News Analysis

Tamil Nadu tops the claims charts under Ayushman scheme

Radhika Merwin BL Research Bureau | Updated on January 11, 2019 Published on January 11, 2019

The State covers about 1.47 crore families, which is double the number targeted by the flagship insurance scheme

Tamil Nadu, which has integrated its Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) with the Centre’s flagship Ayushman Bharat scheme, has submitted the largest amount of claims totalling ₹159 crore so far, with Gujarat a close second with ₹153 crore. While Tamil Nadu ranks third in terms of number of claims (at about 90,300) trailing Chhattisgarh (1.24 lakh) and Gujarat (1.05 lakh), a higher average claims of about ₹17,600 per beneficiary, has put the State on the lead spot. The average claim per patient at the aggregate level for the country as a whole is about ₹13,000. A wide coverage under Ayushman, thanks to large number of families already covered under the Tamil Nadu’s CMCHIS, has helped. Ayushman provides ₹5 lakh cover to deprived rural families and identified occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data.

According to this, about 77 lakh beneficiaries must be covered under Ayushman in Tamil Nadu. However, close to 1.47 crore families are being covered upto ₹5 lakh in the State, as it chose to enhance the cover for all beneficiaries under the earlier CMCHIS. The State’s scheme offers coverage of ₹1 lakh to ₹2 lakh per year for specified procedures for people with annual income of less than ₹72,000.

“Beneficiaries not included under Ayushman, but under the CMCHIS have also been extended the enhanced ₹5 lakh cover, the cost of which will be borne by the State,” says TS Selvavinayagam, additional director of Public Health and Preventive Medicine.

Insurance/hybrid model

For a beneficiary nothing much changes, as he has to produce the CMCHIS card to claim benefits under Ayushman. At the back-end though, the burden of the enhanced cover for larger number of beneficiaries will fall under the State. United India Insurance, which is the State’s insurance partner for the earlier CHCHIS, will cover only specified procedures up to to the sum insured of ₹1 lakh or 2 lakh. “As per 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,” explains Selvavinayagam.

The State has retained its package rates under the earlier CMCHIS rather than going with those under Ayushman, which has led to seamless empanelments of hospitals for Ayushman.

Currently Tamil Nadu (at about 1,700 hospitals) ranks second after Gujarat in terms of number of empanelments.

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