient for consultation and admission.  Liaison with coordinator/administration of the hospital.  Counsel the patient regarding treatment/surgery.  Facilitate early evaluation and posting for surgery.  Facilitate hospital send proper pre-authorization.  Follow-up preauthorization procedure and facilitate approval.  Follow-up recovery of patient.  Facilitate payment of transport charges as per the guidelines.  Facilitate cashless transaction at hospital.  Facilitate discharge of the patient.  Obtain feed back from the patient.  Counsel the patient regarding follow-up.  Coordinate with PHC/Government Hospital Aarogyamithras for follow up of beneficiary.  Follow-up the patient referred by the hospital during the camps.  Coordinate with the Head-Office and Medical officers for any clarifications.  Send death reports  Send daily MIS.  Facilitate Network Hospital in conducting Health Camps as scheduled.

23

35.0

SUBMISSION OF BIDS: The Government of Andhra Pradesh / “Aarogyasri Health Care Trust“ seeks

detailed bid documents from insurance companies interested in implementing “Rajiv Aarogyasri Health Insurance Scheme”, in the State. The bid documents should be both in hard and soft form and should include the following: SECTION A – TECHNICAL PROPOSAL: A) QUALIFYING CRITERIA: Insurance company having full fledged establishment with experience in conceptualizing, designing and implementing large healthcare schemes and registered with IRDA.

Annexure-1

The qualifying requirements data shall be enclosed with the Technical Bid only. The bidders who do not qualify the above criteria, they will be disqualified immediately and their bids will not be considered.

B) AMENDMENT OF BIDDING DOCUMENTS: a) At any time prior to the deadline for submission of bids, the GoAP / Trust may, for any reason modify the Bidding documents, by amendment. b) The amendment will be notified in writing or by fax or telegram to all prospective bidders who have purchased the Bidding documents and amendments will be binding on them. c) In order to afford prospective bidders reasonable time to take the amendment into account in preparing their bids, the purchaser may, at its discretion, extend deadline for the submission of the Bid. NOTE: Oral statements made by the Bidder at any time regarding quality of service or arrangements of any other matter shall not be considered. C. Others: I. Geographical area: The scheme is proposed to be launched in five districts of Andhra Pradesh in Phase I (Renewal). 1. Anantapur 2. Srikakulam 3. Mahabubnagar

24

II. Experience: Experience of the agency in implementing health insurance schemes through government agencies. (Annexure-2) III. Infrastructure: Details of infrastructure available with the agency in the state of Andhra Pradesh. (Annexure-3) IV. Plan for setting up Project Office and other infrastructure as detailed in clause nos. 18 E and 24 (i to xiii) (in house system). (Annexure 3a) V. Plan for Health Camps as detailed in clause 18D

(Annexure 3b)

VI. Empanelled health facilities: List of existing empanelled Tertiary, Multi, Single specialty health facilities with the insurer in the state of Andhra Pradesh (Annexure- 4) VII. The list of Hospitals empanelled with the trust is enclosed. (Annexure- 5) VIII. Package rates: Hospital should agree to the packages for each identified intervention/surgery as approved by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital and charges etc. In other words the package should cover the entire cost of patient from date of reporting to his discharge from hospital and 10 days after discharge, making the transaction truly cashless to the patient. (Annexure - 6) IX. Detailed write-up on scheme: Detailed write-up in conformity with the proposed Insurance scheme. Write-up [detailed prospectus as per the requirement of IRDA] should be the apart of Technical proposal. (Annexure- 7) X. Cash less Transaction: It is desired that for each hospitalization, the transaction shall be cashless for covered procedures. Enrolled BPL beneficiary will go to hospital and come out without making any payment to the hospital subject to procedure covered under the scheme.

XI. Pre existing diseases: All diseases under the proposed scheme shall be covered from day one. A person suffering from any disease prior to the inception of the policy shall also be covered.

XII. Pre and Post hospitalization: This part has been made as a part of package. The package shall cover the entire cost of patient from date of reporting to his discharge from hospital 10 days after surgery, making the transaction truly cashless to the patient. In case of Renal Transplant Surgery with Immunosuppressive therapy, the buffer amount of Rs.50, 000, if required, will also get applied automatically up to 1 year. Network hospital will provide followup free consultation and medicines supplied by the Trust wherever required for the patients undergoing treatment under the scheme for a period of up to one year from eleventh day of discharge. Commonly used follow-up medicines will be supplied to the network hospitals by the Trust from time-to-time. XIII. Draft MOU: The insurer is required to enter into a MOU for implementation of the scheme with GoAP/ Trust. Insurer may propose a draft MOU from their end. GoAP/Trust is not bound to accept the same. [Annexure – 8]

25

XIV. Installment facilities for payment of premium:

The trust will pay the

premium in installments. XV. Premium Refund: If there is a surplus after the actual claims experience on the premium (excluding Service Tax) at the end of the policy period, after providing 20% of the premium paid towards the Company‟s administrative cost, in the balance 80% after providing for claims payment and outstanding claims, 90% of the left over surplus will be refunded to the Government/Trust with in 30 days after the expiry of the policy period. XVI. Activity: Activity wise flowchart depicting the sequence of the activities and a detailed time schedule for all activities proposed. (Annexure–9) XVII. Plan for appointing and maintaining Aarogyamithras as per clause 19.0 and Annexure B. (Annexure – 9a) XVIII. Plan for website, online MIS, 24 hour e-preauthorisation and real-time reporting as per clause 20.0. (Annexure – 9b) XIX. Plan for appointment of Medical Auditors. (Annexure – 9c) XX. Period of agreement: The agreement will be for one year from the effective date. The trust shall be having the right to accord the contract to other insurer in case of finding the unsatisfactory service track of the insurer. XXI. Capacity Building: The insurer will arrange the workshop for the capacity building of the insured, their representatives and other stakeholders in respect of specific field of insurance at each district on the convenience of the insured. XXII. Non-compliance by any medical institution: Empanelled medical institutions are supposed to extend medical aids to the beneficiary under the scheme. A provision is to be made in MOU of non-compliance clause while signing them. Such matter shall be looked in to by an empowered committee constituted by the GoAP/Trust. XXIII. Mechanism for Publicity: Ways and steps to be suggested (Annexure- 10) XXIV. Penalty clause: Failure to abide with the terms will attract penalty as suggested by the GoAP / Trust at the time of finalizing the terms. XXV. Business plan: Detailed business plan highlighting process proposed to be adopted for, should be given as per following manner. The sequence of the same, as under, is to be maintained. (Annexure–11) o

Mechanism for empanelment of desired private / public health facilities / day care health facilities.

o

Mechanism for standardization of various formats used for cashless transactions, discharged summary, billing pattern etc.

o

Mechanism for Awareness generation: i)

Ways and means for making beneficiaries/hospitals/insured aware about the scheme.

26

ii) Regarding list of approved health providers, diseases/illnesses covered, claim limits, etc. iii) Requirements of claims documents. iv) Procedure for submitting claims. v) Time frame for settlement of claims etc. o

Mechanism for monitoring: Enumerate the process.

o Mechanism for ensuring timely receipt of list of empanelled hospitals by the beneficiary. o Mechanism for ensuring proper administration of policy (prompt verification and settlement of claims). o MIS for claims reporting, claims settlement, claims paid, float amount and other related information as required by GoAP / Trust on monthly basis and as and when required. o Time-line for entire process – from beneficiary approaching the network hospital for treatment to lodging of claims and settlement. o Procedure for reporting the progress to appropriate authority nominated by GoAP at state, division and district level. o

Grievance redressal mechanism procedure at district and state level.

XXVI. Other information, if any (Annexure 11a) XXVII. Additional benefits: In case the bidder wants to offer additional benefits in addition to those mentioned earlier, the same may be given in detail. This will be the part of financial bid (Annexure - 12) SECTION B – FINANCIAL PROPOSAL

Annexure-12

Financial costs including administrative expenses, overheads, service charges etc. that the insurance company expects for rendering the services must be a part of premium. A) Premium quote for a sum insured of Rs. 1.50 Lakh per family on floater basis: B) Premium quote for Rupees 10 Crores as buffer / corporate sum insured. A sum of Rs. 50,000 can be availed by the individual if it has consumed the basic sum insured of Rs. 1.50 lakh. This is subject to the case being recommended by the Committee appointed by the Trust and to the availability of balance amount in buffer account. C) Details of Add on cover without any additional premium: S. Benefits Details No. 1 2 3 4 Note: No other documents or attachments are permissible along with annexure 12. Any deviation will attract disqualification. NOTE: TERMS CAN BE AMENDED BY THE GOAP / TRUST BEFORE ENTERING INTO THE CONTRACT.

27

Name of the Insurance Company: ________________________________ SECTION A – DETAILS OF TECHNICAL PROPOSAL:

Section of Technical Bid

Annexures/

To be provided by/ filled up by

Comments A

Qualifying Criteria:

IRDA attached

license Insurer

(Annexure-1) B

Amendment of bidding documents:

Trust

C

Insurer Others:

I

II

Experience:

1. Anantapur 2. Srikakulam 3. Mahbubnagar Annexure-2

III

Office Infrastructure:

Annexure-3

IV

Plan for setting up Project Office Annexure- 3a and other infrastructure detailed in the scheme (in house system).

V

Plan for Health Camps

VI

Empanelled health facilities:

Geographical Area

VII

Annexure – 3b

Insurer Insurer Insurer

Insurer Insurer

With Insurer

Annexure- 4

Empanelled health facilities:

Annexure- 5

Trust

with the Trust VIII

Package rates:

Annexure- 6

Trust

IX

Detailed write-up on scheme

Annexure- 7

Insurer

X

Cash less Transaction:

Insurer

XI

Pre existing diseases:

Insurer

XII

Pre and Post hospitalization:

Insurer

XIII

Draft MOU:

XIV

Installment facilities for payment of premium:

Insurer

XV

Premium Refund:

Insurer

XVI

Activity:

XVII

Plan for appointing and Annexure-9a maintaining Aarogyamithras as per clause 19.0 and Annexure B.

Annexure- 8

Annexure-9

Insurer

Insurer Insurer

28

XVIII

Plan for website, online MIS, e- Annexure-9b preauthorisation and real-time reporting as per clause 20.0.

Insurer

XIX

Plan for appointment of Medical Annexure-9c Auditors

Insurer

XX

Period of agreement:

Insurer

XXI

Capacity Building:

Insurer

XXII

Non compliances by any medical institution:

Insurer

XXIII

Mechanism for Publicity:

XXIV

Penalty clause:

XXV

Business plan:

Annexure-11

Insurer

XXVI

Other information, if any

Annexure-11a

Insurer

XXVII

Additional benefits:

Annexure-12 (Part Insurer of Financial Bid)

Annexure-10

Insurer Trust

NOTE: Bidder is supposed to give point wise reply of the tender document for agreement / disagreement and attach the necessary annexure as mentioned above.

DECLARATION BY THE BIDDER

I, _________________________________ Designated as _______________ At_____________________________ of ___________________________ Insurance Company here by declare that I have read the contents of the tender document and here by submit the bid in the desired format with respective annexures duly signed by me.

DATE:

SIGNATURE

29

Annexure 2

Sr. No .

D. Name of the Scheme and Beneficiary Group 1

State / area where implemented 2

EXPERIENCE OF THE BIDDER Premium (in Rs.) Number of Per Beneficiaries/ Total Beneficiary Families Premium / families 3 4 5

Claims

Number of years the scheme has been in operation (YEAR WISE)

Received (No)

Settled (Rs)

6

7

8

30

Organizational Setup:

Annexure -3

3.1

Organogram of organization at National level

3.2

Organogram of organization at Regional level (Southern Region)

3.3 Organogram of organization at State level – specific to Andhra Pradesh Location of Number of Offices in Name & designation Address. E-mail and Contact Staff in each Andhra of Office In-charge Number of Each office office Pradesh 1 2 4 5

Signature

31

List of Empanelled Health facilities with Insurer in Andhra Pradesh Annexure 4 S.No 1 2 3 4 5 6 7 8 9

NAME OF HOSPITAL

District

LOCATION

SPECIALITY

ADDRESS

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 List must be district wise alphabetically

Signature

32

Annexure – 5 RAJIV AAROGYASRI COMMUNITY HEALTH INSURANCE SCHEME LIST OF NETWORK HOSPITALS

S.No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

Hospital Name KONASEEMA INSTITUTE OF MEDICAL SCIENCES PAVANI HOSPITAL GOVT GENERAL HOSPITAL VARMA HEART CARE CENTRE APOLLO HOSPITALS, ARAGONDA ASRAM HOSPITAL BALAJI CANCER CARE CENTRE ENT NURSING HOME GOVERNMENT GENERAL HOSPITAL GUNTUR CANCER CARE CENTRE LTD KARUMURI MULTI SPECIALITY HOSPITAL LALITHA HOSPITAL NRI ACADAMY OF SCIENCES APOLLO HOSPITAL, DRDO APOLLO HOSPITALS, JUBILEE HISLLS APOLLO HOSPITALS, VIKRAMPURI ASIAN INSTITUTE OF GASTRO ENTEROLOGY BALAJI HOSPITAL BIBI CANCER ANDGENERAL HOSPITAL CARE HOSPITALS, BANJARAHILLS CARE HOSPITALS, NAMPALLY CARE HOSPITALS, MUSHEERABAD DURGABHAI DESHMUKH HOSPITAL AND RESEARCH CENTRE GANDHI HOSPITALS GENESIS HOSPITALS GLOBAL HOSPITAL, LAKDIKAPOOL GOVERNMENT METERNITY HOSPITAL, KOTI GOVERNMENT METERNITY HOSPITAL, NAYAPUL IMAGE HOSPITALS, AMEERPET IMAGE HOSPITALS, MADHAPUR INDO-AMERICAN CANCER INSTITUTE INNOVA CHILDRENS HEART CENTRE KAMINENI HOSPITALS, L.B.NAGAR KAMINENI WOCKHARDT HEART CENTER, KING KOTI KAMINENI WOCKHARDT HEART CENTER, L.B.NAGAR KRISHNA INSTITUTE OF MEDICAL SCIENCES LOTUS CHILDRENS HOSPITAL M.N.J. CANCAR INSTITUTE MAHAVEER HOSPITAL MEDICITI HOSPITAL MEDICITI INSTITUTE OF MEDICAL SCIENCES, MEDCHAL MEDWIN HOSPITAL NIMS HOSPITALS OSMANIA HOSPITAL

City AMALAPURAM ANANTAPUR ANANTAPUR BHIMAVARAM CHITTOOR ELURU GUNTUR GUNTUR GUNTUR GUNTUR GUNTUR GUNTUR GUNTUR HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD

POULOMI HOSPITAL

HYDERABAD

33

46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95

RANIBOW CHILDRENS HOSPITAL REMEDY HOSPITALS S.V.R. SUPER SPECIALITY HOSPITAL SAI BHAVANI HOSPITAL SAI VANI HOSPITAL LTD SHRAVANA MULTI SPECIALITY SIGMA HOSPITALS SOUMYA HOSPITAL SRI SAI KAMALA HOSPITAL SRI SAI SRINIVASA SPECIALITY HOSPITAL USHA MOHAN HOSPITAL VASAVI ENT HOSPITAL VIJAYA HEALTH CARE WOODLANDS HOSPITAL YASHODA HOSPITALS YASHODA HOSPITALS, MALAKPET APOLLO HOSPITAL GOVERNMENT GENERAL HOSPITAL SRI SAI RAGHAVENDRA MULTI SPECIALTY HOSPITAL GOWRI GOPAL HOSPITAL R.R HOSPITAL VIJAYA HOSPITAL VISWABHARATHI SUPER SPECIALITY HOSPITAL GOVT GENERAL HOSPITAL KAMINENI INSTITUTE OF MEDICAL SCIENCES, NALGONDA BOLLINENI SUPER SPECIALITY HOSPITALS NARAYANA MEDICAL COLLEGE HOSPITAL BOLLINENI HEART CENTRE G S L MEDICAL COLLEGE RAJU NEURO & MULTI SPECIALTY HOSPITAL SWATANTRA HOSPITALS GOVERNMENT MATERNITY HOSPITAL RUSSH HOSPITALS S.V.R.R.HOSPITAL SRI VENKATESWARA INSTITUTE OF MEDICAL SCIENCES CARE HOSPITALS CHARITHASRI HOSPITAL LTD CITI CARDIAC CENTER CITY CANCER CENTER GOVERNMENT GENERAL HOSPITAL HELP HOSPITAL MANIPAL SUPER SPECIALITY HOSPITAL NAGARJUNA HOSPITAL PURNA HEART INSITITUTE VIJETHA HOSPITALS APOLLO HOSPITAL CARE HOSPTIALS KALA HOSPITAL KALAVATHI SURGICAL AND LAPROSCOPIC CENTER KING GEORGE HOSPITAL

HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD HYDERABAD KAKINADA KAKINADA KAKINADA KURNOOL KURNOOL KURNOOL KURNOOL KURNOOL NALGONDA NELLORE NELLORE RAJAHMUNDRY RAJAHMUNDRY RAJAHMUNDRY RAJAHMUNDRY TIRUPATI TIRUPATI TIRUPATI TIRUPATI VIJAYAWADA VIJAYAWADA VIJAYAWADA VIJAYAWADA VIJAYAWADA VIJAYAWADA VIJAYAWADA VIJAYAWADA VIJAYAWADA VIJAYAWADA VISHAKAPATNAM VISHAKAPATNAM VISHAKAPATNAM VISHAKAPATNAM VISHAKAPATNAM

34

96 97 98 99 100 101 102 103 104 105

LIONS CANCER HOSPITAL MAHATMA GADHI CANCER HOSPITALS QUEENS NRI HOSPITALS SEVEN HILLS SIMHADRI HOSPITAL SRI SURYA HOSPITALS MAHARAJAH INSTITUTE OF MEDICAL SCIENCES TIRUMALA HOSPITALS JAYA HOSPITAL ST.ANNS CANCER CENTER

VISHAKAPATNAM VISHAKAPATNAM VISHAKAPATNAM VISHAKAPATNAM VISHAKAPATNAM VISHAKAPATNAM VIZIANAGARAM VIZIANAGARAM WARANGAL WARANGAL

35

Annexure - 6 RAJIV AAROGYA SRI COMMUNITY HEALTH INSURANCE SCHEME

PACKAGES GENERAL GUIDELINES ON THE PACKAGES. 1. The package includes  Consultation, medicines, diagnostics, specialist services  Implants, grafts, prosthetics,  Food,  Cost of transportation  Hospital charges etc. In other words the package should cover the entire cost of treatment of the patient from date of reporting to his discharge from hospital and 10 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient. The post-operative hospital stay in all surgical procedures shall be minimum of 10 days except in case of interventions and chemotherapy for cancers. 2. Hospital shall conduct all diagnostic tests as per standard protocols free of cost. 3. Hospital shall provide 10 days post discharge free medicines to the patient within package. 4. Hospital shall provide reasonably good food to the patient, and shall make alternate arrangement for food wherever in-house pantry is not available. The hospital shall not give money as an alternative to food. 5. Hospital shall pay return fare from Mandal Headquarters to the town where hospital is situated based on RTC fare. 6. Hospital use standard prosthetics and implants for surgical procedures and shall not charge extra cost from the patient on the ground of providing a better prosthetic, however if there is genuine technical reason to justify such a higher value prosthetic/implant it can request the technical committee to approve enhancement with evidence. 7. Hospital shall assist and facilitate the patient to procure compatible blood for the surgeries. The hospital shall provide blood from their own blood bank subject to availability within the package. In case of non-availability the hospital shall make efforts to procure from other blood banks, Red Cross, voluntary organizations etc. The hospital shall also issue a copy of the request letter to the patient.

PACKAGE RATES 1 2 3 4 5 6 7 8 9 10 11 12

1 1.1 1.1.1 1.1.2 1.1.3 1.2 1.3 1.4 1.5 1.6 1.7 1.7.1 1.8

CARDIAC Coronary Bypass Surgery Coronary Bypass Surgery-post Angioplasty CABG with IABP pump CABG with aneurismal repair Intracardiac Tumors Coronary Baloon Angioplasty Total Correction of Tetralogy of Fallot Ruptured sinus of valsulva Correction TAPVC Correction Intra cardiac Repair of ASD Intra cardiac Repair of VSD Patent Ductus Arteriousus -Surgery-PDA

Cost 95000 105000 125000 110000 75000 60000 95000 95000 95000 75000 75000 20000

36

13

1.8.1 1.9

14 15

36 37 38

1.9.1 1.9.2 1.10 1.10.1 1.10.2 1.10.3 1.11 1.11.1 1.12 1.12.1 1.12.2 1.13 1.13.1 1.13.2 1.14 1.15.1 1.15.2 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.24.1 1.24.2 1.25

39

1.26

40

1.27

41 42 43

1.28 1.29 1.30 1.31 1.31.1 1.31.2 1.32 1.32.1 1.32.2 1.33 1.33.1 1.33.2 2 2.1 2.2 2.3 2.4

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

44 45 46 47 48 49 50 51 52 53

BT shunt Ross Procedure Intracardiac Repair of Complex congenital heart diseases With Special Conduits Without Special Conduits Balloon Valvotomy Balloon Valvotomy-Pulmonary Balloon Valvotomy-Mitral Balloon Valvotomy-Aortic Open Mitral Valvotomy Open Pulmonary Valvotomy Valve Repairs With Prosthetic Ring Without Prosthetic Ring Systemic Pulmonary Shunts With Graft Without Graft Closed mitral valvotomy Mitral Valve Replacement (With Valve) Tricuspid Valve Replacement (With Valve) Aortic Valve Replacement (With Valve) Double Valve Replacement (With Valve) Mitral Valvotomy (Open) Pericardiostomy surgery CT Pericardiectomy Pericardio Centesis Permanent Pacemaker Implantation Temporary Pacemaker Implantation Coaractation-Arota Repair With Graft Without Graft Aneurysm Resection & Grafting Intrathoracic Aneurysm -Aneurysm not Requiring Bypass (with Graft) Intrathoracic Aneurysm -Requiring Bypass (With Graft) Dissecting Aneurysms Vertebral Angioplasty Annulus aortic ectoria with valved conduits Aorto-Aorto Bypass With Graft Without Graft Femoro- Poplitial Bypass With Graft Without Graft Femorofemoral Bypass With Graft Without Graft LUNGS Pneumonectomy Lobectomy Decortication Lung Cyst

20000

1,25,000 95000 20000 20000 20000 75000 75000 100000 85000 20000 20000 20000 120000 120000 120000 150000 80000 10000 30000 2000 75000 10000 32000 25000 125000 65000 125000 75000 75000 150000 60000 45000 45000 30000 45000 25000 50000 50000 50000 50000

37

2.5 2.6 2.6.1 2.6.2 2.6.3 3 3.1 3.2 3.3 4 4.1 4.2 4.3 4.4 5 5.1 5.2 5.3 5.4 5.5.1 5.5.2 5.6.1 5.6.2 5.7 5.8 5.9.1 5.9.2 5.10 5.11 5.12.1 5.12.2 5.13 5.14 5.15 5.16 5.17 5.18 5.19 6

SOL mediastinum Surgical Correction of Bronchopleural Fistula. Thorocoplasty Myoplasty Transpleural BPF closure LIVER Rt.Hepatectomy Lt.Hepatectomy Segmentectomy PANCREAS Distal Pancreatectomy Enucleation of Cyst Whipples – any type Triple Bypass & other Bypasses PAEDIATRIC CONGENITAL MALFORMATIONS Oesophageal Atresia Diaphragmatic Hernia Intestinal Atresias & Obstructions Biliary Atresia & Choledochal Cyst Anorectal Malformations Stage 1 Anorectal Malformations Stage 2 Hirschprungs Disease Stage1 Hirschprungs Disease Stage 2 Congenital Hydronephrosis Ureteric Reimplantations Extrophy Bladder Stage 1 Extrophy Bladder Stage 2 Posterior Urethral Valves Hypospadias Single Stage Hypospadias Stage1 Hypospadias Stage 2 Paediatric Tumors Cleft lip Cleft Palate Velo-Pharyngial Incompetence Syndactyly of Hand for each hand Microtia/Anotia TM joint ankylosis RENAL

88

6.1

HaemoDialysis (Pre Transplant only)

89 90

6.1.1 6.2

A.V. Fistule(Pre-Transplant Procedure only) Renal Transplantation surgery Post Transplant immunosuppressive Treatment upto 1 year 1st quarter 2nd quarter 3rd quarter 4th quarter Surgery for Renal Calculi Open Pylolithotomy Open Nephrolithotomy Open Cystolithotomy

54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87

6.2.1 91 92 93 94 95 96 97

6.2.1.1 6.2.1.2 6.2.1.3 6.2.1.4 6.3 6.3.1 6.3.2 6.3.3

50000 50000 50000 50000 75000 75000 50000 100000 75000 75000 25000 60000 60000 50000 55000 45000 60000 45000 60000 50000 65000 65000 60000 30000 40000 35000 35000 50000 10000 15000 15000 15000 30000 40000 1000/dialysis up to 5000 5000 130000

15000 15000 15000 15000 10000 10000 10000

38

98 99 100 101 102 103 104

6.3.4 6.3.4 6.3.5 6.3.6 6.3.7 6.3.8 6.4 7

105

7.1

106

7.2

107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141

7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19 7.20 7.21 7.22 7.23 7.24 7.25 7.26 7.27 7.28 7.29 7.31 7.32 7.33 7.34 7.35 7.36 7.37 7.38 8 8.1 8.1.1 8.1.2 8.1.3 8.1.4

142 143 144 145

Open Ureterolithotomy PCNL Laparoscopic Pylolithotomy ESWL Nephrostomy DJ stunt Renal Angioplasty NEUROSURGERY Craniotomy and Evacuation of Haematoma – Subdural(Non-Traumatic) Craniotomy and Evacuation of Haematoma – Extradural(Non-Traumatic) Evacuation of Brain Abscess-burr hole Excision of Lobe (Frontal,Temporal,Cerebellum etc.) Excision of Brain Tumours –Supratentotial Excision of Brain Tumours –Subtentorial Surgery of Cord Tumours Ventriculoatrial /Ventriculoperitoneal Shunt Excision of Cervical Inter-Vertebral Discs Twist Drill Craniostomy Subdural Tapping Ventricular Tapping Abscess Tapping Vascular Malformations Peritoneal Shunt Atrial Shunt Meningo Encephalocele Meningomyelocele C.S.F. Rhinorrhoea Cranioplasty Posterior Cervical Dissectomy Anterior Cervical Dissectomy Meningocele Excision Ventriculo-Atrial Shunt Anterior Cervical Spine Surgery with fusion Anterior Lateral Decompression Laminectomy Combined Trans-oral Surgery & CV Junction Fusion C.V. Junction Fusion Discectomy Spinal Fusion Procedure Spinal Intra Medullary Tumours Spinal Bifida Surgery Major Spina Bifida Surgery Minor Stereotactic Procedures Trans Sphenoidal Surgery Trans Oral Surgery CANCER – Surgeries Head & Neck Composite Resection & Reconstruction Neck Dissection – any type Hemiglossectomy Maxillectomy – any type

10000 10000 15000 10000 2000 1000 60000 40000 40000 25000 40000 40000 45000 25000 20000 15000 15000 15000 15000 20000 40000 15000 15000 25000 25000 20000 30000 15000 15000 25000 20000 45000 30000 25000 30000 20000 25000 30000 30000 20000 15000 20000 20000 25000

60000 25000 15000 25000

39

146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184

185 186 187 188 189 190

8.1.5 8.1.6 8.1.7 8.1.8 8.1.9 8.1.10 8.2 8.2.1 8.2.2 8.2.3 8.2.4 8.2.5 8.3 8.3.1 8.3.2 8.3.3 8.3.4 8.3.5 8.3.6 8.3.7 8.3.8 8.3.9 8.3.10 8.4 8.4.1 8.4.2 8.4.3 8.4.4 8.4.5 8.4.6 8.5 8.5.1 8.5.2 8.5.3 8.5.4 8.5.5 8.5.6 8.6 8.6.1 8.6.2 8.6.3 8.7 8.7.1 8.7.2 8.7.3 8A 8A.1 8A.1.1 8A.1.2 8A.1.3 8A.1.4 8A.1.5 8A.1.6

Thyroidectomy – any type Parotidectomy – any type Laryngectomy – any type Laryngopharyngo Oesophagectomy Hemimandibulectomy Wide excision Gastrointestinal Tract Oesophagectomy – any type 2. Gastrectomy – any type 3. Colectomy – any type 4. Anterior Resection 5. Abdominoperenial Resection Genito Urinary System Radical Nephrectomy Radical Cystectomy Other Cystectomies Total Penectomy Partial Penectomy Inguinal Block Dissection – one side Radical Prostatectomy High Orchidectomy Bilateral Orchidectomy Emasculation Gynaecological Oncology Hysterectomy Radical Hysterectomy Surgery for Ca Ovary – early stage Surgery for Ca Ovary – advance stage Vulvectomy Salpingo – oophorectomy Tumors of the Female Breast 1. Mastectomy – any type 2. Axillary Dissection 3. Wide excision 4. Lumptectomy 5. Breast reconstruction 6. Chest wall resection Skin Tumors 1. Wide excision 2.Wide excision + Reconstruction 3. Amputation Soft Tissue and Bone Tumors 1. Wide excision 2. Wide excision + Reconstruction 3. Amputation CANCER – Chemotherapy* Breast Cancer Adriamycin/Cyclophosphamide (AC) 5- Fluorouracil A-C (FAC) AC (AC then T) Paclitaxel Cyclophosphamide/Methotrexate/5Fluorouracil(CMF) Tamoxifen tabs

20000 20000 40000 75000 25000 25000 60000 40000 40000 50000 40000 40000 60000 40000 25000 15000 15000 60000 15000 10000 30000 25000 30000 25000 40000 15000 25000 25000 15000 5000 3000 25000 20000 10000 20000 20000 15000 25000 20000 Cost/Cycle 3000 3100 3000 9500 1500 85/month

40

191 192 193 194 195 196

8A.1.7 8A.2 8A.2.1 8A.3 8A.3.1 8A.4 8A.4.1 8A.5 8A.5.1 8A.6 8A.6.1 8A.7

Aromatase Inhibitors Cervical Cancer Weekly Cisplatin Vulvar Cancer Cisplatin/5-FU Vaginal Cancer Cisplatin/5-FU Ovarian Cancer Carboplatin/Paclitaxel Ovary- Germ Cell Tumor Bleomycin-Etoposide-Cisplatin (BEP) Gestational Trophoblast Ds.

8A.7.1

Low risk Weekly Methotrexate Actinomycin High risk Etoposide-Methotrexate-Actinomycin / Cyclophosphamide –Vincristine (EMA-CO) Testicular Cancer Bleomycin-Etoposide-Cisplatin (BEP) Prostate Cancer Hormonal therapy Bladder Cancer Weekly Cisplatin Methotrexate Vinblastine Adriamycin Cyclophosphamide (MVAC) Lung Cancer Non-small cell lung cancer Cisplatin/Etoposide (IIIB) Esophageal Cancer Cisplatin- 5FU Gastric Cancer 5-FU –Leucovorin (McDonald Regimen) Colorectal Cancer Monthly 5-FU 5-Fluorouracil-Oxaliplatin –Leucovorin (FOLFOX) (Stage III only) Osteosarcoma/ Bone Tumors Cisplatin/Adriamycin Lymphoma i) Hodgkin Disease Adriamycin – Bleomycin – Vinblastine Dacarbazine (ABVD) ii) NHL Cyclophosphamide – Adriamycin Vincristine – Prednisone (CHOP) Multiple Myeloma Vincristine, Adriamycin,Dexamethasone(VAD) High dose decadron (oral) Melphalan –Prednisone (oral) Wilm’s Tumor SIOP/NWTS regimen(Stages I – III)

197 198

8A.7.1.1 8A.7.1.2 8A.7.2

199

8A.7.2.1

202

8A.9 8A.9.1 8A.10 8A.10.1 8A.11 8A.11.1

203

8A.11.2

200 201

207

8A.12 8A.12.1 8A.12.1.1 8A.13 8A.13.1 8A.14 8A.14.1 8A.15 8A.15.1

208

8A.15.2

204 205 206

209

210

8A.16 8A.16.1 8A.17 8A.17.1 8A.17.1.1 8A.17.2

211 212 213 214 215

8A.17.2.1 8A.18 8A.18.1 8A.18.2 8A.18.3 8A.19 8A.19.1

835/month 2000 5000 5000 10500 8000

600 3000 6000

8000 3000/month 2000 5000

7000 5000 5000 4000 10000

20000

4000

3500

4000 1500 1500 7000/month

41

216 217 218 219 220 221 222 223 224 225

226 227 228

229 230 231

8A.20 8A.20.1 8A.21 8A.21.1 8A.22 8A.22.1 8A.23 8A.23.1 8A.24 8A.24.1 8A.25 8A.25.1 8A.26 8A.26.1 8A.27 8A.27.1 8A.27.2 8A.27.3 8A.28 8A.28.1 8A.28.1.1 8A.28.1.2 8A.28.2 8B 8B.1 8B.1.1 8B.1.2 8B.1.3 8B.2

232 233 234

235 236 238 239

240 241 242 243 244 245 246

8B.2.1 8B.2.2 8B.2.3 8B.3 8B.3.1 8B.3.1.1 8B.3.1.2 8B.3.2 8B.3.2.1 8B.3.2.2 9 9.1 9.1.1 9.1.2 9.1.3 9.1.4 9.2 9.2.1 9.2.2 9.2.3 9.3

Hepatoblastoma- operable Cisplatin – Adriamycin Childhood B Cell Lymphomas Variable Regimen Neuroblastoma ( Stages I-III ) Variable Regimen Retinoblastoma Carbo/Etoposide/Vincristine Histiocytosis Variable Regimen Rhabdomyosarcoma Vincristine-Actinomycin-Cyclophosphamide(VactC) based chemo Ewings sarcoma Variable Regimen Acute Myeloid Leukemia Induction Phase Consolidation Phase Maintenance Acute Lymphoblastic Leukemia Induction 1st and 2nd months 3rd, 4th, 5th Maintenance RADIOTHERAPY Cobalt 60 External Beam Radiotherapy Radical Treatment Palliative Treatment Adjuvant Treatment External Beam Radiotherapy (on linear accelerator) Radical Treatment with Photons Palliative Treatment with Photons Adjuvant Treatment with Photons/Electrons Brachytherapy A) Intracavitary i. LDR per application ii. HDR per application B) Interstitial i. LDR per application ii. HDR – one application and multiple dose fractions BURNS 30% - 50% Burns upto-40% with Scalds( Conservative) upto-40% Mixed Burns(with Surgeries) upto-50% with Scalds (Conservative) upto-50% Mixed Burns( with Surgeries) Above 50% Burns upto-60% with Scalds (Conservative) Up to-60% Mixed Burns (with Surgeries) Above 60% Mixed Burns (with Surgeries) Post Burn Contracture surgeries for Functional Improvement(Package including splints, pressure

15000 Up to 12000 Up to 10000 4000 Up to 8000/month 9000/month

Up to 9000/ month Up to 50000 Up to 40000 3000 per month

Up to 50000 Up to 20000 3000 per month

20,000 10,000 15,000

50,000 20,000 35,000

4,500/2,500/15,000/25,000/-

35,000 50,000 60,000 70,000 80000 1,00,000 1,20,000

42

247 248 249

9.3.1 9.3.2 9.3.3 10

20000 30000 40000 Maximum package

267

11.1 11.2

Orthopedic Trauma Surgical Correction of Longbone Fracture Amputation Surgery Soft Tissue Injury Neuro-Surgical Trauma Conservative Stay in General [email protected]/day Stay in Neuro [email protected]/day Surgical Treatment (Up to) Chest Injuries Conservative Stay in General [email protected]/day Stay in Respiratory [email protected]/day Surgical treatment Abdominal Injuries Conservative Stay in General [email protected]/day Stay in Surgical [email protected]/day Surgical treatment Emergency Room Procedures Tracheostomy Thorocotomy Cochlear Implant Surgery For Children Below 6 Years Cochlear Implant Surgery Auditory-Verbal Therapy

268

11.2.1

Initial Mapping/Switch on

50000

269

11.3.1

Post Switch on Mapping/Initiation of AVP and training of Child and Mother - First Installment

20000

270

11.3.2

Post Switch on Mapping/Initiation of AVP and training of Child and Mother - Second Installment

20000

271

11.3.3

Post Switch on Mapping/Initiation of AVP and training of Child and Mother - Third Installment

20000

272

11.3.4

Post Switch on Mapping/Initiation of AVP and training of Child and Mother - Fourth Installment

20000

250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266

10.1 10.1.1 10.1.2 10.1.3 10.2 10.2.1 10.2.1.1 10.2.1.2 10.2.2 10.3 10,3.1 10.3.1.1 10.3.1.2 10.3.2 10.4 10.4.1 10.4.1.1 10.4.1.2 10.4.2 10.5 10.5.1 10.5.2

garments and physiotherapy) Mild Moderate Severe POLY TRAUMA & ACCIDENT SURGERIES

11

15000 5000 5000

6000 28000 150000

3000 20000 50000

3000 7000 75000 3000 3000

520000

Renal package AV fistula., pre-transplant haemodialysis are approved along with renal transplant surgery only and not separately Cancer. Chemotherapy and radiotherapy should be administered only by professionals trained in respective therapies (i.e Medical Oncologists and Radiation Oncologists) and well versed with dealing with the side-effects the treatment can cause

43

Patients with hematological malignancies- (leukemias, lymphomas, multiple myeloma ) and pediatric malignancies ( Any patient < 14 years of age) should be treated by qualified medical oncologists only Each cycle cost includes  Cost of chemotherapy drugs  Hospital charges  All the infusional chemotherapy cancer cases must be treated as inpatients only.  Doctors fees  Supportive care medications (i.e. i. v. fluids, steroids, H2 blockers, anti-emetics)  All Investigations An average of 2000 to 5000/- has been added to the above cost, to cover for treatment of complications. A cap of 30,000/- has been set on palliative chemotherapy Tumors not included in this list, if have a chemotherapy regimen that is proven to be curative, or provide long term improvements in overall survival will be reviewed on a case by case basis by the technical committee of the Trust. Polytrauma Components of Polytrauma: The following are the components of polytrauma based on the system involved 1. Orthopedic trauma 2. Neuro-Surgical Trauma 3. Chest Injuries 4. Abdominal Injuries The above components may be treated separately or combined as the case warrants. Insurance provision for polytrauma and Its Implications :For providing financial assistance through insurance to emergency polytrauma cases requiring Hospitalization and/or Surgery for BPL families, management of each of the above can be classified as given below:  Orthopedic trauma 1. Surgical Corrections  Nuero-Surgical Trauma 1. Conservative 2. Surgical Treatment  Chest Injuries 1. Conservative 2. Surgical treatment  Abdominal Injuries 1. Conservative 2. Surgical treatment III. All cases, which require conservative management with a minimum of oneweek hospitalization with evidence of (Imageology based) seriousness of injury to warrant admission, only need to be covered to avoid misuse of the scheme for minor/trivial cases. IV. In case of Neurosurgical trauma, admission is based on both Imageology evidence and Glasgow Coma Scale (A scale of less than 13 is desirable). V. All surgeries related to poly-trauma are covered irrespective of hospitalization period. VI. Initial evaluation of all trauma patients has to be free of cost.

44

SECTION B – FINANCIAL PROPOSAL

Annexure-12

A) Premium quote for a sum insured of Rs. 1.50 Lakh per family on floater basis:

S.NO.

No. of FAMILIES

1

25.27 lakhs

PREMIUM PER FAMILY Rs.

TOTAL PREMIUM WITHOUT S.T. Rs.

TOTAL PREMIUM WITH S.T. Rs.

B) Premium quote for Rupees 7 Crores as buffer / corporate sum insured. A sum of Rs. 50,000 can be availed by the individual if it has consumed the basic sum insured of Rs. 1.50 lakh. This is subject to the case being recommended by the Committee appointed by the Trust and to the availability of balance amount in buffer account.

BUFFER AMOUNT

PREMIUM WITHOUT S.T.

Rs. 7 Crores

Rs.

PREMIUM WITH S.T. Rs.

Total Premium without S.T.: (A + B) = Total Premium with S.T.:

(A + B) =

C) Details of Add on cover without any additional premium: S. Benefits Details No. 1 2 3 4 Note: No other documents or attachments are permissible along with annexure 12. Any deviation will attract disqualification.

45

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medical insurance scheme for the poor - Aarogyasri

RAJIV AAROGYASRI COMMUNITY HEALTH INSURANCE SCHEME - PHASE I (RENEWAL) FOR BPL POPULATION IN 3 DISTRICTS OF ANDHRA PRADESH There is a felt need in th...

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