TENDER DOCUMENT Implementation of “Rashtriya Swasthya Bima Yojana” In the State of Himachal Pradesh Government of Himachal Pradesh Department of Health and Family Welfare, Shimla Issued / Released on 13 th September, 2013 1 GOVERNMENT OF HIMACHAL PRADESH DEPARTMENT OF HEALTH AND FAMILY WELFARE TENDER NOTICE RASHTRIYA SWASTHYA BIMA YOJANA (A scheme to provide health insurance coverage to unorganized sector workers) Competitive Quotations are invited from Insurance Companies (Licensed with Insurance Regulatory and Development Authority) to carry on the general insurance/ health insurance for implementation of Rashtriya Swasthya Bima Yojana (RSBY) for approved category of families in 12 Districts namely Bilaspur, Chamba, Hamirpur, Kangra, Kinnaur, Kullu, Lahul & Spiti, Mandi, Shimla, Solan, Sirmour & Una. The tender document for this may be downloaded from the website http://hphealth.nic.in & http://nrhmhp.gov.in. The Tender document can also be obtained in person from the 13 th September 2013 from the below mentioned address on any working day between 10.00 A.M to 4.00 P.M. The technical and financial bid should be sealed by the bidder in a cover duly super- scribed and is to be put in a bigger cover which should also be sealed and duly super- scribed. The existing Insurance Company working in Himachal Pradesh will be given first right to match lowest quotes for both the packages in case it is not the lowest bidder. The Technical and Financial bids will be evaluated by the Bid Evaluation Committee duly constituted by the State Government . Financial bids of only the technically qualified offers shall be opened before the successful bidders by the State Government for awarding of the contract. Following schedule will be observed in this regard. Last date of collection of bid document: 26.09.2013 Last date for submission of queries: 27.09.2013 Last date for submission of bid: 09.10 .2013 (1600hrs) Opening of technical bids: 10.10.2013 (1100hrs) Opening of financial bids: 10.10.2013 (1200hrs) The completed technical Bid documents should be submitted before 09.10.2013 at 04.00 PM, at the following address:- Chief Executive Officer, HP Swasthya Bima Yojna Society, Thakur Villa, Opposite Jal Bhawan, Kasumpti, Shimla-171009 Phone: 0177-2629840 Fax: 0177-2629802 Email: [email protected] All correspondence / communications on the scheme should be made at the above address. 2 TENDER DOCUMENT GOVERNMENT OF HIMACHAL PRADESH RASHTRIYA SWASTHYA BIMA YOJANA A number of studies have revealed that risk owing to low level of health security is endemic for workers, especially those in unorganized sector. The vulnerability of these workers increases when they have to pay out of pocket for their medical care with no subsidy or support. On the one hand, such a worker does not have the financial resources to bear the cost of medical treatment, on the other; the public owned health infrastructure leaves a lot to be desired. Large number of persons borrows money or sells assets to pay for treatment in hospitals. Thus, Health Insurance can be a way of overcoming financial handicaps, improving access to quality medical care and providing financial protection against high medical expenses. The “Rashtriya Swasthya Bima Yojana” announced by the Central Government attempts to address such issues. Government of Himachal pradesh is inviting bids for the 12 districts namely Bilaspur, Chamba, Hamirpur, Kangra, Kinnaur, Kullu, Lahul & Spiti, Mandi, Shimla, Solan, Sirmour & Una district from Insurance Companies registered by IRDA for implementation of RSBY. For effective operation of the scheme, partnership is envisaged between the Insurance Company, public and the private sector hospitals and the State agencies. State Government/Nodal Agency will assist the Insurance Company in networking with the Government/Private hospitals, fixing of treatment protocol and costs, treatment authorization, so that the cost of administering the scheme is kept at the lowest, while making full use of the resources available in the Government/Private health systems. Public hospitals, including ESI hospitals and such private hospitals fulfilling minimum qualifications in terms of availability of inpatient medical beds, laboratory, equipments, operation theatres, smart card reader etc. and a track record in the treatment of the diseases can be enlisted for providing treatment to the identified families under the scheme. Only such companies as are in agreement with scheme and its clauses, only need to participate in the bidding. Any disagreement in this regard is liable for disqualification/rejection of bid at technical level. Hence all the companies are expected to go through the scheme carefully and submit their acceptance in specific format given in the bid document. 3 Table of Contents GLOSSARY .......................................................................................................................................... 8 PART I- INFORMATION TO THE BIDDER ............................................................................... 14 1. NAME.......................................................................................................................................... 14 2. OBJECTIVE ................................................................................................................................ 14 3. BENEFICIARIES ....................................................................................................................... 14 4. ENROLMENT UNIT AND ITS DEFINITION ...................................................................... 15 4.1 Unit of Enrolment ......................................................................................................................... 15 4.2 Size of Famil y .................................................................................................................................. 15 4.3 Definition of Family ..................................................................................................................... 15 5. BENEFITS .................................................................................................................................. 15 5.1 Benefit Package ............................................................................................................................. 15 5.2 Package Rate ................................................................................................................................... 17 6. ELIGIBLE HEALTH CARE PROVIDERS ............................................................................. 18 7. EMPANELMENT OF HEALTH CARE PROVIDERS .......................................................... 18 7.1 Criteria for Empanelment of Public Health Care Providers .......................................... 18 7.2 Criteria for Empanelment of Private Health Care Providers ........................................ 19 7.3 IT Infrastructure needed for Empanelment in RSBY ....................................................... 19 7.4 Additional Benefits to be provided by Health Care Providers ..................................... 19 7.5 Additional Responsibilities of the Health Care Providers ............................................. 20 7.6 Process for Empanelment of Hospitals ................................................................................. 20 7.7 Agreement with Empanelled Hospital .................................................................................. 21 7.8 Delisting of Hospitals................................................................................................................... 21 7.9 List of Empanelled Health Care Providers to be submitted .......................................... 22 8. SERVICES BEYOND SERVICE AREA................................................................................... 22 9. DISTRICT KEY MNAGER AND FIELD KEY OFFICER ..................................................... 23 10. PAYMENT OF PREMIUM AND REGISTRATION FEE .................................................. 23 11. Period of Contract and Insurance ................................................................................. 25 11.1 Term of the Contract ................................................................................................................. 25 11.2 Issuance of Policy ....................................................................................................................... 25 11.3 Commencement of policy in districts .................................................................................. 26 12. ENROLMENT OF BENEFICIARIES ................................................................................... 29 13. Terms and Conditions for Outpatient Benefits for Weavers and Artisans Families ............................................................................................................................................ 31 13.1 Benefits: ......................................................................................................................................... 32 13.2 Eligible Health Services Providers for RSBY Outpatient:............................................. 32 13.3 Empanelment of Hospitals for RSBY Outpatient:............................................................ 32 13.4 Payment of Premium: ............................................................................................................... 34 13.5 Process for Providing Cashless Service under RSBY Outpatient: ............................