Contents

A. Project Report with Budgets and ApprovalsI. Megha Health Insurance Scheme Phase I: 1st May 2013 to 31st July 2015

i. Enrollment Report on MHIS I May 2013 –July 2015.ii. Enrollment Figures.

iii. Challenges faced during enrolment.iv. Hospital Empanelment MHIS I May 2013 – July 2015.v. Some of the Challenges face by Public/Private Hospital.

vi. MHIS’s cover consists of four components.vii. Claims Utilization

viii. Claims Reports from Public and Private Hospitalsix. Average Claims Size in Public and Private Hospital

Project Report with Budgets and Approvals

Megha Health Insurance Scheme is unique, the first time that such an all-encompassing government-sponsored universal health insurance scheme is being implemented for every household in the state. The first six months of implementing the Megha Health Insurance Scheme was challenging. The team displayed exemplary dedication and commitment in planning and implementing the project. Initial awareness and enthusiasm among the people was low. There was a lot of resistance to the project.

Megha Health Insurance Scheme Phase I: 1st May 2013 to 31st July 2015Enrollment Report on MHIS I May 2013 –July 2015: Enrolment for the scheme was scheduled to start by mid-January 2013. With the announcement of the dates for Meghalaya Assembly Elections 2013 and the enforcement of the Electoral Code of Conduct, enrolment was postponed to the month of March 2013. Following are the start dates of enrolment in all the eleven (11) districts of Meghalaya with the blocks and villages mentioned:

Sl. No. Enrolment Start Date District Block Enrolment Station1 18th March 2013 East Khasi Hills Mawkynrew Thynroit2 18th March 2013 South West Garo Hills Betasing Bainapara3 05th April 2013 West Garo Hills Dalu Barengapara & Chaipani4 06th April 2013 Ri Bhoi Umsning Umsning A and B5 08th April 2013 West Jaintia Hills Amlarem Amlarem6 16th April 2013 East Jaintia Hills Khliehriat Khliehriat7 16th April 2013 South West Khasi Hills Mawkyrwat Mawlangwir8 17th April 2013 East Garo Hills Samanda Kalak Songgital9 17th April 2013 West Khasi Hills Nongstoin Porsohsat

10 18th April 2013 North Garo Hills Resubelpara Jampara & Geneng11 18th April 2013 South Garo Hills Baghmara Arapara & Dabram

With the scheme being universal, targeting all the genuine residents of Meghalaya, enrolment was taking place in all the districts simultaneously. As of the 18th April, 2013, enrolment had gone live in all districts of Meghalaya. From the first start date of 18th March 2013, it took a month for the Insurance Company ILGIC to go live in all the districts. The total Data of MHIS I May 2013 – July 2015 is 486695 (Four Lakhs Eighty Six Thousand Six Hundred and Ninety Five) House Hold and the total Enrolled is 199815 (One Lakh Ninety Nine Thousand Eight Hundred and Fifteen) House hold.

Enrollment Figures:

Sl. No. District Total Data Enrolled House-Hold Total Enrolled (%)Total Enrolled HH( % )

(minus 10% Govt Employees )

1 East Khasi Hills 149,673 51,815 35 382 South West Garo Hills 37,477 19,054 51 563 West Garo Hills 48,535 16,361 34 374 Ri Bhoi 42,260 20,677 49 545 West Jaintia Hills 42,774 23,465 55 616 East Jaintia Hills 20,337 11,532 57 637 South West Khasi Hills 19,407 8,053 41 468 East Garo Hills 24,094 8,250 34 389 West Khasi Hills 44,456 17,565 40 44

10 North Garo Hills 33,307 14,479 43 4811 South Garo Hills 24,375 8,564 35 39

Meghalaya 486,695 199,815 41 46

East Khasi Hills

South West Garo

Hills

West Garo Hills

Ri Bhoi West Jaintia

Hills

East Jaintia

Hills

South West Khasi

Hills

East Garo Hills

West Khasi Hills

North Garo Hills

South Garo Hills

0

5

10

15

20

25

30

35 31

810 9 9

4 4 59

75

12

4 4 5 53 2 2

4 3 2

Total State Data % against Total Enrolled in the District %

Total Data % Total Enrolled Data %

Here were some challenges faced during enrolment, some of which are unique to Meghalaya: Data inconsistency in the beneficiary list was one of the most important issues faced by the implementing

agencies. Villages didn’t appear in the correct districts. One complete block was shown in a different district, the problem

was acute, particularly in the newly formed districts where there is data mismatch with the parent district Population was often different on the ground from what was mentioned in the list. For instance, the list would

say that the population of a particular village was 20 people. However, when the team visited the village, they would find 50 people. Sometimes, headmen of villages refused to allow enrollment unless the entire village population was enrolled.

The heads of the families mentioned in the list were often different from actual heads. In some cases, the head of the family had passed away, making it difficult to enroll the family.

The households were defined as per the house number, but often more than one family was staying in a house. Power shortages in remote areas made it necessary to carry 50-kilogram batteries along with the enrolment kits.

Many remote villages did not have motorable roads due to rough terrain, so the kits had to be carried physically for 4 to 5 hours and this became very difficult during the monsoon seasons.

Because of unsatisfactory previous experiences with RSBY, some village headman did not allow enrolment in their villages.

Of the three months of the enrolment period, heavy rains prevented the enrolment process for one whole month

Since villagers in Meghalaya have free access to healthcare dispensaries and PHCs, they did not understand the need for MHIS I May 2013 – July 2015. The benefits, including the fact that they would no longer have to pay for medicines, had to be explained to each beneficiary.

Superstition beliefs had affected the enrolment up to 10 % of target households. Militancy issue also affected the enrolment in some part of the State.

It took a combination of determination and hard work to spread the message through radio programs, village meetings, door-to-door visits, and talking to influencers such as village headmen. Communications in this hilly state with remote villages is not ideal, so NGOs and others were also involved. Training had to be provided to government doctors and staff to ensure that procedures were followed. Incentives were provided, and a lot of hand-holding was needed to teach them on how to work with the insurance company.

Hospital Empanelment MHIS I May 2013 – July 2015:

ICICI Lombard General Insurance Company Ltd. is the insurance company identified to implement the Megha Health Insurance Scheme Phase One; it was selected through a rigorous competitive bidding process.

The State Nodal Agency along with the Insurance Company had empaneled 147 Public Hospitals in Meghalaya and 11 Private Hospital out of 14.

The scheme provides residents of this remote north-east state access to hospitals across the rest of India, with a special focus on social protection by covering expensive diseases such as cancer, heart diseases, trauma, critical care, and catastrophic hospitalization which cause economic hardship and financial stress. The team had identified common and the most visited hospitals by patients from Meghalaya across the country for the treatment of critical illness and a total of 13 Private Hospitals were empaneled with the Scheme. Further, cancer and critical illness covers are available only in MHIS I May 2013 – July 2015 -empaneled hospitals and not all over India.

108 PHCs (100 percent of total available in state) 28 CHCs (100 percent of total available in state) 11 District hospitals out of 12 (91 percent of total available in state) 11 Private hospitals in Meghalaya out of 14 (91 percent of total available in state) 13 Private hospitals outside state for critical care (as against none before)

Some of the Challenges face by Public/Private Hospital:

Most of the Hospital are not technically equip with the hardware. Internet Connectivity is an issue throughout the state. Power shortage is an issue in most remote areas. Hospital Knowledge of the software was a challenge since most of the hospital are new to the system. Most of the Private Hospital are complaining about the Package rates which is very low. Packages rates is not as per the most prevailing diseases in Meghalaya.

Under MHIS I May 2013 – July 2015, a family of up to five members is entitled up to Rs. 1,60,000 coverage for fully cashless hospitalization across India. The premium of Rs. 31 per family is paid by each family enrolled and is valid for a year. Cashless medical treatment is thus available for every Meghalaya resident at all public / private hospitals in the state, as well as empanelled private hospitals across the country. There is no age limit and pre-existing diseases are also covered under this insurance scheme.

MHIS’s cover consists of the following four components:

Base Cover (Rs 30,000): To meet hospitalization expenses for medical and surgical procedures. No pre-authorization needed. Claims processed online according to standard package rates pre-determined by the Government of India.

Replenishment Cover (Rs. 30,000): Additional cover to meet hospitalization expenses for medical and surgical procedures, once the base cover is fully utilized. No pre-authorization from the insurance company needed. Claims processed online according to standard package rates pre-determined by the Government of India.

Cancer Cover (Rs. 30,000): Additional cover to meet expenses for cancer treatment, once base and replenishment covers are fully utilized. Pre-authorization from the insurance company needed.

Catastrophic Illness Cover (Rs. 70,000): Additional cover for treatment, procedure, or intervention for catastrophic illnesses (the list includes approximately 20 identified catastrophic illnesses), provided hospitalization expenses are over Rs. 30,000 and base, replenishment and cancer covers are first utilized. Pre-authorization from the insurance company needed.

MHIS I May 2013 – July 2015 covers 'end-to-end' hospitalization costs, including a day’s pre-hospitalization costs (15 days for catastrophic illnesses), post-hospitalization costs for 5 days (30 days for catastrophic illnesses), transport expenses of Rs. 100 per incidence, and economic loss compensation of Rs. 100 per incidence. For critical illness, transport expenses remains the same, but economic loss compensation is Rs. 900 per incidence.

Beneficiaries: MHIS I May 2013 – July 2015 provides insurance cover to the whole resident population (non-BPL: 1,78,300 households and BPL: 3,60,000 households) enrolled in Meghalaya’s voters’ list, excluding state and central government employees, who are already covered. Beneficiaries are identified on the basis of voter ID cards issued to heads of households.

Insurance cover: MHIS I May 2013 – July 2015 provides an effective cover up to Rs 1,60,000 per household (up to five members on a floater basis) through a professional insurance service provider. The cover is provided through a private insurance company identified after a competitive bidding process. ICICI Lombard General Insurance Company Ltd. won the tender for the first year.

Diseases covered: MHIS I May 2013 – July 2015 covers all diseases covered under RSBY. It also covers specific conditions that create tremendous pressure on family finances such as trauma, cancer, and heart disease.

Relevance to beneficiaries: MHIS I May 2013 – July 2015 provides for effective treatment of frequently occurring diseases in Meghalaya, including cancer, heart diseases, and trauma cases (catastrophic diseases).

Incentive for utilization: Incentive schemes for doctors and nurses ensure higher utilization of government health service centers (pull factor). Payments to patients for wages lost loss ensure higher utilization of cards (push factor).

Strategies adopted for bringing about the transformation and positive impact: Given the unique geography of Meghalaya and the culture of its people the team knew early on that innovative solutions would be needed to solve difficult issues on the ground. Early on, the International Finance Corporation (IFC), a member of the World Bank Group, was roped in to provide technical assistance in design and implementation of the project. IFC worked seamlessly with central and state governments, integrating vast experience from across the globe, to provide solutions to complicated problems. Here are just a few of them.

Creating an accurate beneficiary list: The team successfully conducted a never-before attempted exercise to create a list of all 4.8 lakh beneficiary families in the state numbering almost 30 lakh people. This list was drawn up with the help of International Finance Corporation which drew upon the World Bank Group’s profound knowledge of social health insurance. IFC roped in the best global health insurance experts to help design and implement the programme. Novel and innovative data analytics techniques were used to merge multiple databases available with various government departments. This is ground-breaking technology into action, and can be replicated as MHIS I May 2013 – July 2015 moves ahead. Additionally, the processes and algorithms created are versatile enough to be used in other states that need to generate similar comprehensive lists of beneficiaries.

Demonstrating success: To successfully implement innovations, it is critical to demonstrate success even if the solution is not always fully ready. The team designed a simpler roll out in the first phase, focusing on key innovations while leveraging several components of the existing RSBY scheme, such as its IT smartcard platform. This way, several teething problems were avoided.

Incentivizing project participants: It was critical to ensure that all stake-holders would work together to make the project a success. Incentives for participants had to be carefully designed to ensure this. The team cross-fertilized insurance experiences with skills in designing incentives in PPP contracts to design incentives for:

Community workers to mobilize citizens; Insurance company to go to remote parts to enroll people; Public doctors to proactively serve patients who choose public hospitals; Private hospitals not to ask patients for informal payments; Poor patients to seek healthcare, by compensating them for economic loss.

MHIS May 2013 – July 2015, Claims Utilization:

The Policy Period for MHIS I start from 1st May 2013 to 30th April 2014 and it was further extended with the same Insurance Company from 1st May 2014 to 31st July 2015

Below is the claims reported of Beneficiaries claiming from all 11 Districts:

PATIENTS DISTRICT MALE FEMALE TOTAL AMOUNT CLAIMEDEAST GARO HILLS 289 451 740 2,878,131EAST JAINTIA HILLS 891 1900 2791 9,001,465EAST KHASI HILLS 3567 7969 11536 49,679,375NORTH GARO HILLS 572 1103 1675 6,172,850RI BHOI 1666 3281 4947 18,638,014SOUTH GARO HILLS 720 1105 1825 6,520,125SOUTH WEST GARO HILLS 1396 3023 4419 17,465,904SOUTH WEST KHASI HILLS 324 775 1099 4,488,027WEST GARO HILLS 540 1089 1629 7,655,564WEST JAINTIA HILLS 1583 4026 5609 21,155,382WEST KHASI HILLS 1596 4017 5613 22,768,854NON-MEGHALAYA MEMBERS 32 17 49 239,500Grand Total 13176 28756 41932 166,663,191

EAST GARO HILLS

EAST JAINTIA

HILLS

EAST KHASI HILLS

NORTH GARO HILLS

RI BHOI SOUTH GARO HILLS

SOUTH WEST GARO HILLS

SOUTH WEST KHASI HILLS

WEST GARO HILLS

WEST JAINTIA

HILLS

WEST KHASI HILLS

0

5

10

15

20

25

30

2

7

28

4

12

4

11

3 4

13 13

District Wise Claims %

The Claims portions of Male and Female shows that 68.57 % of claims by number are from females, demonstrating higher utilization by females than males at 31.42%.

The hard work and initiative by the team and stakeholders eventually paid off, MHIS I May 2013 – July 2015 is on auto-pilot. The villagers have started to see others get the benefits of the scheme and now come forward to enroll themselves. Health workers are invited

to speak at village meetings.

Claims by Private & Public Hospital: Average claim size similar across government and private hospitals, the reports shows that

52.15 % of claims by number is from Private hospitals 47.63 % of the claims by number is from Public hospitals 0.22% of claims by number is from Private Hospitals outside Meghalaya More than 97 government hospitals have raised claims as of 31st July 2015. Private Hospital Total Claims 21866 Total Amount Claimed Rs 95572746 Public Hospital Total Claims 19973 Total Amount Claimed Rs 69029068 Private Hospital Outside Meghalaya Total Claims 93 Total Amount Claimed Rs 2061377 (Critical Illness

Treatment)

*o/s – Outside Meghalaya

Female

Male

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

68.57%

31.42%

Male & Female Utilization %

Public Hospital Private Hospital Private Hospital o/s Megh0.00

10.00

20.00

30.00

40.00

50.00

60.00 47.63

52.15

0.22

Public & Private Hospital Claims Uti-lization%

Claims Reports from PHC/CHC/District Hospitals/Private Hospitals in Meg/ Private Hospitals Outside Meghalaya: 1st May 2013 to 31st July 2015

Member District PHC CHC DH PVT in Meghalaya PVT o/s Meghalaya

Female Male Total Pt

Amount Claimed Female Male Total

Pt Amount Claimed Female Male Total

Pt Amount Claimed Female Male Total

Pt Amount Claimed Female Male Total

Pt Amount Claimed

EAST GARO HILLS 123 65 188 748375 133 79 212 604775 155 123 278 1143106 40 21 61 281875 0 1 1 100000EAST JAINTIA HILLS 43 44 87 108650 666 310 976 1570275 270 143 413 1188000 921 389 1310 6060540 5 5 74000EAST KHASI HILLS 543 135 678 1930515 394 149 543 1326050 1478 927 2405 11738956 5539 2350 7889 34211954 15 6 21 471900NORTH GARO HILLS 429 194 623 2170000 400 238 638 1525025 197 99 296 1574075 93 46 139 1062919 4 11 15 366000RI BHOI 343 190 533 1343000 852 495 1347 4305450 754 387 1141 4276875 1316 569 1885 7907920 8 12 20 463100SOUTH GARO HILLS 212 161 373 1308250 188 126 314 865000 579 362 941 3359875 125 70 195 964000 2 1 3 29000SOUTH WEST GARO HILLS 253 80 333 1094000 1080 478 1558 4285280 776 389 1165 6000124 938 455 1393 6359512 2 5 7 135000SOUTH WEST KHASI HILLS 14 8 22 34500 229 120 349 827000 123 50 173 820600 411 156 567 2881627 0 0 0 0WEST GARO HILLS 215 86 301 1501000 147 80 227 435000 356 171 527 2722687 365 196 561 2775500 5 7 12 215377WEST JAINTIA HILLS 175 42 217 687750 132 46 178 379375 878 422 1300 4139875 2815 1061 3876 15510370 1 1 30000WEST KHASI HILLS 161 51 212 403500 48 38 86 161000 921 380 1301 4284125 2870 1109 3979 17484029 3 5 8 177000NON-MEGHALAYA MEMBERS

0 0 0 0 1 0 1 2500 10 27 37 164500 6 5 11 72500 0 0 0 0

Grand Total 2511 1056 3567 11329540 4270 2159 6429 16286730 6497 3480 9977 41412798 15439 6427 21866 95572746 39 54 93 2061377

Average Claims Size in Public and Private Hospital:

34564371

22165

Average Claims Size - MHIS I May 2013 - July 2015

Public Hospital Private Hospital Private Hospital o/s Meghalaya

Budget & Approvals for MHIS 2013 - 2015:

Budget for MHIS is prepared on an annual basis only on the state share component only, since Central Share is paid to the State when requisition is made against the Invoice raised by the Insurance Company. State Share is budgeted on the 10% RSBY Component and 100% of the MHIS component. Budget is estimated only on the total Premium layout of the Scheme for a financial year of the State Share, taking into account all categories. The following is taken into consideration for budgeting.

• The Estimated percentage of enrollment.

• Rate of premium (which is estimated as per the current market trends)

The total budget is the total premium payable for the total estimated enrolled households. In order to run the scheme, the requirement for expenses like salary of staff, furniture & equipment, office supplies etc that are required to run the scheme on a day to day basis are sustained out of the ₹ 30/- (being the 1 st installment of premium) collected from beneficiaries at the time of enrollment.

Budget for MHIS I 2013 to 2014:- 95511570/- Budget for MHIS I 2014 to 2015:- 102598447.83/-