A look at the Goa model and the road ahead
Dr. Manorama Bakshi & Dr. Arjun Kumar
India’s health protection landscape has gradually moved from fragmented, state-specific insurance arrangements towards broader public assurance systems. Within this shift, Goa offers a distinctive model.
Goa’s health assurance question
The Deen Dayal Swasthya Seva Yojana (DDSSY) was introduced in September 2016. Its predecessor, the Goa Mediclaim Scheme, was largely restricted to households earning below Rs. 1.5 lakh annually and to procedures unavailable in government hospitals. Patients generally had to pay first and seek reimbursement later. DDSSY replaced this narrower approach with cashless treatment across government and empanelled private hospitals, making residency rather than income the principal basis of eligibility.
Residents who have lived in Goa for at least five years can enrol through a family health card. The annual registration or renewal fee is Rs. 200 for families of up to three members and Rs. 300 for larger families, with a 50% concession for specified groups. Following the July 2026 revision, the annual inpatient protection limit rose to Rs. 4 lakh for families of up to three members and Rs.
6 lakh for larger families.
DDSSY now covers more than 447 medical and surgical packages, alongside an outpatient medicine allowance of up to Rs. 15,000 annually for specified chronic conditions including diabetes and hypertension. Mental health and ayurveda hospitalisation in public institutions and certain high-end diagnostics are also included, with no age restriction on benefits. The scheme operates through 11 government and 67 private empanelled hospitals within and outside Goa and alongside Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which provides interstate portability to eligible beneficiaries.
How DDSSY works
DDSSY today covers around 1.81 lakh families. The scale is significant but it also comes with a growing fiscal commitment. The state spends about Rs. 50 crore a year on average, while historical payouts have ranged from Rs. 36 crore to Rs. 72 crore. Following the increase in benefit limits in 2026, annual expenditure is expected to rise to around Rs. 75-85 crore or more.
How families use the scheme is equally revealing. The median cost of a treatment package is below Rs. 35,000, and more than 94% of families use less than Rs. 1.5 lakh in a year. General surgery, orthopaedics and ophthalmology account for much of the routine demand, while the larger bills tend to come from cardiac procedures, cancer treatment and complex urological care.
This helps put the Rs. 6 lakh ceiling in perspective. Most families will never need anything close to it, but that is not necessarily an argument for a lower limit. A family dealing with prolonged cancer treatment or major cardiac care can run through a smaller entitlement quickly. The higher ceiling therefore matters most in the relatively uncommon cases where the financial consequences of serious illness are greatest.
Goa is also integrating DDSSY with the Ayushman Bharat Digital Mission (ABDM), with Ayushman Bharat Health Accounts (ABHA) helping make health records, prescriptions and laboratory reports accessible across participating facilities.
Where it breaks down
But the real test of the system begins when a patient arrives at a hospital and tries to use the assurance promised on paper. Infact, the experience of using the scheme is not always as smooth as the enrolment numbers suggest.
The first weakness is administrative. DDSSY relies on digital authorisation, and reports have documented cases in which portal failures or delayed OTPs held up approval, including during emergencies. For a scheme designed to prevent families from paying upfront, such delays can be especially damaging. The problem is not the use of digital systems itself, but the lack of a dependable fallback when they fail.
Private hospitals face their own pressures. Some empanelled providers have reportedly refused DDSSY cards or limited beds for beneficiaries, citing delayed reimbursements and package rates that they say do not always match the cost of complex treatment. When these disputes are unresolved, the burden shifts back to the patient, who may have to find another hospital or pay unexpectedly out of pocket.
The five-year residency rule raises a different question. It makes DDSSY widely available to long-term residents, but excludes newer migrant workers in sectors such as hospitality, construction and seasonal employment.
Quality of care matters just as much as access. Goa could strengthen empanelment by tying it more closely to National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards, while allowing smaller facilities time to upgrade. Clinical monitoring should also look beyond the number and value of claims to outcomes such as hospital-acquired infections, readmissions and mortality after specialised procedures.
Verification, meanwhile, must remain rigorous without becoming intrusive; diagnostic records and authenticated clinical documentation offer a better basis for checks than photographs of wounds or intimate body parts. A stronger grievance mechanism through Goa Online could also give patients a clearer route to report poor care.
Strengthening the Goa model
Goa does not need to reproduce the much larger health assurance systems of other states, but some of their experience is worth adapting.
One lesson concerns exceptionally expensive treatment. Rajasthan offers one approach: a higher top-up reserved for rare and catastrophic illnesses, rather than raising the entitlement across all claims.
The range of treatment covered also deserves periodic review. DDSSY has 447 medical packages, compared with 1,100-1,700 under comparable schemes in Rajasthan and Tamil Nadu and more than 2,350 in Punjab. More packages do not automatically make a better scheme, but clinical experts within the Directorate of Health Services could use these lists to identify genuine gaps in Goa.
Tamil Nadu offers another useful idea: allowing government hospitals to retain and reinvest part of the insurance reimbursement generated by the treatment they provide. At institutions such as Goa Medical College, this could support equipment and service improvements.
There is also a fiscal case for closing the remaining protection gap. An estimated eight-10% of the population remains uninsured because of renewal lapses or documentation and residency requirements. The original estimates put the additional annual cost at Rs. 35-43 crore: roughly
Rs. 5-6 crore to absorb registration and renewal fees, Rs. 10-12 crore to bring currently uncovered households into the system, and Rs. 20-25 crore for the additional claims likely to follow. Against annual state expenditure of more than Rs. 28,000 crore, the total amounts to about 0.16% of Goa’s budget. This suggests that further expansion is fiscally manageable, although extending protection to those excluded by the five-year residency rule would still require a separate decision on eligibility.
Administrative reform could accompany that expansion. Linking DDSSY records with the electoral roll and Aadhaar could support more automatic enrolment and renewal for eligible residents, while a real-time e-KYC override could prevent OTP or documentation failures from delaying emergency care. Such linkage, however, cannot substitute for a separate route for residents who are not on the electoral roll or do not meet the residency threshold.
Stronger taluka and sub-district facilities, better specialist availability, faster TPA claims processing, non-intrusive verification and periodic revision of package rates in line with clinical costs would address several of the problems patients and providers encounter today.
Making health assurance count
As the state looks towards Swayampurna Goa and Viksit Bharat @2047, the challenge is no longer simply to make the scheme bigger, but to make it work better—for the patient waiting for approval, the family facing an expensive diagnosis, and those who still remain outside its reach.
Goa already has much of the foundation in place. What matters now is whether it can turn health assurance from an entitlement people possess into a promise they can trust. In the end, the real measure of DDSSY will not be how many cards it issues or how high the ceiling rises, but what happens when a family walks into a hospital and needs that promise to hold.
(Manorama Bakshi is a public health expert, institutional leader, and dedicated policy advocate. She is director, health care and advocacy, Consocia Advisory and founder /director Triloki Raj Foundation. Arjun Kumar is director, IMPRI Impact and Policy Research Institute, New Delhi)
