Introduction
Employees
Health Scheme(EHS) is formulated to offer cashless treatment to the personnel,
pensioners of the nation authorities and their dependent circle of relatives
participants, to ipso facto update the prevailing scientific repayment gadget
underneath the ‘Andhra Pradesh integrated scientific Attendance policies, 1972
(APIMA rules, 1972)’, with additional advantages such as post-operative care
and treatment of chronic sicknesses, which do now not require hospitalization
and treatment in impaneled Hospitals.
Objective
Employee
health Scheme is formulated to provide a cashless remedy to the employees,
pensioners of the country authorities, and their established circle of
relatives participants, so that it will ipso facto replace the prevailing
medical compensation machine underneath the ‘Andhra Pradesh included clinical
Attendance guidelines, 1972 (APIMA rules, 1972)’, with additional benefits
consisting of post-operative care and remedy of continual diseases, which do
now not require hospitalization and treatment in impaneled Hospitals.
IMP Stakeholders in the Scheme
Beneficiaries:
The Scheme is supposed to benefit Serving employees and Retired employees of
the state.
Dr.YSR Aarogyasri Health Care Trust(AHC):
Dr.YSR
Aarogyasri Health Care considers will implement the Scheme under the
supervision of the government of Andhra Pradesh.
Steering Committee below the chairmanship of the leader
Secretary to the government will evaluate the implementation of the Scheme once
in a while. The Steering Committee will meet as often as required, discuss,
screen, and evaluation the Scheme, gain programs, grievances, and satisfaction
of hospital therapy which includes the modalities of a personnel health belief.
the overall administration (offerings & HRM) branch will have difficulty
orders forming the steering Committee with 50% participants from employees and
pensioners institutions, and 50% members from the government.
Network Hospitals – provider vendors:
A fitness care provider shall be a health facility or nursing home in Andhra
Pradesh set up for indoor medical care and treatment of disease and injuries
and have to be registered underneath Andhra Pradesh non-public Allopathic
scientific institutions (Registration & law) Act and Pre-idea and Pre-Natal
Diagnostic strategies Act (wherever applicable).
Software Company – Technology Answers:
A devoted actual-time online workflow device was designed with the aid of the
belief in an effort to deliver dynamism and decentralization of work like
online processing of the cases beginning from registration of case at a
community health facility, pre-authorization, remedy, and different services on
the medical institution, discharge and post-treatment follow-up, claim
agreement, price gateway, accounting gadget, TDS deductions, e-office answers
and so forth. The protection of the workflow is accomplished around the clock.
Eligible beneficiaries:
Serving personnel:
All ordinary state government employees. A country government worker can have
the means as described under essential regulations.
Provincialized personnel of nearby bodies.
Retired personnel:
All carrier pensioners
circle of relatives pensioners with dependents
Re-hired carrier Pensioners
Beneficiaries now not covered:
- Folks that are included underneath other insurance schemes which include CGHS,
- ESIS, Railways(RLY), Aarogya Bhadratha of Police department(ABPD), and Aarogya
Sahayatha of Prohibition & Excise department(ASPEX). - Regulation officers (advise well-known, country Prosecutors, national Counsels,
government leaders, and Public Prosecutors). - Informal and daily paid workers;
- Organic mother and father if adopted dad and mom exist;
- All impartial children; and
- AIS officials and AIS pensioners.
Own family:
The subsequent will represent the circle of relatives:
- Based on mother and father (either adoptive or organic, but not each).
- One legally wedded wife in case of a male employee(ME)/ service pensioner(SP).
- Husband in case of a female employee/ provider pensioner.
- Thoroughly dependent valid youngsters (along with step youngsters and followed
children); and - Dependents of own family pensioners shall additionally be eligible as inside
the case of carrier Pensioners.
Dependency:
In the case of dad and mom, individuals who are dependent on the employee for
his or her livelihood.
In the case of unemployed daughters, those who are single or widowed or
divorced or abandoned.
In the case of unemployed sons, folks who are under the age of 25 years
Disabled kids with a disability which renders them unfit for employment.
Authentication:
The eligible beneficiaries can be supplied with fitness playing cards also
called eligibility cards.
The system of verification of eligibility of beneficiaries underneath the
scheme will be by means of online authentication of the health Card details.
The beneficiary shall provide both the eligibility card and the cardboard
number in case the card is unavailable. The body of workers at the kiosk inside
the community clinic shall affirm the information online by using having access
to the database. As soon as the authentication is whole, the eligibility
verification ends.
Penal actions:
Any irregularities or misuse dedicated through the beneficiaries coming to the
notice of the presidency or Dr. YSR AHCT will entail disciplinary movement
according to A.P. C.S. (CCA) policies, 1991, and can entice penal action as in
line with the law.
Benefit coverage
In-patient remedy:
The scheme will offer Inpatient treatment for the listed treatment plans for
diagnosed sicknesses underneath all specialties within the impaneled hospitals.
list of IP therapies and healing procedures
Package deal consists of the
subsequent services:
stop-to-quit cashless carrier provided thru an NWH from the time of reporting
of a patient until ten days publish discharge remedy, together with headaches
if any as much as thirty (30) days post-discharge, for those sufferers who go
through an “indexed remedy(ies);
loose OP assessment of patients for indexed treatments who won’t undergo IP
treatment which includes consultation and investigations
Follow-up Services Offerings:
Comply with-up services are supplied for a length of one year through constant
programs to the patients who require long-term observe-up remedies so that it
will get most fulfilling enjoy the method and keep away from complications.
follow-up bundle includes sessions, investigations, capsules, and many others.,
for three hundred and sixty-five days for indexed treatment plans. listing of
IP treatments
Outpatient remedy for diagnosed chronic illnesses:
OP treatment for pre-defined lengthy-term (chronic) sicknesses will be provided
in notified hospitals.
Hospital/clinic stay:
The eligibility for Slab-A (inclusive of personnel with Pay Grades from I to
IV), and Slab B (together with personnel with Pay Grades from V to XVII) will
be semi-personal ward, and for Slab- C (along with employees with Pay Grades
from XVIII to XXXII) could be personal ward.
Financial Coverage
- The personnel, pensioners, and their
structured circle of relatives contributors may be eligible for a sum of
Rs.2.00 lakhs (Rupees lakhs best) per episode of contamination with no
restriction on the variety of episodes as current in APIMA guidelines, 1972.
but, within the cases where the value of treatment exceeds Rs.2.00 lakhs,
cashless treatment will retain. No community health center shall deny the
remedy in such cases. - The restriction of Rs.2.00 lakhs will no longer follow in instances wherein
predetermined bundle prices are above Rs.2.00 lakhs. - Chief executive Officer, Dr.YSR Aarogyasri Fitness Care consider will settle
the claims which exceed Rs.2.00 lakhs, following the standard claims agreement
system after obtaining the approval of the Technical Committee constituted with
the aid of the authorities.
Financing:
- 50% of the total amount can be borne by using government and 50% by means of
the employee/pensioner contribution. - The monthly contribution could be Rs.225/- (for Slab A such as personnel with
Pay Grades from I to IV, and Slab B which includes employees with Pay
Grades(PG) from V to XVII) and Rs.300/- (for Slab C inclusive of emp with Pay
Grades(PG) from XVIII to XXXII). The Pay Grades for the three Slabs below
different Pay Scales, along with university grants fee Pay Scales, maybe those
equivalents to the corresponding Pay Grades underneath the country authorities.
The contribution for carrier pensioners or family pensioners can be in step
with the existing Pay Grade of the publisher from which the pensioner retired
from the provider. - If each of the spouses are government employees or service Pensioners,
contribution by using anybody of the spouses is sufficient. In such a case, the
applicant shall give a declaration to the effect that the alternative partner
is a government employee/provider Pensioner, duly indicating the worker Code /
Pensioner Code of the alternative partner. - The expenditure in walking the Scheme and Scheme revel can be reviewed at the
end of six months and revision of contribution effected hence.
Network Hospital
Empanelment:
Recommendations for the empanelment of hospitals in the country and outside,
reauthorization, and different modalities at the same time as implementing the
scheme might be in conformity with the prevailing widespread tactics being
accompanied by Dr.YSR Aarogyasri Health Care believe. The listing of impaneled
hospitals may be made available inside the reliable internet site locate-health
center
Hospital Payments:
payments below the scheme could be based totally on permitted bundle prices.
Penal actions:
Impaneled hospitals resorting to irregularities or misuse shall be blacklisted
and the entire amount recovered except launching crook motion.
Patient Process Flow
Mode of OP capture(OP)
A beneficiary tormented by a disorder can method any of the subsequent ”
first factor of contact ” for registration below the scheme. The mode of
OP(out-patient) capture is directly at the NWH in case of emergencies or
through referral.
OP Process flow at the NWH(OPNWH)
Arrival: The beneficiary arrives at the NWH kiosk both with a referral card or
with a grievance for registration.
Registration: NAM first mandatorily registers the affected person. In case the
affected person is a baby(kids), the affected person’s identification and
complaint are registered. OP is registered and OP price tag issued.
OP session: an affected person is forwarded to the OP and receives counseling
to envision the eligibility below Scheme. Investigations are prescribed if
required.
Investigations: He thereafter moves to the research centers if required,
receives tests, and returns to the doctor. If he can be handled as an OP case,
a prescription is given. The diagnosis and prescription are entered within the
device by NAM and the case is disposed of.
uncovered OP system: If the affected person’s remedy warrants the use of any of
the uncovered OP, MEDCO enters the details inside the gadget and refers the
case to the government health center.
IP registration: If the patient’s treatment warrants the use of any of the
listed remedies, the MEDCO enters the info of technique and Investigations
inside the machine, converts the case to IP, and despatched to the ward
involved (semi-personal or personal based totally on the eligibility) and
increases preauthorization.
Evaluation and Admission
After the initial evaluation of the patient, the patient is admitted if needed
and evaluated similarly. The patient may be evaluated as an out-affected person
to begin with and after ascertaining the prognosis and finalization treatment
mode admitted and transformed as an “in-affected person” in the
online workflow.
Final diagnosis and categorization
After the evaluation of the affected person:
If the affected person is found to be stricken by listed cures, MEDCO shall
publish the pre-authorization via the believe portal within 24 hours.
If the affected person is determined to be suffering from diseases aside from
people who can not be managed within the NWH or are now not included in the
listed treatments, he will be counseled and stated nearest suitable sanatorium
for further control.
Pre-authorization
MEDCO shall upload all of the applicable documents and ship the case for
pre-authorization.
Treatment
The NWH shall render the whole treatment to the patient after obtaining
pre-authorization. Any headaches arising throughout the direction of
hospitalization shall additionally be attended to.
Discharge
The affected person is discharged after complete recovery. The NWH shall
problem discharge precis, 10 days put up-discharge medicinal drug, recommend
the affected person for observe-up. A letter of fine offerings shall be
received from the beneficiary at the time of discharge.
MEDCO shall add the files.
Follow-up
the patient will be supplied comply with-up offerings as consistent with the
same old clinical norms duly counseling and recording the same in the discharge
summary.
The observe-up packages supplied below the scheme will be applied for this
motive to provide cashless compliance with-up services.
Declare Claim submission
The NWH will improve the claim after the 10 days of first-class discharge of
the patient.
Emergency Registration and Admission
All the beneficiaries will be admitted via an NWH and handled right now. MEDCO
or treating doctor shall obtain emergency telephonic pre-authorization thru
devoted spherical the clock cellphone strains of the agree with if the patient
is affected by indexed healing procedures.
If the patient is stricken by illnesses aside from indexed treatments he must
be counselled and facilitated safe transportation to the nearest government
hospital.
If the patient’s circumstance warrants moving him to a better center, safe
shipping shall be facilitated to different NWHs if suffering from indexed
treatments.
| Category | Status |
|---|---|
| Health Card Status | |
| Meeseva application_pensioners | |
| EHS / Treatments Search | |
| Follow Up Packages | |
| State Empanelled Hospitals | |
| Check Treatment History | |
| Know Your Aarogya Mithra |
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