Presentation on PMJAYCMCHIS Convergence Government of Tamil Nadu

Presentation on PMJAY-CMCHIS Convergence Government of Tamil Nadu Department of Health & Family welfare Dr T S Selvavinayagam , M. D. , D. P. H, D. N. B drsvinayagam@gmail. com Date : 30. 09. 2019 & 01. 10. 2019 30. 9. 19 TN CMCHIS-Selva 1

Basic details of CMCHIS before convergence 30. 9. 19 Inception 23. 07. 2009/11. 01. 12/11. 01. 17/23. 9. 18 Eligibility Annual Income < Rs 72, 000 & SECC list Sum insured Rs 1 L / 2 L/. Now 5 L Up to Rs 35. 5 L Procedures 1027 with 38 DC and 9 HE plus 423 of PMJAY Population covered 1. 57 crore families 65% of population Premium Rs 699/year/family (No cap on FS) plus Rem ICR 90. 43%. 90. 01% and 100. 68% in 6/7/8 H Budget Rs 1326 crore/year in 2019 -20 TN CMCHIS-Selva 2

Basic details of CMCHIS Convergence Validity of tender 4 plus 1 years up to 2022 Insurance company United India Insurance Company SHA TNHSP with team of 15 officials Empaneled Hospitals 976 with 243 Govt 733 private GHs claims share 45% and 37%/ Integration with Primary care Limited Beneficiaries 37. 42 L/Rs 6147 Cr as on 30. 07. 19 GH 16. 74 L/ Rs 2272 cr HEP -Beneficiaries 30. 9. 19 7994 HE/Rs 597 Cr – 3927 CI, 2604 Renal TN CMCHIS-Selva 3

Strategic purchasing - CMCHISTN • Enrollment • Provider payment • Empanelment • IT systems • Benefit package • Fraud management • DK/ Field • Resident / < Rs 72000 per annum • Online, Graded • Preference to Government • Defined, Reserved to Govt • No co pay • Quality • Entry level NABH 30. 9. 19 • Package cost in public domain • TAT – 98% payments within 7 days • Entirely online and multiple users • API to PMJAY • Triggers, DVO residential visit • Citizen empowerment • IEC, Call center, merra hospital • Governance TN CMCHIS-Selva 4

Rational Behind Convergence • RSBY Why Not • Primary Care Prior • Rigid Policies Current Rationale Now 30. 9. 19 TN CMCHIS-Selva • PMJAY-Flexible • Willing to work with State • Critical Care • PMJAY roll out is similar to existing CMCHIS Model 5

Challenges towards convergence • Political 30. 9. 19 • Enrollment Vs Adoption, SECC list no common identifier & incomplete, Delay in getting Hon PM letter • Empanelment – Big Vs small hospitals, grading • Benefit package – Different rates, mapping of packages • Quality – Incentive Vs everyone • Provider payment – TAT < 7 days • IT systems - Existing vs migration • Fraud management- IT based Vs Field verification • Citizen empowerment- Call center integration • Governance- Insurance Vs Trust TN CMCHIS-Selva 6

Steps taken by Tamil Nadu towards convergence • Political • Every family enrolled under CMCHIS, who are not covered under SECC list also eligible for all the procedures of both the scheme and their sum insured also raised to 5 Lakhs • PMJAY = CMCHISTN in TN 30. 9. 19 • Operational – Existing system- SHA, Districts, AM etc. Additional administrative cost of PMJAY • Hospitals – Addendum to MOU, BIS&NTMS opened for portability • Risk pooling – SECC list is the subset of CMCHIS, except small part • IT – Existing system with API • Timelines – Same TAT • Packages – Retained TN rates TN CMCHIS-Selva 7

Financial implications • Limited impact on State. • Need study the impact on population • Additional resources around Rs 350 crores in year from GOI as 60% of SECC list • No additional requirement in view of increased sum insured • Technical support • Third party validation 30. 9. 19 TN CMCHIS-Selva 8

Impact of convergence. Needs refinement? 30. 9. 19 TN CMCHIS-Selva 9

Thank you Transparency All details CMCHIS Website drsvinayagam@gmail. com 30. 9. 19 TN CMCHIS-Selva 10