At least four states from the Hindi heartland have expressed a desire to move to a hybrid model under the Pradhan Mantri Jan Arogya Yojana scheme (PMJAY), also called Ayushman Bharat. Sources told Moneycontrol that non-life insurers have been approached to work out a process for the model. “A few states have sought details on a proposed structure that can be adopted for PMJAY under a hybrid model. Both the states and the insurance companies will work in tandem to settle claims,” said a senior general insurance executive. The scheme has a trust model and an insurance model. A trust model means that each state will set up a trust of its own to collect premium funds and pay-out claims. Individual states will be responsible for settling claims and maintaining the fund. Under a hybrid model, both the state and the insurance company have a role to play.
The insurance company could be responsible for claims settlement while the state governments will maintain funds. Further, states may also assign districts which will be fully managed by the insurer. Most states have opted for the trust model and only four states including Jharkhand, Nagaland, Manipur and West Bengal have opted for the insurance route. While the scheme is free of cost for customers, the premium is divided between the Center and states in a 60:40 ratio. West Bengal is one of the states that has openly stated it is going for a hybrid insurance model under PMJAY. This means that both state governments and insurance companies have a role to play.
PMJAY offers a health insurance cover of Rs 5 lakh to a certain set of customers. It is a family floater health plan with no exclusions. They are selected as per their socio-economic status from the 2011 data. About 100 million families are expected to be covered under the scheme, making it the largest state-funded health insurance program in the world. Insurance companies are selected for the scheme through a tender process. Those quoting the lowest rate per family will be awarded the contract. On an average a rate of Rs 800-900 is being quoted. Under the earlier Rashtriya Swasthya Bima Yojana, a majority of states had engaged insurance companies to collect premiums and also ensure timely settlement of claims. – Money Control