Modicare to offer 20% lower rates than CGHS rates

Modicare to offer 20% lower rates than CGHS rates

Sushm Dey | TNN | Updated: May 24, 2018, 10:14 IST

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The health ministry has finalised the rates for 1,354 packages, which will be covered under NHPS.The packages include 23 specialties such as cardiology, ophthalmology, orthopaedics, urology and oncology, etc, an official said.

NEW DELHI: In a move likely to set new pricing standards for medical procedures in the country, the government-sponsored National Health Protection Scheme (NHPS), popularly known as Modicare, will offer common treatments such as coronary bypass, knee transplant and C-section at a rate which is around 15-20% lower than Central Government Health Scheme(CGHS), which provides comprehensive medical care to government servants, pensioners and their dependants.

The health ministry has finalised the rates for 1,354 packages, which will be covered under NHPS. The packages include 23 specialties such as cardiology, ophthalmology, orthopaedics, urology and oncology, etc, an official said.

For instance, the rate for vertebral angioplasty with single stent has been fixed at Rs 50,000, whereas that with double stent will cost Rs 65,000. Similarly, the price for total knee replacement is fixed at Rs 80,000, whereas a C-section will be charged at Rs 9,000. The list also includes paediatric surgeries, different packages for cancer treatment as well as mental disorders.

For comparison, an angioplasty would cost about Rs 1.5-2 lakh, a C-section around Rs 1.5 lakh and a total
The NHPS rate list is part of a model tender document for the Pradhan Mantri Rashtriya Swasthya Suraksha Mission, reviewed by TOI.

The document, finalised after consultation with Niti Aayog and Indian Council of Medical Research (ICMR), also details the minimum number of days of hospitalisation required to make a claim as well as pre-surgery and post-surgery investigations needed for approval. The document has been shared with state governments for comments. It will also be circulated among the bidding insurers by the states.
Indu Bhushan, chief executive of Ayushman Bharat, said CGHS and Rashtriya Swasthya Bima Yojana (RSBY) rates have been used as reference prices for fixing the rates under the scheme. “However, the rates under the new scheme are on an average 15-20% lower than that of CGHS,” Bhushan said. Lower prices mean beneficiaries of the scheme will be able to opt for more number of procedures under the cover if required or can even enrol more family members for treatment.
Besides, it is expected to reflect in a major drop in health expenditure and set new pricing standards, which, in turn, will create pressure on healthcare providers to bring down their rates for general public, healthcare experts said.
The health insurance scheme aims to cover nearly 50 crore beneficiaries from over 10.74 crore “deprived” families as per socio-economic and caste census (SECC) data with an annual health cover of Rs 5 lakh per family per year. This cover will take care of almost all secondary care and most tertiary care procedures. There is no cap on family size and age in the scheme, ensuring that nobody is left out.

The basic risk cover includes hospitalisation expenses such as registration, nursing and boarding charges in general ward. Besides, consultation fees, surgical equipment and procedure charges and cost of implants, medicines, diagnostic tests and food to patients are also covered. The scheme also covers follow-up care along with pre- and post-hospitalisation expenses.

In case of multiple surgeries, the highest package rate will be waived for the first treatment, and 50% and 25% of the package rate will be provided for the second and third treatment. The rest will be borne by the policy holder.

Prime Minister Narendra Modi is expected to launch the scheme on August 15. Bhushan said the scheme also entails added incentives for private hospitals, especially those providing quality services. “If a hospital is certified by NABH for entry level, it can get 10% more, whereas those certified for advanced level will get 15% more as incentive. Besides, we also want to give advantage to hospitals in lagging areas and such hospitals will get an additional 10%,” he said.

Bhushan said IT infrastructure is the backbone of the scheme and currently the ministry is working to put that in place so that hospitals and providers from across the country can be brought on the platform. The IT platform, to be launched by July, has been modelled on the existing health insurance portal for Telangana.