Twelve empanelled hospitals in Nagaland—six under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and six under the Chief Minister’s Health Insurance Scheme (CMHIS)—have been found involved in cases of charging beneficiaries amounts beyond prescribed treatment package rates, the Nagaland Legislative Assembly was informed on Tuesday.
Health and Family Welfare Minister P. Paiwang Konyak disclosed this while responding to a supplementary question raised by MLA Kuzholuzo Nienu on whether empanelled hospitals were permitted to charge beneficiaries amounts over and above the prescribed package rates and whether cases of unauthorised charging had been reported.
The Minister said empanelled hospitals under both AB-PMJAY and CMHIS are not permitted to levy charges beyond the prescribed treatment packages without following due procedure.
He said all treatments and surgeries covered under the two schemes have prescribed package rates and protocols, which empanelled hospitals are required to follow.
According to Konyak, beneficiaries who suspect that they have been charged an additional or unauthorised amount can lodge complaints, either verbally or in writing, with the concerned authorities, including the Nagaland State Health Protection Society (NSHPS).
Complaints are investigated and appropriate action is taken against hospitals found violating the prescribed norms, he said. Hospitals failing to comply with the requirements may face action, including withholding or affecting reimbursement, as provided under the applicable provisions.
The disclosure came during a discussion on the coverage available under AB-PMJAY. Responding to Nienu’s starred question, Konyak said the scheme provides cashless coverage for secondary and tertiary hospitalisation, covering approximately 1,970 treatment procedures across 25 specialties.
The scheme covers hospitalisation and specified day-care treatments, including dialysis, chemotherapy, radiation therapy and minor surgeries. Unspecified surgical packages may also be provided by the National Health Authority for eligible procedures not specifically included in the listed interventions, subject to prescribed criteria and approval.
However, outpatient services and certain procedures—including cosmetic and aesthetic procedures, dental procedures and fertility treatments such as IVF and surrogacy—are excluded under the PM-JAY exclusion policy.
Nienu, while appreciating the implementation of CMHIS, said the scheme had provided financial relief to families facing serious illnesses and had gained popularity in the state.
He suggested strengthening awareness and enrolment, establishing a responsive grievance-redressal mechanism, improving fraud-prevention measures, empanelling more hospitals and improving internet connectivity for online implementation.
Nienu also proposed graded employee contributions towards CMHIS based on salary categories instead of a uniform contribution rate.
The MLA’s questions on excess charges brought attention to the enforcement of package-rate norms under the two government health-insurance schemes, particularly for beneficiaries who may otherwise have to bear significant out-of-pocket expenses for treatment.
