Health Insurance Government Scheme XI

In this Post of Health Insurance Government Scheme XI , We will describe scheme run by Mizoram State Government

• Mizoram State Health Care Scheme

Mizoram State Health Care Scheme

Mizoram State Health Care Scheme (Health Insurance Government Scheme XI)  was Implemented in April 2008. The Objectives of this scheme is to provide quality medical care facilities which include hospitalization and surgery through an empaneled network of hospitals for families.

Initially, The Scheme was introduced on Public Private Model between the Government, Insurance companies and the third-Party Administrator and the network of empaneled hospital (public and private). However, Things does not work out due to dissatisfaction and lack of flexibility in claims payment to the beneficiaries. Thus, The Society has Started on Self Finance basis since 2011.

To take care of all the people of Mizoram, The Government of Mizoram established the Mizoram State Health Care Society as the Innovator. RSBY (Rashtriya Swasthya Bima Yojana) is linked with MSHCS as a top-up to RSBY.

Here RSBY is implemented through an Insurance Company and the MSCHS is being Implemented in Self-Finance Basis and they both combine to form one Scheme.

 

Vision of this Scheme

The vision of this Scheme are as follows

• It improves access to quality healthcare.
• It protects the people/families from huge healthcare expenditure thus helps in reduction of misery.
• It reduces financial hurdle to health care. It means that even a poor people can have an access to quality medication.
• Rashtriya Swasthya Bima Yojana has been linked with MSHCS to give extensive health insurance coverage. MSCHS provides top-up cover for RSBY Beneficiaries up to Rs 2.70 lakhs, It means that the total health insurance cover is Rs. 3 Lakhs (MSHCS+ RSBY= 0.30 + 2.70 lakhs= 3.0 Lakhs). It also covers sum of Rs. 3 Lakhs for Above Poverty Line families for identified Critical Illness.

 

 Benefits of this Scheme

Some of the Benefits with this Scheme is mentioned below

• This Scheme Provides Hospitalization and Surgical Procedures Expenses for BPL Beneficiaries up to Rs.70,000/ per family per year (It is on floater basis which means that the sum assured amount can be utilized individually or collectively whole family). RSBY also covers Rs. 30,000/.
• For BPL families, The Sum Assured amount of Rs. 70,000/ is given for normal cover and Rs. 2,00,000/ amount is given for Critical Illness and RSBY cover Rs. 30,000/ (So Total Amount for Critical Illness for BPL families is Rs 3 Lakhs). For APL families, Sum of Rs. 3 Lakhs is given only in terms of critical Illness
• Travel Expense with one Attendant is covered up to Maximum of Rs. 1000 per claim within State and Rs. 10,000 Outside the State.
• This Schemes also cover Pre and Post Hospitalization. Here the Medical expenses are covered from the 01st day of Hospitalization and up to 10 days after discharge from hospital. The Pre-Hospitalization coverage also include all Pre-Admission Investigation.  However, in case of Organ Transplantation, The Post Hospitalization coverage is extended to 30 days.
• This Scheme covers All Pre-existing diseases/treatment procedures with minimal prohibition or exclusion are given. Eg: Vaccination, Sterilization and Fertility related procedures, Condition that do not require hospitalization and that can be cured in home, Dental treatment, Disease/Injury/Infection directly or indirectly caused by nuclear weapons, Cosmetic or Aesthetic treatment of any kind, Cost of spectacles, contact lenses or hearing machine etc.
• This Schemes covered Maternity and New Born Child for BPL Beneficiaries and New Born Child for APL families.
• This Schemes cover for dependents and family members who lives in the same roof.
• The health care services are now treated on day care basis and the Scheme covers such procedures on day care (OP)

Some of the List of Day care Services covered

 

Epilepsy	Surgery of Prostate	Surgery of Nose, Ear & Throat
Hepatitis B&C	Dental Surgery following Accident	Lithotripsy
Drug Resistant TB	Genital Surgery	Surgery of Hydrocele
Hysterectomy	Surgery of Hernia	Any Surgery under General Anesthesia
Laparoscopic therapeutic surgeries	Treatment of fractures/dislocations, contracture releases and minor reconstructive procedures of limbs which require hospitalization	Any disease/procedure mutually agreed upon by the Society before treatment
Dialysis	Surgery of Urinary System	Gastrointestinal Surgery
Radiotherapy	Surgery of Appendix	D&C (not MTP)
Parental Chemotherapy	Eye Surgery

List of Critical Illness

Some of the List of Critical Illness are as mentioned below

• Cardiologic & Cardiothoracic Surgery: They perform Heart and Chest Surgery. It is the conjugation of Cardiologist (who performs complete evaluation) and Surgeons (Who take care of Surgery). Eg-By-Pass Surgery, Pacemaker Implantation (Temporary ad Permanent), Angioplasty etc.
• Oncology:  It is exclusive to the Diagnostic and treatment of cancer like Tumors, Chemotherapy etc.
• Nephrology: They care and treat kidney disease. Eg: – Kidney Failure which require Replacement Therapy
• Respiratory System: It basically deals with the Organ and tissues that help you to breathe. Eg: Lung Disease, Pneumothorax, Respiratory Failure.
• GI Tract: It is called Gastrointestinal Tract. The Organs that consist of the following process like swallowing food (mouth, throat, esophagus), Digestion (Stomach), Absorption (small Intestine, Large Intestine) and leave the body through excretion (Anus).
• Endocrinology: Science of treating disorders of Hormonal Imbalances like Diabetes, Thyroid etc.
• CNS: It is also called Central Nervous System consist on brain and spinal cord. Eg: – CNS Infections, Hydrocephalus, Myelopathies etc.
• Hepatology: It basically deals with the Management and disorders of livers, gallbladder, biliary tree, pancreas etc.
• Hematology: It generally diagnose and treat problems related blood and its structures. Eg: -Hemophilia, Aplastic, Sickle Cell Anaemia etc.
• Infective Diseases: Diseases which are infected through Organism like Bacteria, Fungi, Parasites, Virus. Eg: – Malaria, Tuberculosis
• Connective Tissue Disease: As the name Suggest, It attack/affect the parts of the body that connect the structures of the body together.
• Organ Transplant: Here the Healthy Organ is removed from the body and is planted into the infectious body
• Urology/Nephrology: It generally deals with the Urinary Tract (Kidneys, bladder, ureters & urethra) of the human body While Nephrology deals with diseases of kidneys.
• Plastic Surgery:  Eg- Burns, Skin Grafting etc.
• Gastroenterology: It basically deals with the digestive system disorders. Eg- Appendicitis, Volvulus etc.
• Neurology And Neurosurgery:  They are specialized about disorders regarding nervous system. However, Neurologist do not perform Surgery. It is only doe by Neurosurgeon.
• Ophthalmology: It cares and remove problems associated to the eye disorders. Eg: – Eye Surgery, Laser Treatment, Retina, Glaucoma etc.
• ENT:  ENT means Ear, Nose and Throat. It basically cures the problems of this (Ear, Nose and Throat) disorders. Eg: – Hearing Lost Implantation, Complicated Sinus Surgery etc.
• Orthopedic Surgery: The Surgery are devoted to Bones, Joints, Ligaments, Tendons, Muscles related disorders. Eg: – Hip/Knee Surgery, Fractures of Bones and Joints, Repair of Ligaments
• Dermatology: It take care of Skin, Hair and Nail .Eg:- Fungus Infection, All variants of Pemphigus
• Psychiatry:  It treats mental health disorders. Eg: – Depressive Disorder, Bipolar Disorder, Schizophrenia, Dementia etc.

 

 How to Claim for the Payment

You have to submit details for Claims Submission, Pre-Authorization and Referrals. This format is designed by the Innovator and are used. Hospital submit Claims, the innovator, after processing it sends the paid claims back to the hospital for further disbursement to the patients. Payment is done according to the Government details. The average Turn-around Time for Payment is 15 days with a standard deviation of 10 days.