National Health Insurance Scheme (NHIS): Eligibility, Features, & Benefits

Posted on: Dec 26, 2024 | 3 mins | Written by: HDFC ERGO Team

National Health Insurance Scheme (NHIS): Eligibility, Features, & Benefits

The cost of healthcare has been rising steadily in recent years, making it increasingly difficult for many to access quality treatment. This poses a significant challenge for economically disadvantaged individuals and families with limited financial resources. To address this, the Government of India introduced the National Health Insurance Scheme (NHIS), an important initiative aimed at improving access to health insurance and quality healthcare for the underprivileged. The scheme comprises several health insurance plans, including the Rashtriya Swasthiya Bima Yojana (RSBY), Central Government Health Scheme (CGHS), Employees’ State Insurance Scheme (ESIS), Aam Aadmi Bima Yojana (AABY), and Ayushman Bharat – National Health Protection Mission.

To further this mission, the Central Government, in collaboration with the National Knowledge Commission and the Ministry of Health and Family Welfare, has also developed a National Health Portal, providing comprehensive information on healthcare. Let’s talk about NHIS health insurance plans in detail.

Popular Programs under the National Health Insurance Scheme India

The following are some popular programs or health plans under the National Health Insurance Scheme —

1. Rashtriya Swasthiya Bima Yojana (RSBY)

The Rashtriya Swasthiya Bima Yojana (RSBY) is a health insurance scheme launched by the Ministry of Labour and Employment to provide financial protection to families living below the poverty line. It aims to offer affordable health insurance coverage to these families, helping them access essential healthcare services and recover more quickly.

The features and benefits of the RSBY scheme are —

• It covers unrecognised sector workers and their families. A maximum of five family members can be covered, including self, spouse, and three dependents.

• The scheme offers a total sum insured of INR 30,000 per family per annum.

• Policyholders can receive cashless treatment at any network hospital by presenting their NHIS ID card.

• The policy covers the hospital bills for most common illnesses, with some exclusions.

• Both public and private sector hospitals are incentivised to treat policyholders under the scheme.

• The scheme also covers pre-existing conditions with no age restrictions.

• Transportation costs of up to INR 100 per visit will be covered within an overall limit of INR 1000.

• The government pays policy premiums on behalf of the insured. The beneficiary must pay only INR 30 per annum as the registration/renewal fee.

2. Central Government Health Scheme (CGHS)

The Central Government Health Scheme (CGHS) was launched in 1954. For the past 7 decades, it has been delivering comprehensive medical care to Central Government Employees and pensioners covered under the scheme. CGHS addresses the healthcare needs of eligible beneficiaries from all four pillars of India’s democracy – Legislative, Executive, Judiciary and Press. Serving as a primary healthcare provider for Central Government employees and pensioners, CGHS stands out due to its large beneficiary base and its flexible approach to delivering healthcare services.

The features and benefits of the Central Government Health Scheme are:

• It covers Allopathic treatments as well as alternative remedies, such as Homeopathy, Ayurveda, Unani, Yoga, and Siddha.

• The scheme covers hospital bills, expenses incurred in medical tests, home healthcare bills, the cost of medications, consultation with specialised doctors, and more.

• It offers cashless medical treatment to beneficiaries.

• CGHS has more than 40 lakh beneficiaries from over 80 cities across the country.

3. Employees’ State Insurance Scheme (ESIS)

The Employees’ State Insurance Scheme (ESIS) is a social security and health insurance program designed to provide financial and healthcare support to employees and their dependents during medical emergencies. The scheme was launched in 1952 and is currently available in 33 states and Union Territories across the country. However, the scheme is implemented on an area-specific basis across all states except for Sikkim, Manipur, Mizoram, Arunachal Pradesh, and the Union Territories.

The following are the features and benefits of the Employees’ State Insurance Scheme (ESIS):

• The scheme ensures cash benefits to policyholders in the event of a health emergency, death due to occupational hazards, employment injuries, temporary or permanent disabilities, and more.

• The ESIS is applicable for non-seasonal factory workers, provided the factory employs more than 10 individuals.

• The policy also covers employees in shops, hotels, restaurants, cinemas, newspaper establishments, and road-motor transport enterprises employing more than 20 workers.

4. Aam Aadmi Bima Yojana (AABY)

Launched in 2007, the Aam Aadmi Bima Yojana (AABY) scheme is administered by the Life Insurance Corporation of India (LIC). This government-sponsored social security scheme works towards providing life insurance coverage to rural and unorganised sector workers. It mostly targets low-income families, offering financial protection in the event of death or disability due to accidents.

The features and benefits of the Aam Aadmi Bima Yojana (AABY) scheme are —

• The scheme covers individuals who work in unorganised sectors, such as agriculture, dairy, handloom, fishery, construction, and other similar occupations.

• The enrolment process is quite simple, and individuals can enrol for the scheme at any time of the year.

• It provides a life insurance cover of INR 30,000 in the event of death due to any reason. Additionally, it provides a sum of INR 37,500 in case of partial disability and INR 75,000 in case of total permanent disability due to an accident.

• The scheme also covers natural calamities like floods and earthquakes.

• The premium of the scheme is quite affordable, with the government contributing a significant portion.

• The policy is typically valid for one year and can be renewed annually.

• The scheme offers additional benefits for women, including maternity coverage and provisions for female-headed households.

5. Ayushman Bharat – National Health Protection Mission (AB-NHPM)

The Ayushman Bharat – National Health Protection Mission (AB-NHPM), also known as Pradhan Mantri Jan Arogya Yojana (PMJAY), is a flagship health insurance scheme launched by the Government of India. It aims to provide affordable healthcare to millions of vulnerable families across the country.

The following are the features and benefits of the Ayushman Bharat – National Health Protection Mission (AB-NHPM) —

• The scheme provides hospitalisation coverage of INR 5 lakhs per family per year. This includes coverage for a wide range of medical conditions, surgeries, and treatments.

• The beneficiaries can opt for cashless treatment at any public/private empanelled hospital around the country.

• The scheme covers pre-existing conditions from day one.

• It covers up to 3 days of pre-hospitalisation bills and 15 days of post-hospitalisation expenses. These include diagnostic tests, follow-up procedures, and more.

• The scheme offers coverage for about 1400 medical procedures.

National Health Insurance Scheme Registration Process

The following is the registration process for the National Health Insurance Scheme —

1. Eligibility check: The first step is to confirm eligibility for the scheme. The insurer is provided with a list of eligible BPL families, government employees, pensioners, and other specific groups depending on the scheme.

2. Enrolment schedule: With the help of the district-level officers, the insurance company then prepares an enrolment schedule for every village. The list of eligible households is posted at enrolment stations and other important places in the village. The date and venue for enrolment are published in advance and mobile enrolment stations are also set up in various government-designated centres.

3. Filling the application form: The eligible individuals and families must fill out the application form with the required details. These forms are available at the enrolment stations/registration centres as well as online. They must also submit the required documents and passport-sized photographs. The enrolment stations may also collect the biometric information of insurance seekers.

4. Payment of registration fee: The beneficiaries must pay a nominal registration fee to complete the application process. Once they have paid the fee, they will receive a smart card authenticated by a government official. This smart card provides personal identification and helps beneficiaries store their medical data for easy access.

The enrolment officers also give a pamphlet containing information about the scheme and the list of empanelled hospitals.

5. NHIS ID card: After completing the registration process, the beneficiaries receive an NHIS ID card containing important details, like the beneficiary’s name, family members covered, and the validity period of the insurance. This card is essential for availing of cashless treatment at network hospitals and health centres under the scheme.

Conclusion

Summing up, the National Health Insurance Scheme (NHIS) play a vital role in providing affordable healthcare to various sections of society, especially those with limited financial resources. The scheme provides comprehensive coverage, which includes benefits for critical illnesses and accident benefits, ensuring financial protection during medical emergencies. This easily accessible and affordable scheme focuses on promoting the overall welfare of society.

If you are concerned about rising healthcare costs, staying covered under a health insurance policy and critical illness insurance can help. These insurance products can help cover your medical bills and ease your financial burden, especially during expensive hospitalisations.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.

Aarogya Raksha Scheme: Eligibility, Benefits, and Coverage

Saansad Adarsh Gram Yojana (SAGY) Scheme Explained

ECHS Scheme 2024: Benefits, Eligibility & Latest Updates

17 Types of Government Health Insurance Schemes in India

Central Government Health Scheme (CGHS)