Health Insurance Regulation, 2075

Type: Regulation
Year: २०७५ BS
Status: In force
Category: खण्ड १५: स्वास्थ्य · Volume 15: Health
Made under: Health Insurance Act, 2017
Official text: Official page Official text (PDF)

Analysis drawn from official reports, court rulings and published research, each cited. Figures are being double-checked against the source documents; corrections are welcome.

What does it do?

A family of up to five people joins the health insurance programme as one unit; larger families pay extra for each additional member. Government offices must enrol the families of their civil servants and other public employees, and establishments the families of their workers, at five members per unit. Residents of old-age homes, orphanages and similar institutions are enrolled as family units, and each senior citizen aged 70 or over counts as a unit of their own. A worker going abroad must attach a copy of their health insurance card when applying for labour approval, where the programme is in force in their district. People enrol through an enrolment assistant or online.पाँच जनासम्मको परिवार स्वास्थ्य बीमा कार्यक्रममा एक एकाइका रूपमा आबद्ध हुन्छ; ठूलो परिवारले थप सदस्यका लागि छुट्टै योगदान तिर्छ। राष्ट्रसेवकको परिवारलाई निजको कार्यालयले र श्रमिक तथा कर्मचारीको परिवारलाई प्रतिष्ठानले पाँच जना बराबर एक एकाइ मानी आबद्ध गराउनुपर्छ। वृद्धाश्रम, अनाथालयजस्ता संस्थामा आश्रित व्यक्तिलाई परिवार सरह एकाइ मानिन्छ र ७० वर्ष पुगेका हरेक ज्येष्ठ नागरिक छुट्टै एक एकाइ हुन्छन्। कार्यक्रम लागू भएका जिल्लामा वैदेशिक रोजगारमा जाने कामदारले श्रम स्वीकृतिको निवेदनसाथ स्वास्थ्य बीमा परिचयपत्रको प्रतिलिपि पेस गर्नुपर्छ। दर्ता सहयोगीमार्फत वा अनलाइन प्रणालीबाट आबद्ध हुन सकिन्छ। Ministry of Law, Justice and Parliamentary Affairs Rules 3(1)-(6), 4 and 5(1), PDF p. 2
The yearly contribution for the general public is Rs 3,500 for a family of up to five and Rs 700 for each extra person. In the formal sector (civil servants and employees of establishments) the contribution is 2 per cent of the starting salary scale, shared 1 per cent by the employer and 1 per cent by the employee, up to Rs 10,000 a year. The government pays the full contribution for families holding an ultra-poor identity card, families with a member who is severely disabled or has leprosy, HIV or multi-drug-resistant TB, and senior citizens aged 70 or over, and half for families of Female Community Health Volunteers. Contributions are not refunded, but a family that uses no benefit and renews on time gets a 10 per cent discount.सर्वसाधारणका लागि वार्षिक योगदान पाँच जनासम्मको परिवारका लागि रु. ३,५०० र थप हरेक व्यक्तिका लागि रु. ७०० छ। सङ्गठित क्षेत्र (राष्ट्रसेवक र प्रतिष्ठानमा कार्यरत) का लागि सुरुको तलब स्केलको २ प्रतिशत योगदान लाग्छ, जसमा रोजगारदाता र कर्मचारी दुवैले १/१ प्रतिशत तिर्छन् र वार्षिक रु. १० हजारभन्दा बढी हुँदैन। अति गरिब परिचयपत्र भएका परिवार, अति अशक्त अपाङ्गता, कुष्ठरोग, एचआईभी वा जटिल क्षयरोग भएका सदस्य भएका परिवार र ७० वर्ष पुगेका ज्येष्ठ नागरिकको पूरै योगदान र महिला स्वास्थ्य स्वयंसेविकाको परिवारको आधा योगदान सरकारले तिर्छ। तिरेको योगदान फिर्ता हुँदैन, तर कुनै सुविधा प्रयोग नगरी समयमै नवीकरण गर्नेलाई १० प्रतिशत छुट हुन्छ। Ministry of Law, Justice and Parliamentary Affairs Rule 15(1)-(5), Rule 16(1), PDF pp. 5-6; Schedule 1, PDF p. 13
A family of up to five can use services worth up to Rs 100,000 a year, plus Rs 20,000 for each extra member up to Rs 200,000. Senior citizens over 70 have a separate Rs 100,000 for their own use, and an extra Rs 100,000 covers treatment of the diseases listed in Schedule 6. Benefits start from the first day of the third month after enrolment. Membership lasts one year; renewal is requested a month before it expires and must be processed within three days, and renewed members' benefits continue from the renewal date. Spectacles and hearing aids above the Board's limit, most cosmetic surgery and most dental treatment are not covered, and ambulance service is covered only in emergencies.पाँच जनासम्मको परिवारले वार्षिक रु. १ लाखसम्मको सेवा पाउँछ; थप हरेक सदस्यका लागि रु. २० हजारका दरले बढीमा रु. २ लाखसम्म पाइन्छ। ७० वर्ष नाघेका ज्येष्ठ नागरिकले आफूले मात्र प्रयोग गर्ने गरी छुट्टै रु. १ लाख र अनुसूची-६ मा उल्लिखित रोगको उपचारका लागि थप रु. १ लाख पाउँछन्। दर्ता भएको महिनापछिको तेस्रो महिनाको १ गतेदेखि सुविधा लागू हुन्छ। सदस्यता एक वर्षको हुन्छ; अवधि सकिनुभन्दा एक महिनाअघि नवीकरणको निवेदन दिनुपर्छ र तीन दिनभित्र नवीकरण गरिनुपर्छ; नवीकरण भएपछि सुविधा निरन्तर रहन्छ। बोर्डले तोकेभन्दा महँगा चस्मा र श्रवण यन्त्र, धेरैजसो कस्मेटिक सर्जरी र धेरैजसो दाँतको उपचार समेटिँदैन; एम्बुलेन्स सेवा आकस्मिक अवस्थामा मात्र पाइन्छ। Ministry of Law, Justice and Parliamentary Affairs Rule 6(4), Rule 8(1)-(3), Rule 10(1)-(2), PDF pp. 3-4; Rules 13-14, PDF p. 5; Rule 17(2)-(4), PDF pp. 6-7
Insured people must first go to their first service point; if it cannot treat them it refers them to another provider, and in an emergency any listed provider can be used. Hospitals become service providers through a five-year agreement with the Health Insurance Board, which can suspend or cancel it for poor service, false reports or unnecessary referrals. Providers submit claims through the insurance management information system; the Board assesses them and must pay through the banking system within 15 days of finishing the assessment. Providers must run a pharmacy open 24 hours, and the Board can set up a sub-committee to monitor service quality and set maximum prices for listed medicines.बीमितले पहिले प्रथम सेवा बिन्दुबाट सेवा लिनुपर्छ; त्यहाँ उपचार हुन नसके प्रेषण गरिएको सेवा प्रदायकबाट लिनुपर्छ र आकस्मिक अवस्थामा जुनसुकै सेवा प्रदायकबाट सेवा लिन सकिन्छ। अस्पतालहरू स्वास्थ्य बीमा बोर्डसँग पाँच वर्षको सम्झौता गरी सेवा प्रदायक बन्छन्; सेवा नदिएमा, झुटा प्रतिवेदन दिएमा वा अनावश्यक प्रेषण गरेमा बोर्डले सम्झौता स्थगन वा रद्द गर्न सक्छ। सेवा प्रदायकले बीमा व्यवस्थापन सूचना प्रणालीमार्फत दाबी पेस गर्छन्; बोर्डले मूल्याङ्कन गरी मूल्याङ्कन सकिएको १५ दिनभित्र बैङ्किङ प्रणालीबाट भुक्तानी दिनुपर्छ। सेवा प्रदायकले चौबीसै घण्टा खुला फार्मेसी राख्नुपर्छ र सेवाको गुणस्तर अनुगमन तथा तोकिएका औषधीको अधिकतम मूल्य निर्धारण गर्न बोर्डले उपसमिति बनाउन सक्छ। Ministry of Law, Justice and Parliamentary Affairs Rule 7(1)-(3), Rule 18(1)-(3), Rule 19(1), PDF pp. 3, 7-8; Rule 21(1)-(3), Rule 24(1), PDF p. 9; Rule 30, PDF p. 11

Gaps, loopholes and improvement ideas

Not enforced Claims are not paid within the 15 days Rule 21(3) requires. The Auditor General's performance audit found that the liability for claims arising in each year has been paid only in the following year, and that an estimated Rs 19.43 billion in claims for 2081/82 remained unpaid. Because claims are larger than the premiums collected, the amount the government must cover keeps rising, and budget shortfalls have delayed payments to health facilities; it listed ten providers, led by Bharatpur Hospital, with the largest unpaid amounts.नियम २१(३) ले तोकेको १५ दिनभित्र दाबी भुक्तानी भएको छैन। महालेखापरीक्षकको कार्यमूलक लेखापरीक्षणअनुसार हरेक वर्षको दाबी दायित्व अर्को वर्ष मात्र भुक्तानी भएको छ र २०८१/८२ को अनुमानित रु. १९ अर्ब ४२ करोड ९८ लाख दाबी भुक्तानी गर्न बाँकी छ। सङ्कलित प्रिमियमभन्दा दाबी ठूलो हुँदा सरकारले बेहोर्नुपर्ने दायित्व बढ्दै गएको र बजेट अभावले स्वास्थ्य संस्थालाई समयमै भुक्तानी गर्न ढिलाइ भएको उल्लेख छ; भरतपुर अस्पतालसहित सबैभन्दा बढी भुक्तानी बाँकी रहेका दस सेवा प्रदायकको सूची पनि दिइएको छ। Office of the Auditor General, Nepal · Ministry of Law, Justice and Parliamentary Affairs OAG 63rd Annual Report, performance audit 'Effectiveness of the health insurance programme', para 4, printed pp. 669-670 (PDF pp. 705-706); Rule 21(3), PDF p. 9
Not enforced Insured patients often cannot get the listed medicines. The Auditor General, citing Rule 24, sent questionnaires to ten Kathmandu Valley hospitals; of the seven that replied, three had more than 75 per cent of listed medicines regularly available and four only 25-50 per cent. In its survey of 150 insured patients at Bir, Patan, Sukraraj Tropical and other hospitals, 19 per cent got all prescribed medicines through insurance, 73 per cent only some and 8 per cent none, so many had to buy medicines outside.बीमितले सूचीकृत औषधी पाउन सकेका छैनन्। महालेखापरीक्षकले नियम २४ उल्लेख गर्दै उपत्यकाका १० अस्पतालमा प्रश्नावली पठाएकोमा जवाफ दिएका सातमध्ये तीनमा ७५ प्रतिशतभन्दा बढी र चारमा २५ देखि ५० प्रतिशत मात्र सूचीकृत औषधी नियमित उपलब्ध रहेको पाइयो। वीर, पाटन, शुक्रराज ट्रपिकललगायतका अस्पतालका १५० बीमित सेवाग्राहीको सर्वेक्षणमा १९ प्रतिशतले सबै औषधी, ७३ प्रतिशतले आंशिक र ८ प्रतिशतले कुनै पनि औषधी बीमाबाट नपाएको बताएका छन्; धेरैले बाहिरबाट किन्नुपरेको छ। Office of the Auditor General, Nepal · Ministry of Law, Justice and Parliamentary Affairs OAG 63rd Annual Report, performance audit, paras 6.1 and 8, printed pp. 670 and 672 (PDF pp. 706 and 708); Rule 24(1), PDF p. 9
Outdated Premiums cover only a small part of what the scheme pays out. Referring to the contribution set in Rule 15 and Schedule 1 (Rs 3,500 a year for a family of five), the Auditor General found that premiums paid by contributing members met only about 19.2 per cent of claim payments in 2079/80, 24.5 per cent in 2080/81 and 29.1 per cent in 2081/82. It also found that premiums the government should pay for target groups had not been received as provided, and that co-payment was too limited to control use, raising questions about the scheme's long-term sustainability.प्रिमियमले दाबी भुक्तानीको सानो अंश मात्र धान्छ। नियम १५ र अनुसूची-१ ले तोकेको योगदान (पाँच जनाको परिवारका लागि वार्षिक रु. ३,५००) को सन्दर्भमा महालेखापरीक्षकले शुल्क तिर्ने बीमितबाट सङ्कलित प्रिमियमले २०७९/८० मा करिब १९.२, २०८०/८१ मा २४.५ र २०८१/८२ मा २९.१ प्रतिशत मात्र दाबी भुक्तानी धानेको भेट्टाएको छ। लक्षित समूहको प्रिमियम सरकारबाट व्यवस्थाअनुसार प्राप्त नभएको र सह-भुक्तानीको दायरा र दर न्यून भएकाले सेवा उपयोग नियन्त्रण हुन नसकेको उल्लेख गर्दै कार्यक्रमको दिगोपनामा प्रश्न उठेको भनेको छ। Office of the Auditor General, Nepal · Ministry of Law, Justice and Parliamentary Affairs OAG 63rd Annual Report, performance audit, para 3, printed pp. 668-669 (PDF pp. 704-705); Rules 15-16 and Schedule 1, PDF pp. 5-6, 13
Loophole Fees collected by enrolment assistants are not fully accounted for. Enrolment and renewal fees are collected through enrolment officers and enrolment assistants under Rules 11 and 12. The Auditor General found that the Board, which reported Rs 3.73 billion in insurance fee income in 2081/82, kept no record of fees collected and deposited for enrolment and renewal, and had not updated its records of cash receipts issued to assistants, used, cancelled or unused, so it could not be confirmed that everything the assistants collected reached the Board.दर्ता सहयोगीले उठाएको शुल्कको पूरा हिसाब छैन। नियम ११ र १२ बमोजिम दर्ता अधिकारी र दर्ता सहयोगीमार्फत आबद्धता र नवीकरण शुल्क उठाइन्छ। महालेखापरीक्षकका अनुसार २०८१/८२ मा बीमा शुल्कबापत रु. ३ अर्ब ७३ करोड २२ लाख आम्दानी देखाएको बोर्डले आबद्धता र नवीकरण शुल्क असुली र दाखिलाको अभिलेख राखेको छैन; सहयोगीलाई दिएका नगदी रसिदमध्ये प्रयोग भएका, रद्द भएका र बाँकी रसिदको अभिलेख पनि अद्यावधिक गरेको छैन। यसैले सहयोगीले उठाएको सबै रकम बोर्डमा जम्मा भएको यकिन हुन सक्ने अवस्था छैन। Office of the Auditor General, Nepal · Ministry of Law, Justice and Parliamentary Affairs OAG 63rd Annual Report, MoHP chapter, Health Insurance Board para 48, printed p. 537 (PDF p. 569); Rules 11(2)(क) and 12(1), PDF p. 4

Ideas to fix it

Make the claim assessment system effective and balance available funds against liabilities so that claims are paid within the time set by the regulation.दाबी मूल्याङ्कन प्रणालीलाई प्रभावकारी बनाउँदै उपलब्ध स्रोत र सिर्जित दायित्वबीच सन्तुलन मिलाई नियमावलीले तोकेको समयभित्रै भुक्तानी दिने व्यवस्था मिलाउने। Proposed by: Office of the Auditor General Office of the Auditor General, Nepal
Widen coverage, review the insurance fee over time, implement co-payment effectively and diversify funding to make the scheme financially sustainable.कार्यक्रमको दिगोपनाका लागि बीमाको दायरा बढाउने, बीमा शुल्क समयानुकूल पुनरावलोकन गर्ने, सह-भुक्तानी प्रभावकारी रूपमा लागू गर्ने र स्रोत विविधीकरण गर्ने। Proposed by: Office of the Auditor General Office of the Auditor General, Nepal
Make sure listed medicines are regularly available at service providers, with effective management and monitoring by the responsible bodies.सम्बन्धित निकायले प्रभावकारी व्यवस्थापन र अनुगमन गरी सेवा प्रदायकमा सूचीकृत औषधी नियमित उपलब्ध हुने सुनिश्चित गर्ने। Proposed by: Office of the Auditor General Office of the Auditor General, Nepal
Keep up-to-date records of insurance fees collected and of receipts issued to enrolment assistants, so the fee income can be confirmed.बीमा शुल्क असुली र दर्ता सहयोगीलाई दिएका रसिदको अद्यावधिक अभिलेख राखी शुल्क आम्दानी यकिन गर्ने। Proposed by: Office of the Auditor General Office of the Auditor General, Nepal

Where does it conflict with other laws?

No conflict with another law is documented in the sources we have reviewed so far.

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