Swasthya Bima Nepal: Health Insurance Premium, Renewal & Hospital List

The Social Health Insurance Program, popularly called Swasthya Bima, is Nepal's national contributory health scheme managed by the Health Insurance Board (HIB), an autonomous body under the Ministry of Health and Population. It is built on prepayment and risk-pooling: households pay an annual premium in advance, and in return receive cashless treatment at empanelled public and private health facilities up to a set ceiling. The aim is to reduce catastrophic out-of-pocket spending and move Nepal toward universal health coverage.

The program is grounded in the National Health Insurance Policy 2071 (2014) and the Health Insurance Act 2074 (2017), which envisages that every Nepali citizen be brought under a social health insurance arrangement. The HIB was established in 2017 to administer the scheme, replacing the earlier Social Health Security Development Committee. Enrolment is family-based rather than individual, so the whole household is registered together under one insurance identity.

The scheme first rolled out in fiscal year 2071/72 (2015/16) in three pilot districts, Kailali, Baglung and Ilam, and has since expanded to all 77 districts of Nepal. HIB data indicate several million people are actively insured at any time, though renewal rates and financial sustainability remain ongoing challenges the Board and government are working to address.

The premium is deliberately kept low and is charged per family per year. A household of up to five members pays a single annual premium of Rs 3,500, which covers all five members. For each additional member beyond five, the family pays an extra Rs 700 per year. So a family of seven, for example, pays Rs 3,500 plus Rs 1,400, a total of Rs 4,900 for the year.

The premium buys one year of coverage from the date it is paid, after which it must be renewed to keep the policy active. Formal-sector employees may be brought in through a payroll-based contribution rather than the flat family premium. Certain groups do not pay at all because the government or local bodies bear their premium, as described in the subsidy section below.

Because the premium is annual and household-based, the cost per person falls sharply for larger families. It is one of the lowest-cost formal health-financing options available to Nepali households, but the low premium relative to the benefit ceiling is also why the program's finances are strained and why timely renewal by healthy members matters for the risk pool.

The base benefit ceiling is Rs 100,000 per family per year for a household of up to five members. For each additional member above five, the annual ceiling rises by Rs 20,000, up to a maximum family ceiling of Rs 200,000. Within this limit the scheme is cashless at the point of care, so an insured patient generally does not pay the empanelled facility directly for covered services.

On top of the base amount, the benefit package provides documented top-ups for specified high-cost needs. Senior citizens aged 70 and above receive an additional ceiling of Rs 100,000 per year. Patients with certain chronic and catastrophic conditions specified by the Board, such as cancer, kidney disease requiring dialysis, heart disease, Parkinson's, Alzheimer's, spinal injury, sickle cell anaemia and head injury, also receive an additional Rs 100,000 per year for treatment of that condition.

Covered services broadly include outpatient and inpatient care, essential medicines from the approved list, laboratory and radiological investigations, surgery, ICU care, haemodialysis and some Ayurvedic services, subject to the benefit package and its periodic amendments. The exact list of covered drugs and services is defined in the HIB benefit package, which has been revised several times, most recently by amendments through 2083 (2026); patients should confirm current coverage for a specific procedure with the Board or the facility before treatment.

While most families pay the flat premium, the state fully subsidizes enrolment for defined vulnerable groups, meaning they are insured without paying anything themselves. The most prominent group is senior citizens aged 70 and above, whose premium is borne by the government so that every eligible elderly Nepali can be enrolled free of charge.

Other fully subsidized categories include ultra-poor households and those holding poverty-identity or red cards, people living with HIV, patients with multidrug-resistant tuberculosis (MDR-TB), leprosy patients, and persons with severe or complete disability. Female community health volunteers receive a partial subsidy on their premium in recognition of their frontline role.

Subsidy eligibility is verified through local government, health offices and the relevant identity cards, and the categories are set by the HIB and the Ministry of Health and Population and can be updated by policy. Households that believe they qualify should approach their ward office, local enrolment assistant or the nearest empanelled first service point to have their status recorded so the government contribution is applied.

Enrolment is voluntary, family-based and open year-round in participating districts. A household registers together, submitting the citizenship and identity details of its members, and is issued a single insurance identity used for all members. Enrolment can be done through local enrolment assistants, at empanelled facilities, or through digital channels linked to the HIB's information system.

A defining feature of the scheme is the first service point. At enrolment each family selects one designated first contact facility, typically a nearby government primary health care centre or hospital, which becomes the entry point for routine care. Patients are expected to visit their first service point first and are referred upward to higher-level or specialist hospitals when clinically needed; the referral chain is what allows the cashless system to control costs.

In genuine emergencies, insured patients may go directly to an empanelled hospital without a prior referral. Families can change their first service point at renewal or through the Board's process if they move or are dissatisfied, and should keep their insurance identity number handy, as it is required for every claim and for online renewal.

Coverage lasts one year, and lapsed policies stop paying, so renewal is the step most families search for. The HIB has moved renewal online so members no longer need to queue at a service centre. Renewal is available through the Board's information system at imis.hib.gov.np and through popular digital wallets and payment services, so premiums can be paid from home.

To renew, open a supported service such as eSewa, Khalti, connectIPS or the Nagarik App, find the Health Insurance Board / Swasthya Bima service, enter your family or insurance identity number, verify that the listed family members are correct, and pay the applicable premium. Renewing before the current period expires avoids any coverage gap; renewing during a grace period may still be possible but risks a lapse in benefits in between.

For help, members can contact the Health Insurance Board at its Kathmandu office and helpline numbers (including 01-4100223/224/225 and the toll-free line) or by email at info@hib.gov.np. Always confirm the current premium and any updated benefit rules on the official hib.gov.np website, because rates, the benefit package and covered facilities are periodically revised.

Only facilities empanelled by the HIB can deliver cashless Swasthya Bima services, so the common question is which hospital accepts the insurance, often phrased as bima chalne hospital. Empanelled providers include government hospitals and primary health care centres across the districts, along with a number of empanelled private and mission hospitals; the total network runs to several hundred facilities nationwide and is updated as new agreements are signed.

The authoritative, current list is published by the Health Insurance Board, which maintains directories of empanelled health facilities and of designated first service points by district. Because empanelment changes over time, patients should check the latest HIB list rather than relying on an old copy, and confirm directly with the hospital that the insurance is active for the specific service they need before admission.

For a Kathmandu Valley patient, empanelled options typically include major government hospitals and selected private hospitals; for patients elsewhere, the district hospital and local primary health care centres are the usual empanelled entry points. Use the district filter on the empanelled-facility directory to see the facilities and first service points available in your own district before you travel for treatment.