National Health Insurance (Swasthya Bima) Nepal: Premium & Coverage

The National Health Insurance Program (Rastriya Swasthya Bima Karyakram), commonly called swasthya bima, is Nepal's government-run social health insurance scheme. It is administered by the Health Insurance Board (HIB, Swasthya Bima Board), an autonomous body under the Ministry of Health and Population (MoHP) with its head office at Babarmahal, Kathmandu. Its purpose is to protect Nepali households from the financial burden of illness by pooling small annual contributions and buying health services on behalf of members.

The program is a contributory social security scheme, not a commercial insurance product. HIB acts as the purchaser of care, while public and empanelled private health facilities act as providers. Members pay a fixed family premium rather than a risk-based rate, and the government fully subsidises premiums for defined vulnerable groups, making it distinct from the policies sold by private non-life insurers.

Piloting began in Fiscal Year 2072/73 BS (2016 AD) in three districts, Kailali, Baglung and Ilam, and the scheme was then scaled up nationwide. It is legally grounded in the National Health Insurance Act, 2074 (2017 AD), which envisions bringing every Nepali citizen under social health protection.

For an ordinary family, the annual premium is a flat Rs 3,500, which covers up to five members enrolled together as a single household unit. This is the headline figure most people search for when they look up the swasthya bima premium amount.

For families larger than five, each additional member is added for an extra Rs 700 per year. So a six-member family pays Rs 4,200, a seven-member family Rs 4,900, and so on. Members must be enrolled as one family; individuals cannot ordinarily buy the basic scheme on their own outside a household.

The contribution is designed to be affordable relative to the cost of hospital care. Because the government subsidises premiums for several categories (see below), many of the poorest and oldest members of society are enrolled without paying the Rs 3,500 themselves.

In return for the premium, a family of up to five members is entitled to a benefit ceiling of Rs 100,000 of covered health services per year. For larger families, the ceiling rises by Rs 20,000 for each additional member, up to a maximum of Rs 200,000 per family per year.

Two important top-ups exist for high-need members. Citizens aged 70 and above receive an additional benefit of up to Rs 100,000, and patients with specified chronic conditions (a defined list that has included conditions such as cancer, kidney disease, heart disease and others) receive a further top-up so that catastrophic illness does not exhaust the ordinary ceiling. Exact eligible conditions and amounts are set in the HIB benefit package, which is revised periodically.

The package covers promotive, preventive and curative services, including outpatient consultations, inpatient admission, emergency care, diagnostics and a large list of medicines dispensed free at the point of care within the ceiling. The HIB drug list has grown over successive revisions to more than 1,100 listed medicines, so members can obtain most routine drugs without paying out of pocket while their ceiling lasts. Members should always confirm the current benefit package on the HIB website, as the list and terms are updated over time.

The state pays the premium in full for several priority groups so that inability to pay does not exclude those who need care most. Ultra-poor households identified through the government's poverty-identification process, and holders of poverty (red) identity cards, are enrolled without paying the Rs 3,500.

Citizens aged 70 years and above have their contribution borne by the government and, as noted above, also receive an enhanced benefit ceiling. This aligns with Nepal's broader geriatric health commitments to free or subsidised care for older adults.

Full (100%) premium subsidy has also been extended to other defined vulnerable groups. These have included people living with HIV, patients on multidrug-resistant tuberculosis (MDR-TB) treatment, people affected by leprosy, and people with severe disability. The precise list of subsidised categories is set by government decision and should be checked against the current HIB rules, as it has expanded over time.

The program has been expanded from its three-district 2016 pilot to reach all 77 districts of Nepal. Nationwide district coverage means enrolment desks and empanelled facilities exist across every province, although actual population enrolment remains well below universal coverage and varies by district.

When a family enrols, it must choose a first service point (FSP), the health facility it will use for general check-ups and initial treatment. Only public facilities, such as government hospitals and Primary Health Care Centres (PHCCs), can serve as an FSP. Members go to their FSP first for routine care and to obtain a referral slip when specialist or higher-level services are needed.

From the FSP, members can be referred up to higher (referral) hospitals, including empanelled private hospitals, for services not available at the first point. A prescribed referral slip is required for planned referral care; however, in genuine emergencies a member may seek care at any empanelled service point without a referral slip. This gate-keeping and referral chain is a core design feature of the Act.

Enrolment runs throughout the year in implemented districts. A household can enrol through local enrolment assistants (empanelled community-level agents), at a designated enrolment centre or health facility, or via HIB's online/digital channels. At enrolment the family registers all members, chooses its first service point, and pays the applicable premium (unless it belongs to a subsidised category). On successful registration the family receives a health insurance (bima) card or membership that identifies it at the point of service.

Membership must be renewed every year to stay active. Renewal means paying the next year's premium before or around the anniversary of enrolment; HIB has introduced digital renewal so that families can renew online rather than only in person. It is important to renew on time, because a lapse can interrupt benefits and, depending on the rules in force, may require re-enrolment or a waiting period before cover resumes.

To use benefits, a member presents the bima card (or verifies membership) at the chosen first service point, receives covered services and medicines free within the benefit ceiling, and obtains referral slips for higher care. Note that a co-payment provision was introduced from mid-January 2024 under which insured patients bear a share of certain treatment costs (reported at around 10%) to discourage unnecessary testing; members should confirm the current co-payment rules, since these terms are periodically revised by HIB.

The scheme is governed by the National Health Insurance Act, 2074 (passed by Parliament on 24 Ashwin 2074 BS, corresponding to 10 October 2017 AD) and the associated Health Insurance Regulations. The Act establishes the Health Insurance Board, defines membership and benefits, and sets out the goal of universal social health protection for Nepali citizens.

Unlike commercial medical insurance sold by private non-life insurers, swasthya bima charges a single flat family premium regardless of individual risk, is subsidised for the poor and elderly, and channels care through public first service points and a referral system. There is no medical underwriting to join, and pre-existing conditions do not bar enrolment.

Because rates, ceilings, the medicine list and co-payment rules are set by government decision and updated over time, members and prospective enrolees should treat the figures on this page as the durable structure of the scheme and verify the exact current amounts and terms on the official Health Insurance Board website before enrolling, renewing or claiming.