High-value claims to be 32% of Modicare payout

NEW DELHI: Payouts for high-value claims under Ayushman Bharat over Rs 30,000 and those categorised as very high value of Rs 1 lakh and above are likely to cross Rs 2,300 crore this year as the medical insurance of Rs 5 lakh a year for poor families picks up pace. High- value claims are likely to account for 32% or almost one third of payouts.
About 36,000 households have claims exceeding Rs 1 lakh and 354 households have already exhausted the 5 lakh limit by May 2019, a data analysis by National Health Authority shows depicting a better coverage of advanced care.So far, over 9.3 crore beneficiary e-cards have been generated and over 37.7 lakh hospital admissions were recorded under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana.
The mean claim size is around Rs 13,000, and half of all the pre-authorised claims are below Rs 7,000. Seven percent claims are in high value category and just 1% in the very high category since the scheme was launched last year. The NHA is working to tighten scrutiny and checking fraud, but statistics suggest most claims are in low and medium categories, in keeping with the more usual needs of beneficiaries.

Launched in September last year, the schemes intend to reach nearly 50 crore people from 10.74 crore ‘deprived’ families selected on the basis of SECC data. NHA’s estimates high- value claims to cross Rs 1,800 crore in 2019, whereas very-high-value claims (those exceeding Rs 1 lakh) are likely to exceed Rs 500 crore. The analysis points to the need to step up efforts to reach women beneficiaries and certain states.
Trends so far reflect high-value claims are tilted towards male beneficiaries, cardiology services and cardiac surgery packages, private hospitals and brownfield states where similar schemes were running but with a lesser coverage limit ranging between Rs 50,000 to Rs 3 lakh.
The scheme’s higher cap offering greater financial protection has led to coverage of more advanced care, it also points towards challenges including larger financial outlays, higher stakes in the fight against unnecessary care and fraud.
“We are pleased to note the scheme has provided effective financial protection to many families. However, we need to expand the reach of the scheme,” Ayushman Bharat chief executive Indu Bhushan said. High-value claims are more prevalent among children under 5 years and those above 50 years, which are known to bear a higher disease burden. Beneficiaries of high-value claims are predominantly male with women accounting for only 38% of high-value claims.