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Tamil Nadu, which has integrated the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) with the Centre’s Ayushman Bharat scheme, has submitted 1.25 lakh claims so far totalling ₹274 crore. United India Insurance, the State’s insurance partner for the earlier CMCHIS, currently charges a premium of ₹699 per cover, which is borne by the State (under Ayushman, it is split between the Centre and the State in 60:40 ratio for 77 lakh beneficiaries).
The existing tender comes up for renewal in 2022. The fact that the State’s health scheme has been in operation for over seven years, and claims have more or less stabilised, lends comfort on the premium front. But integration of Ayushman with CMCHIS is likely to increase awareness and also lead to substantial rise in claims over the next two to three years. This could bump up premium costs significantly when the tender comes up for renewal.
A wider coverage
Tamil Nadu’s CMCHIS offered a coverage of ₹1 lakh to ₹2 lakh per year for specified procedures for those with an annual income of less than ₹72,000. Under Ayushman (PMJAY-CMCHIS), while about 77 lakh beneficiaries must be covered as per SECC data, the State covers close to 1.47 crore families for up to ₹5 lakh according to the income criteria.
According to the existing tender, which is up to 2022, the insurance company will take care of specified procedures up to the sum insured of ₹1 lakh or ₹2 lakh. For uncovered procedures beyond the sum insured, reimbursement will be done by the State.
As awareness increases and claims shoot up, premium costs could go up over the next two to three years. Currently, the overall utilisation has been 3-4 per cent over the past few years – that is, of the 1.4 crore families – about six lakh have been availing benefits under the CMCHIS every year. If utilisation moves up to 5-6 per cent, premiums could go up substantially.
Mitigating factors
However, there are some factors that lend comfort. Ayushman covers 1,393 procedures, while CMCHIS covered 1,027 packages.
About 335 packages fall under both schemes, while 635 are covered in one and not the other. All three types – totalling 970 – are clubbed and covered under the new integrated health scheme called PMJAY-CMCHIS.
“The remaining 423 packages (1,393 less 970) have been reserved only for government hospitals. These are mainly low-end procedures. The re-jigging of the packages in such a way ensures minimal burden on the insurer as the procedures reserved for government hospitals are zero packages,” explains Selvavinayagam.
This implies that these procedures will be free for a patient, but the government hospital will not get reimbursed for this. “With the high-volume low-end procedures pushed to government hospitals, the misuse is also reduced,” adds Selvavinayagam.
High-end specialised procedures that were already covered under CMCHIS continue under Ayushman, hence, capping the extent of revision in premium. The top claims in the State have been related to high-end procedures such as cardiology and renal.
The State agreeing to bear the burden of excess claims also helps cap the premium, adds Prema Mukilan, Chief Manager, United India Insurance.
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