The expense ceiling under the government’s health insurance scheme has been significantly reduced in a measure aimed at curbing the ongoing financial crisis faced by the Health Insurance Board.

As per the Board’s new decision, outpatient services will be covered only up to Rs25,000 per patient or the same amount may be used collectively by up to four members of an insured family. Previously, patients could access services worth up to Rs100,000, covering outpatient, inpatient, and emergency care.

“This is a short-term measure the board is taking for the continuation of the scheme and to address the ongoing financial crisis faced by the board,” said Bikesh Malla, information officer at the board. “The new decision will take effect from February 13.”

Officials say the new decision to lower the ceiling for outpatient care is in line with an expert panel's recommendation.

They say that the new ceiling has been set only for outpatient care, and patients requiring inpatient or emergency treatment will still receive coverage up to Rs100,000.

“Overall, 71 percent of the total existing expenses are from outpatient care,” said Malla. “Due to a lack of ceiling of service in outpatient care, our expenses increased alarmingly. Without reducing costs, the board is no longer in a position to continue the service.”

Some hospitals, including the Tribhuvan University Teaching Hospital, have stopped providing services under the government’s health insurance scheme since January 15. Several others have warned that they will be forced to stop services if long overdue payments are not reimbursed immediately.

Every day, hundreds of patients who arrive at the hospital for treatment with a health insurance card either return without receiving care or are required to pay hospital charges, just like patients without insurance coverage.

The TU Teaching Hospital administration cited overdue payments of around Rs400 million, rejected claims, and low service rates as major issues. According to officials, around 50 percent of the hospital’s claims were not approved by the board, so the hospital lost over Rs20 million every month.

Officials at the board said all government funds allocated for health insurance and premiums collected from the public have already been paid to health facilities. Altogether, Rs14 billion had been paid by December. This included Rs11 billion from the Ministry of Health and over Rs3 billion collected in premiums from the public.

The board needs to pay an additional Rs 10.5 billion in dues to over 500 health facilities, including the TU Teaching Hospital. Officials said this shortfall is due to a funding crunch, not intentional delays. On average, about 50,000 people use services each day, and over 10 million people are covered by health insurance.

Officials say the Ministry of Health and Population has also asked the board to limit expenses to around Rs14 billion, and the new decision to set a ceiling in the outpatient care is in line with the ministry’s direction.

They also said the Social Security Fund provides outpatient coverage of only Rs 25,000 and hope that the board’s decision will not have a serious impact on patient care.

Experts however, say the decision to limit outpatient care contradicts the health insurance policy and could affect policy renewal.

“People are told that they will be provided coverage up to Rs100,000 when they buy the policy,” said Dr Senendra Upreti, former health secretary and also former director of the Board. “People may not renew their policies, if the outpatient coverage is reduced.”

Under the original scheme, a family of up to five members pays Rs3,500 for treatment, including medicines, check-ups, and counselling. One family member can use the insurance coverage worth Rs100,000 per year, or the amount can be divided among five members. Families with more than five members pay Rs700 per additional member for an extra Rs20,000 in health insurance coverage.

People covered by the insurance can access healthcare services at designated facilities by presenting their identity cards. Expenses incurred by health facilities are reimbursed by the Health Insurance Board.

For patients of chronic diseases, the government provides Rs200,000 in insurance coverage, and as of this fiscal year, the board has paid over Rs50 million, officials said.

The government also covers premiums for certain groups—those living below the poverty line in 26 districts, those above 70 years, family members of people living with HIV, disabled people, and those suffering from leprosy and multi-drug resistant tuberculosis.

Currently, the government pays the insurance premiums for around 55 percent of people enrolled in the scheme.