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Guidelines on Constitution of State Health Agency (SHA)

In order to facilitate the effective implementation of the scheme, the State Government shall set up the State Health Agency (SHA) or designate this function under any existing agency/ trust/ society designated for this purpose, such as the state nodal agency for RSBY or a trust/ society set up for a state insurance program. SHA can either implement the scheme directly (Trust/ Society mode) or it can use an insurance company to implement the scheme. The SHA shall be responsible for delivery of the services under AB-PMJAY at the State level.

Similar to the National Health Agency (NHA) at the central level, the day-to-day operations of the SHA will be administered by a Chief Executive Officer (CEO) appointed by the State Government. The CEO will look after all the operational aspects of the implementation of the scheme in the State and shall be supported by a team of specialists (dealing with specific functions). The CEO/ operations team will be counselled and overseen by a governing council set up at the State level.

Roles and Responsibilities of SHA

All key functions relating to delivery of services under AB-PMJAY shall be performed by the SHA viz. data sharing, verification/validation of families and members, awareness generation, monitoring etc. The SHA shall perform following activities through staff of SHA/Implementation Support Agency (ISA):

  • 01.  Policy related issues of State Health Protection/ Insurance scheme and its linkage to AB-PMJAY
  • 02.  Convergence of State scheme with AB-PMJAY
  • 03.  Selection of Insurance Company through tendering process (if implementing AB-PMJAY through Insurance Companies)
  • 04.  Selection of Implementation Support Agencies (in Trust/ society mode) if needed
  • 05.  Awareness generation and Demand creation
  • 06.  Aadhaar seeding and issuing print out of E-card to validated AB-PMJAY beneficiaries
  • 07.  Empanelment of network hospitals which meet the criteria
  • 08.  Monitoring of services provided by health care providers
  • 09.  Fraud and abuse Control
  • 10.  Punitive actions against the providers
  • 11.  Monitoring of pre-authorizations which are already approved by Insurer/ ISA
  • 12.  Administration of hospital claims which are already approved by Insurer/ ISA
  • 13.  Package price revisions or adaptation of AB-PMJAY list
  • 14.  Adapting AB-PMJAY treatment protocols for listed therapies to state needs, as needed
  • 15.  Adapting operational guidelines in consultation with NHA, where necessary
  • 16.  Forming grievance redressal committees and overseeing the grievance redressal function
  • 17.  Capacity development planning and undertaking capacity development initiatives
  • 18.  Development of proposals for policy changes –e.g. incentive systems for public providers and implementation thereof
  • 19.  Management of funds through the Escrow account set up for purposes of premium release to Insurance Company under AB-PMJAY
  • 20.  Data management
  • 21.  Evaluation through independent agencies
  • 22.  Convergence of AB-PMJAY with State funded health insurance/ protection scheme (s)
  • 23.  Alliance of State scheme with AB-PMJAY
  • 24.  Setting up district level offices and hiring of staff for district
  • 25.  Oversee district level offices
  • 26.  Preparation of periodic reports based on scheme data and implementation status
  • 27.  Implementing incentive systems for ASHA workers & public providers in line with national guidance