1. MEGHA HEALTH INSURANCE SCHEME
(RSBY+UHIS)

2. Presentation Flow
• Introduction
• MHIS (RSBY+UHIS)
• Participation of Public Hospitals
• Claims
• Progress of facilities
• IEC initiative
• Other Support Structure- Grievance Redressal……
• MIS structure

3. State profile - Meghalaya
Population 2964007
Total No. of Districts 11
Total no. of Blocks 39
Capital Shillong
Languages
Khasi, Pnar, Garo and
english
Literacy 75.48%
Total Households 768332
District Hospitals 11
Community Health
Centres 28
Primary Health Centres 108
ASHA 6258

4. Meghalaya in Images

5. Megha Health Insurance Scheme is a universal health insurance scheme in the
State of Meghalaya, utilizing the existing RSBY framework to provide health
insurance to all persons that are resident in the State, including existing categories
of RSBY beneficiaries.
Brief Description:
•Covers all residents of Meghalaya(APL as well as BPL) except government employees
•Covers all diseases covered by RSBY. Additional cover for critical care i.e. trauma cases,
cancer and heart diseases.
•Provides cover up to INR 160,000 (USD 2,667) per household (up to five members) with
a maximum claim size of INR 100,000 (USD 1,667)
•Inclusion of 20 day-care procedures, 70 tertiary-care packages and 1087 secondary-care
packages
•Provides transport expenses of INR 100 and economic loss compensation of INR 100
(INR 900 for critical care).
•Dedicated agency with 18 FTE under Department of Health and Family Welfare, set up
for implementationof MHIS-1
A Brief on MHIS

6. District Programme Officer
(11 nos.)
Finance &
Accounts
Manager
Jt. CEO
IT
Manager
Enrollment -
IEC Manager
Grievances
Redressal
Manager
Monitoring
& Control
Officer
Claims
Officer
State MHIS MgerState MHIS Manager
FKO
CEO - MHIS
Nodal Agency
►Formation of a state level MHIS State Agency to managethe programme
►The structure formed for the MHIS State agency as shown below

7. Enrolled HH v/s Data touch

8. Progress of MHIS - Comparison of empanelled facilities
6
20
14
11
28
108
District Hospital CHC PHC
Public Facilities
MHIS
RSBY

9. Public Hospitals empanelled with MHIS
 Empanelled Hospitals
• 11 DistrictHospitals
• 28 Community Health Centres
• 108 Primary Health Centres
In addition
10 Private hospitals inMeghalayaand13 Private hospitals (Critical Care) outside Meghalayahave alsobeen
empanelled

10. • Incentive structure for doctors and staff of Public health facilities
• IEC/ awareness initiatives
• Timely settlement and payment of Claims by Insurance company
• Capacity building of staff of DH/CHC/PHC and constant support
from the staff of SNA
• Regular monitoring of DH/CHC/PHC
• Regular follow up and monitoring with regards to Claims and
payment/rejection of claims
• Monitoring of Insurance Company for regular claims settlement
• Increased facilities in public hospitals because of the use of the 70%
infrastructure fund
• In Several areas FKO’s (ASHA) motivate the patients to utilise MHIS
smart card in public facilities
• Provision of transportation charges and reimbursement of
medical/lab bills motivates beneficiaries to utilise the smart cards
Main Reasons for participation of Public facilities

11. Sl.No Incentive for Staff (Case base) 50%
1 Surgeon/MainPhysician/Doctortreating the case 25%
2 Surgeon assisting the surgery/other physician/doctors involvedin
treating the case/ else will go to main doctor
10%
3 Anaesthetist/Doctorsof other dept. actively involvedin case
management through case referrals/ else will go to administrativepool
15%
Sl.No Incentive for Staff (Shared out to the rest of the staff from the remaining
pool)
50%
4 Consultations/call duty,etc (if amountnot sufficient, money from
unspent amount from item 3 above can be given)
5%
5 Staff Nurses 12%
6 Nursing Asst & HospitalAttendant (Grade I&II) 8%
7 Lab Tech 5%
8 X Ray/ Ultra Sound Scanners/CT/ECG/ScanTechnician 5%
9 AdministrativePool(including) Record keeping/ System Management 10%
10 PRO1 5%
11 TOTAL (of the 30% of the claims received through MHIS) 100%
100 % Claims : 70% for Infrastructure & 30% for Staff
MHIS I: Incentive Method in Public Hospitals

12. 12
MEGHA HEALTH INSURANCE SCHEME
MHIS I: Claims Raised
 No of Hospitals raising Claims
61 Public Hospitals in Meghalaya
9 Private hospitalsin Meghalaya
3 Private (Critical Care) hospitalsoutside Meghalaya
 Public Hospitals
No. of patients– 5928
Amount of Claim raised – ₹ 2,62,93,186
 Private Hospitals
No. of patients– 10314
Amount of Claim raised – ₹ 5,42,5,2706
 All Districts are Raising Claims

13. 13
MEGHA HEALTH INSURANCE SCHEME
MHIS I: Average Claim Size ( Public Hospitals)
13.66%
62.13%
16.96%
4.89%
1.85%
0.36% 0.10% 0.05%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
0 -1000 1001 - 5000 5001 - 10000 10001 - 15000 15001 - 20000 20001 - 25000 25001 - 30000 30001 +
Average Claims Size - Public Hospitals
Amountin INR

14. 14
MEGHA HEALTH INSURANCE SCHEME
MHIS I: Average Claim Size ( Private Hospitals)
13.98%
54.68%
18.48%
5.78%
3.64%
0.92% 0.10%
2.42%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
0 -1000 1001 - 5000 5001 - 10000 10001 - 15000 15001 - 20000 20001 - 25000 25001 - 30000 30001 +
Average Claim Size - Private Hospitals
Amount in INR

15. 15
MEGHA HEALTH INSURANCE SCHEME
MHIS I: Claims as per package (Public Hospitals)
0.02% 0.03% 0.02% 0.02%
5.98%
2.20%
20.74%
65.18%
0.02%
4.66%
0.07% 0.47% 0.08% 0.03% 0.44% 0.05%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Packages Percentage

16. 16
MEGHA HEALTH INSURANCE SCHEME
MHIS I: Claims as per package (Private Hospitals)
0.03% 0.15% 0.01% 0.21%
3.00% 4.34%
18.44%
66.59%
0.77% 0.04% 0.05% 0.22%
4.31%
0.69% 0.10% 0.22% 0.15% 0.03% 0.64%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Packages Percentage

17. 17.41%
63.36%
1.05% 1.05%
3.58%
1.30% 1.34%
10.90%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Malaria Fever Infected
Wound
Gastric Chest Pain Chronic
Obstructive
Pulmonary
disease
Acute
Pancreatitis
Diarrhoea &
Vomiting
Medical Diseases Percentage
MHIS I: Percentage of Medical diseases

18. Tura Civil Hospital
No. of MHIS patients - 542
Amount of Claims raised - 3535625
 Purchased Laptop(MHIS),
Xerox machine, cupboard
from MHIS infrastructure
fund
 Tie Up with pharmacy for
purchase of medicines not
available in hospital
 Free investigation from
private labs for MHIS
patients
Improved Services – District Hospitals
Forms to be filled by Lab or pharmacy
for reimbursement by hospital

19. Improved Services – District Hospitals
NongpohCivil Hospital
Amount of claims raised - 86375
 Utilised funds for
purchase of furniture
 Improving facilities at the
hospital

20. Improved Services – CHC
Ampati CHC
No. of patients – 702
Amount of claims raised - 2469750
 Purchase of new mobile
phone for upload of data
 Tie Up with pharmacy for
MHIS patients
 Purchase of Medicine rack
 Improvement of
infrastructure at hospital
 Purchase of wheel chair, x
ray film and other
equipment needed at
facility

21. Improved Services – CHC
Bhoirymbong CHC
No. of Claims –
Amount of claims raised -
 Purchased a laptop from
MHIS fund
 Purchase of electrical
wires for provision of
electricity
 Tie up with pharmacy, for
provision of medicines

22. Improved Services – PHC
Tikrikilla PHC
No. of MHISpatients – 98
Amount of claims raised - 511000
 Purchase of mobile (2G) for
raising claims
 Construction of canteen for
beneficiaries from
infrastructure fund
 Tie up with pharmacy, for
provision of medicines.
 Plans to indent medicines for
diseases prevalent in the area
like malaria
 Organisedawareness through
cricket tournaments

23. Improved Services – PHC
LaitlyngkotPHC
No. of Claims –
Amount of claims raised -
 Purchase of tanks for
water storage
 Purchase of medicines
from pharmacy
 Purchase of lab reagents
for various tests
 Purchase of utensils
 IEC activities

24. Improved Services – PHC
Nogorpara PHC
No. of Claims – 53
Amount of claims raised - 278000
 Purchase of desktop for
MHIS
 Proposed to purchase
washing machine for PHC
 Construction of canteen
at the facility

25. For staff of public hospitals
Subtitle of RSBY Hospital training film
Pamphlet about MHIS and incentive structure
Incentive Training workshops for doctor and staff
of all Public hospitals
TMS software training at hospitals
For Beneficiaries
Pamphlet about scheme
Leaflet about utilisation of card and list of
hospitals
Various IEC materials indicating public hospitals
empanelled with the scheme
Make them know about availability of public
hospitals
IEC initiatives

26. Grievance Redressal
CALL CENTER : 1800-345-3644
To providesupportthrough toll free for any enquiries and
complaints
GrievanceRedressalcommittee to address grievances of
beneficiaries ,hospitals etc and to make suregrievances
and complaints are being address within the giving time
frame
Feedback fromHospital, Beneficiary to improvethe service
of the scheme as well as the hospitals
Follow up with beneficiary and hospital ( pre-post
hospitalization)

27. MIS STRUCTURE - Enrolment DATAflow
Enrolment
station
Third Party
Administrator
SNA
server
MIC data
District
server
District DKMA
data
Ministry of
Labour & Employment
Insurance
Company
Excel
Report
SNA Finance
Department
Extraction of
Data from all
sources

28. MIS STRUCTURE – Claims data flow
TPA – TSE
ICICI Lombard Claims Processing Dept
District MHIS
Account
DPM
TPA
Server
SNA
Server
RSBY Server
Connection Available
Hospital Directlyuploadto Servers
Connection Unavailable
Data Email / Write onCD
DataProcessingbyILGIC
Details of Claims –
Rejected or approved
ManualPre-authorisationforms
Directpaymentofsettledclaims
forhospitalswithonlinefacilities
Claims Settled/Rejected
Settled Claims Report
Rejected/ApprovedClaims
ClaimsMoneytransferto
DistrictAccountforhospitlas
withoutonlinefacilities
ChequeofSettledClaims
DPMSettleClaimstoPHC/CHCbyCheque
Raw Data for reports
State Nodal
Agency
Analyseddata -
ClaimsReport
Claims
Officer

29. THANK YOU

30. 30
MEGHA HEALTH INSURANCE SCHEME
Sl. No. Hospital Female Male Total
Amount Claimed
(Rs.)
Amount Settled
(Rs.) (as of
31.03.14)
1 ShillongCivil Hospital 400 543 943 51,82,956 40,81,775
2 Ganesh Das Hospital Shillong 308 24 332 21,11,325 21,13,625
3 Pomlum PHC 11 1 12 28,875 11,750
4 Mawsynram CHC 153 62 215 5,69,100 4,81,800
5 Dangar PHC 1 0 1 2,500 2,500
6 Ryngku PHC 0 3 3 5,000 3,000
7 Pynursla CHC 61 24 85 2,45,000 2,45,000
8 PongtungPHC 11 0 11 26,000 5,000
9 Jatah PHC 59 29 88 2,77,775 2,70,925
10 Sohra CHC 15 9 24 57,875 44,625
11 Laitkynsew PHC 3 1 4 26,000 10,000
12 Laitlyngkot PHC 30 6 36 1,62,000 1,45,000
13 Swer PHC* 20 1 21 84,500 26,000
14 MawryngknengPHC 28 2 30 94,250 39,250
15 MawphlangPHC 0 1 1 1,000 0
16 Tura Civil Hospital 291 253 544 35,63,125 32,39,625
17 MCH Hospital Tura 297 16 313 15,43,905 13,74,624
18 Tikrikilla PHC 73 25 98 5,11,500 3,96,000
19 Pedaldoba PHC 44 12 56 6,63,500 5,96,500
20 Dalu CHC 19 1 20 90,250 48,750
21 Kherapara PHC 3 2 5 9,500 4,500
22 Phulbari CHC 1 1 2 2,000
23 Mellim PHC 1 0 1 2,500
24 Nongstoin Civil Hospital * 91 49 140 2,04,375 2,08,875
25 Tirot Sing Memorial Hospital Mairang 142 41 183 5,89,125 1,56,000
26 Markasa PHC 52 10 62 1,39,500 1,32,000
27 Kynshi PHC 15 2 17 41,000 14,000
28 RiangdoCHC 9 13 22 38,750 38,000
Grand Total 10,885 5,357 16,242 8,05,45,892 7,11,23,429
MHIS I – Claims (Hospital Wise)

31. 31
MEGHA HEALTH INSURANCE SCHEME
Sl. No. Hospital Female Male Total
Amount Claimed
(Rs.)
Amount Settled
(Rs.) (as of
31.03.14)
29 Ampati CHC 476 226 702 24,69,750 23,82,125
30 BetasingPHC* 57 31 88 2,88,000 2,71,500
31 Nogorpara PHC* 45 8 53 2,78,000 2,86,500
32 Zikzak PHC 9 3 12 40,750 17,500
33 Salmanpara PHC 1 0 1 4,500 4,500
34 Nongpoh Civil Hospital 33 29 62 86,875 78,750
35 BhoirymbongCHC 206 126 332 20,80,750 19,72,500
36 UmsningCHC 32 9 41 1,27,125 53,000
37 Kyrdem PHC 77 40 117 5,04,375 4,03,750
38 Umden PHC 54 23 77 1,39,000 1,31,000
39 Williamnagar Civil Hospital 4 0 4 10,500 3,500
40 Samanda PHC 7 0 7 17,625 7,000
41 Bansamgiri PHC 12 1 13 52,625 16,500
42 RongjengCHC 2 0 2 3,000
43 Jowai Civil Hospital 270 128 398 12,25,000 12,07,375
44 ShangpungPHC 52 18 70 2,39,750 3,13,500
45 NartiangPHC* 28 10 38 2,49,500 60,500
46 Laskein CHC 13 5 18 37,000 0
47 Kharkutta PHC 55 7 62 2,84,500 2,33,500
48 Wageasi PHC 45 13 58 3,01,125 99,000
49 Adokgre PHC 1 0 1 2,500
51 Resubelpara CHC 2 0 2 4,000 1,500
49 Mendipathar PHC 7 1 8 38,875 11,000
50 Gabil PHC 13 5 18 71,500 65,000
52 Khliehriat CHC 25 5 30 74,000 26,000
53 Sutnga CHC 15 5 20 36,000 13,000
54 Baghmara Civil Hospital 93 56 149 4,62,500 4,15,625
55 Siju PHC 52 21 73 2,90,000 2,08,000
56 Nangal Bibra PHC 1 0 1 3,500 3,500
57 Chokpot CHC 37 32 69 2,18,000 1,77,000
58 Rongara PHC 4 0 4 8,000 3,500
59 Sibbari PHC 4 1 5 14,000 9,000
Grand Total 10,885 5,357 16,242 8,05,45,892 7,11,23,429
MHIS I – Claims (Hospital Wise)

32. 32
MEGHA HEALTH INSURANCE SCHEME
Sl. No. Hospital Female Male Total
Amount Claimed
(Rs.)
Amount Settled
(Rs.) (as of
31.03.14)
60 Mawkyrwat CHC 81 37 118 3,46,125 2,80,000
61 Ranikor CHC 5 1 6 11,250 6,000
62 MT Bawri Nethralaya Shillong* 49 21 70 4,34,612 4,55,087
63 Bansara Eye Hospital Shillong 221 130 351 17,67,280 16,70,405
64 The ChildrensHospital Shillong* 61 56 117 5,00,500 1,28,000
65 Dr. H.G.RobertsHospital Shillong 986 506 1,492 79,39,376 75,39,169
66 Nazareth Hospital Shillong 3,144 1,386 4,530 2,40,27,884 1,97,87,467
67 Dr.Norman Tunnel Hospital Jowai 855 342 1,197 48,73,625 43,40,750
68 Holy Cross Health Centre Mairang 854 472 1,326 68,01,277 74,15,852
69 Holy Cross Hospital Tura 564 362 926 58,82,500 56,95,500
70 Tura Christian Hospital 169 77 246 10,85,375 10,08,750
71 Hayat Hospital Guwahati 19 21 40 6,34,877 3,63,500
72 NECancer Hospital & RI - Guwahati 7 9 16 2,54,400 2,17,700
73 GNRC Hospital Guwahati 0 3 3 51,000 51,000
Grand Total 10,885 5,357 16,242 8,05,45,892 7,11,23,429
MHIS I – Claims (Hospital Wise)

33. Progress of MHIS – Inclusion of new packages
MHIS I: Packages specific to Meghalaya have been included
MHIS 2: Further expansion of Packages:
1036
RSBY
(2010-11)
MHIS -1
@ signing of contract
MHIS -1
@ Sept 30, 2013
1288
MHIS 2
288$
1288
1579
106
146
1036
106
1036
125
160
6 MCH

34. 34
MEGHA HEALTH INSURANCE SCHEME
 Empanelled Hospitals:
• 149 Public Hospitals in Meghalaya
• 10 Private hospitals in Meghalaya
• 13 Private hospitals (Critical Care) outside Meghalaya
 Hospitals (Claims Raised):
• 61 Public Hospitals in Meghalaya
• 9 Private hospitals in Meghalaya
• 3 Private (Critical Care) hospitals outside Meghalaya(in Guwahati)
 All Districts are Raising Claims
 Most Public Hospitals of all districts are raising Claims
 16,242 : Total No. of MHIS patients (as of 15th April 2014)
 Rs.8,05,45,892/- : Total Amountof Claims Raised (as of 15th April 2014)
MHIS I: Claims

35. 35
MEGHA HEALTH INSURANCE SCHEME
Sl. No. District Female Male Total
Amount
Claimed(Rs.)
1 East Garo Hills 99 31 130 6,58,981
2 East Jaintia Hills 541 243 784 40,64,365
3 East Khasi Hills 3,236 1,636 4,872 2,38,82,875
4 West Jaintia Hills 1,651 721 2,372 1,07,00,403
5 North Garo Hills 204 75 279 17,07,226
6 Ri Bhoi 1,074 575 1,649 84,43,846
7 South Garo Hills 323 193 516 22,81,875
8 South West Garo Hills 1,286 648 1,934 93,82,762
9 South West Khasi Hills 307 146 453 23,54,415
10 West Garo Hills 483 225 708 46,50,189
11 West Khasi Hills 1,663 835 2,498 1,21,94,955
Non-Meghalayadistricts 18 29 47 2,24,000
Grand Total 10,885 5,357 16,242 8,05,45,892
MHIS I: District Claims (as of 15th April 2014)