Rashtriya Swasthya Bima Yojana (RSBY) Benefits, Eligibility Criteria and Claim Settlement

What is Rashtriya Swasthya Bima Yojana (RSBY)?

RSBY full form is Rashtriya Swasthya Bima Yojana and it was initiated in the year 2008 by the Ministry of Labor and Employment. The scheme was aimed at offering best health facilities as well as social security to people or families living under the line of poverty. The government initiated the scheme to limit the medical expenditure done out-of-the-pocket by the families living under the poverty line as well as to enhance awareness and access to health facilities.

Insurance Coverage available under Rashtriya Swasthya Bima Yojana

The insured sum available as family floaters under RSBY swasthya bima is Rupees 30,000, which allow coverage for 5 family members of a BPL family. Along with treatment charges, the scheme also allows 100 rupees transportation charges for single trip to the network hospital. Once a BPL family enrolls, they can start getting treatment starting from the following month from the date of enrollment.

Benefits of RSBY Scheme

Under the Rashtriya Swasthya Bima Yojana Scheme, the members of BPL families and unspecified sector workers’ can choose to get health care facilities either from government hospitals or from a private hospital.

So, this scheme allows the insured to get good access to treatment in good hospitals. This is because the scheme allows  significant revenue to healthcare providers or hospitals.

Eligibility Criteria of RSBY Scheme

Below are the criteria of eligibility to avail health benefits under Rashtriya Swasthya Bima Yojana Scheme:

• The workers of unorganized sectors who belong to BPL families are eligible under the scheme.
• Also, individuals registered under different welfare boards can avail benefits under this scheme.
• RSBY schemes do not have any upper limit for individuals to apply for the RSBY scheme.
• Irrespective of age, the scheme suits all family members.
• This scheme is available for everyone eligible.
• It can benefit almost a third of India’s population.

Procedure of Claim Settlement under RSBY

Below are the steps to claim Swasthya Bima Yojana:

• As soon as the treatment of the insured under the scheme is over, the TPA or Third Party Administrator or a government representative receives a report from the enlisted hospital.
• The TPA looks through the report and pays the hospital bill as per the time frame that is agreed upon between the insurer and the enlisted hospital.

Access Scheme with Smart Card

When an individual under BPL household receives the policy, a smart RSBY card is offered to them, which is used by the insured to avail treatment at any network hospital across India registered under the scheme. All network hospitals under this scheme allow cashless hospitalization and treatment to the beneficiary on getting RSBY card check online.

Financing for RSBY

Since RSBY is a central government sponsored initiative, especially crafted for the BPL families in the country, so 75% of finances are offered by the central government, while the remaining 25% is offered by the state government of the respective states that the insured belongs to.

However, in case of J&K and the North-eastern states, the central govt. contribution is 90%, while only 10% is contributed by the state govt. The insured families are only required to pay Rs. 20 as registration fee, which is used by the government as administrative cost incurred under the Yojana.

How the Health Insurance Provider is selected under this scheme

It is done through a process of public bidding initiated by state governments. Through this bidding, the government selects IRDA approved insurance providers (both public and private).  The bid act as the annual premium to cover BPL families under the scheme.

The Government of India sets coverage benefits for BPL families through cashless treatment at network hospitals by availing smart cards. The insurer has to agree to the cover and benefits fixed by the government. One district has a single insurer who works through the district, while a state can have more than one insurance company.

Process to do Empanelment of Health Insurance Companies under this scheme

The government selects the health insurance provider based on the bidding process as mentioned above. Once the selection of the insurer is done, the selection of the network hospitals is also done because all or most of the network hospitals of the insurer come under the RSBY scheme as agreed by the government and the insurer.  It is the responsibility of the health insurance company to allow enough government and private network hospitals to Rashtriya Swasthya Bima Yojana hospital list 2022, so that more benefits can be availed by the insured.

All the network hospitals enlisted under this scheme must have a committed RSBY desk with qualified officials. The insurer is also expected to offer a list of network hospitals under RSBY scheme while a BPL family registers for the scheme.

How Beneficiaries Utilize the Services Under RSBY Scheme – Rashtriya Swasthya Bima Yojana Benefits

To utilize the services under RSBY, the insured should visit a RSBY help desk in a network hospital. Once the insured reaches the desk, his identity is verified with the help of a smart card via photograph, fingerprints, etc.

If the insured requires hospitalization, the help desk official checks the procedure for ensuring the amount with the price available from the insurer. At the time of the insured getting discharged from the hospital, his/her smart card gets swiped to deduct the cost of treatment from the card.