Dental Tribune India

GoI increases OMFS procedure rates under Ayushman Bharat

By Divyesh Mundra, Dental Tribune South Asia
November 15, 2021

National Health Authority (NHA) has made three revisions to its national Health Benefit Package (HBP) master since its launch in September 2018. The fourth HBP to be released in November 2021 has increased packages for four oral surgical procedures. Read the full article by Dr. Divyesh Mundra, Asst Editor (Public Health Policy), Dental Tribune South Asia

National Health Authority (NHA), under the aegis of the Ministry of Health and Family Welfare (MOHFW), is India’s official authority for implementing Govt. India’s flagship health insurance scheme, Ayushman Bharat (AB).

Ayushman Bharat has two components: 

  1. Health and Wellness Centres
  2. Pradhan Mantri Jan Arogya Yojana (PMJAY)

Through PMJAY, Govt. of India is mandated to provide health cover up to INR ₹ 5.00 lakh per annum per family for secondary and tertiary care hospitalization to ~10.74 crore families (~50 crores Indians) belonging to the poor and vulnerable sections of the society. It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics & medicines.

Since the scheme’s launch on 23rd September 2018 in Ranchi, Jharkhand, by the Hon’ble Prime Minister of India, it has issued cards to 16.79 CR Indians & covered expenses of 2.27 Cr hospital admissions.

Health Benefit Packages (HBP)

Empanelled health care providers (EHCP) are paid based on specified HBP rates. A package consists of all the costs associated with the treatment, including pre and post-hospitalization expenses. The specified surgical packages are paid as bundled care where a single all-inclusive payment is payable to the EHCP by the insurer/ State Health Authority (SHA). However, the medical packages are payable to the EHCP at a per-day rate depending upon the admission unit (general ward, HDU, ICU). Day-care packages are payable just like surgical packages.

HBP rate (in case of surgical or defined day-care benefits) includes:

  • Registration charges
  • Bed charges (General Ward)
  • Nursing and Boarding charges
  • Surgeons, Anaesthetists, Medical Practitioners, Consultants fees, etc.
  • Anesthesia, Blood Transfusion, Oxygen, OT Charges, Cost of Surgical Appliances, etc.
  • Medicines and Drugs
  • Cost of Prosthetic Devices, implants (unless payable separately)
  • Pathology and radiology tests: radiology to include but not be limited to X-ray, MRI,
    CT scan, etc. (as applicable)
  • Food to patient
  • Pre and Post Hospitalisation expenses: Expenses incurred for consultation, diagnostic tests, and medicines before the admission of the patient in the same hospital, and up to 15 days of the discharge from the hospital for the same ailment/ surgery

NHA has made three revisions to its national HBP master since its launch in September 2018.

Sr. No. Health Benefit Package (HBP) version Release Date New packages added Changes in rates of existing packages 
1 HBP 1.0 Sept 2018 1,393 0
2 HBP 2.0 November 2019 671 450
3 HBP 2.1 November 2020 76 0
4 HBP 2.2 November 2021 1 409

1st HBP released by NHA in September 2018 had 1,393 packages but just 9 oral surgical procedures as follows:

Sr. No. Name of Oral Surgical Procedure Package Price (in INR)
1 Fixation of fracture of 1 jaw with closed reduction using wires- under LA ₹ 5,000
2 Fixation of fracture of 1 jaw with closed reduction using wires- under GA ₹ 12,000
3 Sequestrectomy ₹ 1,500
4 TMJ Joint Ankylosis of both jaws under GA ₹ 15,000
5 Release of fibrous bands & grafting in Oral Submucous Fibrosis Rx under GA ₹ 3,000
6 Extraction of an impacted tooth under LA ₹ 500
7 Cyst & tumor of Maxilla/Mandible by Enucleation/ Excision/Marsupialization under Local Anaesthesia (LA) ₹ 2,500
8 Mandible Tumor Resection and Reconstruction/ Oral Cancer surgery ₹ 6,000
9 Cleft Lip and Palate surgery ₹ 15,000 for EACH stage

 

2nd HBP 2.0 released by NHA in November 2019 added 671 procedures, increasing the total to 2,064 packages, but only 9 oral surgical procedures were added, increasing the count to 18, as follows:

Sr. No. Name of Oral Surgical Procedure Package Price (in INR)
1 Apicoectomy of a single tooth ₹ 1,500
2 Correction of Oro-antral communication ₹ 7,000 – LA
₹ 12,000 – GA
3 Intra-oral submandibular sialolithotomy (Soft & Hard Tissue) ₹ 6,000 – LA
₹ 9,000 – GA
4 Dentoalveolar trauma- wiring ₹ 3,000
5 Intra-Oral Parotid sialolithotomy ₹ 6,000 – LA
₹ 9,000 – GA
6 Extra-Oral Parotid sialolithotomy under GA ₹ 11,000
7 Re-implantation of an avulsed tooth with wiring  ₹ 1,500
8 Osteo-radio necrosis management by excision ₹ 5,000 – LA
₹ 9,000 – GA
9 Open Reduction and Internal Fixation of Maxilla/Mandible/Zygoma ₹ 18,000 – Single
₹ 25,000 – Multiple

 

3rd HBP 2.1 released by NHA in November 2020 added 76 NEW packages, but none from oral surgery and did not change rates of any packages.

4th HBP 2.2 by NHA to be released in November 2021 has increased packages for the following four oral surgical procedures:

Package Name Procedure Name Current Price Proposed price 
Surgery for Cyst & Maxilla/Mandible tumor Enucleation/ Excision/Marsupialization for cyst & tumor of Maxilla & Mandible ₹ 2,500 ₹ 10,500
Submandibular (SM) Salivary Gland  Excision of SM Salivary Gland ₹9,000 ₹ 21,600
Closed Reduction for Fracture of Maxilla Inter-maxillary fixation for fracture of Maxilla ₹9,200 ₹11,300
Closed Reduction for Fracture of Mandible Inter-maxillary fixation for fracture of Mandible & Zygoma ₹9,200 18,500

 

Prof. Department of Oral & Maxillofacial Surgery (OMFS), Dean, Pacific Dental College and Hospital, Udaipur, Rajasthan & Executive Committee Member Association of Oral and Maxillofacial Surgeons of India (AIOMSI) Dr. Bhagvandas Rai: 

“I welcome National Health Authority (NHA) & Ministry of Health & Family Welfare (MOHFW) decision regarding revision of health benefit packages under Ayushman Bharat, which was much needed. Also, I do hope they revise the package of extraction of impacted wisdom tooth, which is very currently very low and, if possible, include other essential & most common dental procedures like simple extraction, conservative restorations, gum surgeries and prosthetic procedures, like dental caries, periodontitis and loss of teeth are most common oral health conditions across the world & India bears a high burden of it.”

Let us hope that National Health Authority (NHA) team also analyses the state-wise utilization of all 18 health benefit packages done under oral and maxillofacial surgery specialty and broadly dentistry and shares it in the public domain for the public health dentistry community to frame better oral health policies for improving the overall health status of the community.

Reference: Official Website of PMJAY Health Benefit Packages https://pmjay.gov.in/about/pmjay

 

About the author:

Dr. Divyesh Mundra (BDS) completed his Masters in Public Health (MPH) Administration from the School of Health Systems Studies (SHSS),  Tata Institute of Social Sciences (TISS), Mumbai. He is a healthcare management professional having 5 years of diverse experience across hospital administration, patient advocacy, public health policy, and implementation of public health programs. Divyesh actively tweets on challenges confronting the Indian healthcare system including medical and dental education.

Dr. Divyesh Mundra on Twitter
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