Ayushman Bharat Yojana, also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY), is a scheme that aims to help economically vulnerable Indians who are in need of healthcare facilities. Prime Minister Narendra Modi rolled out this health insurance scheme on 23 September 2018 to cover about 50 crore citizens in india and already has several success stories to its credit. As of September 2019, it was reported that 18,059 hospitals have been empanelled, over 4,406,461 lakh beneficiaries have been admitted and over 10 crore e-cards have been issued.
The Ayushman Bharat Yojana – National Health Protection Scheme, which has now been renamed as Pradhan Mantri Jan Arogya Yojana, plans to make secondary and tertiary healthcare completely cashless. The PM Jan Arogya Yojana beneficiaries get an e-card that can be used to avail services at an empanelled hospital, public or private, anywhere in the country. So with it, you can walk into a hospital and obtain cashless treatment.The coverage includes 3 days of pre-hospitalisation and 15 days of post-hospitalisation expenses. Moreover, around 1,400 procedures with all related costs like OT expenses are taken care of. All in all, PMJAY and the e-card provide a coverage of Rs. 5 lakh per family, per year, thus helping the economically disadvantaged obtain easy access to healthcare services.
Health Cover Categories of this scheme:
The scheme has certain pre-conditions by which it picks who can avail of the health cover benefit. While in the rural areas the list is mostly categorized on lack of housing, meagre income and other deprivations, the urban list of PMJAY beneficiaries is drawn up on the basis of occupation.So the PMJAY scheme aims to provide healthcare to 10 crore families, who are mostly poor and have lower middle income, through a health insurance scheme providing a cover of Rs 5 lakh per family. The 10 crore families comprise 8 crore families in rural areas and 2.33 crore families in urban areas. Broken into smaller units, so this means the scheme will aim to cater to 50 crore individual beneficiaries.
Eligibility for this scheme:
The PMJAY scheme aims to provide healthcare to 10 crore families, who are mostly poor and have lower middle income, so this health insurance scheme providing a cover of Rs 5 lakh per family. The 10 crore families comprise 8 crore families in rural areas and 2.33 crore families in urban areas so broken into smaller units, this means the scheme will aim to cater to 50 crore individual beneficiaries so However, the scheme has certain pre-conditions by which it picks who can avail of the health cover benefit. While in the rural areas the list is mostly categorized on lack of housing, meagre income and other deprivations, the urban list of PMJAY beneficiaries is drawn up on the basis of occupation.
In Rural areas eligibility criteria:
The 71st round of the National Sample Survey Organisation reveals that a staggering 85.9% of rural households do not have access to any healthcare insurance or assurance so Additionally, 24% of rural families access healthcare facilities by borrowing money. PMJAY’s aim is to help this sector avoid debt traps and avail services by providing yearly assistance of up to Rs 5 lakh per family so the scheme will come to the aid of economically disadvantaged families as per data in the Socio-Economic Caste Census 2011. Here too, households enrolled under the Rashtriya Swasthya Bima Yojana so they (RSBY) will come under the ambit of the PM Jan Arogya Yojana.
In the rural areas, the PMJAY health cover is available to:
- 1) Those living in scheduled caste and scheduled tribe households
- 2) Families with no male member aged 16 to 59 years
- 3) Beggars and those surviving on alms
- 4) Families with no individuals aged between 16 and 59 years
- 5) Families having at least one physically challenged member and no able-bodied adult member
- 6) Landless households who make a living by working as casual manual labourers
- 7) Primitive tribal communities
- 8) Legally released bonded labourers
- 9) Families living in one-room makeshift houses with no proper walls or roof
- 10) Manual scavenger families
In Urban areas eligibility criteria:
According to the National Sample Survey Organisation (71st round), 82% of urban households do not have access to healthcare insurance or assurance So, 18% of Indians in urban areas have addressed healthcare expenses by borrowing money in one form or the other. So, Pradhan Mantri Jan Arogya Yojana helps these households avail healthcare services by providing funding of up to Rs 5 lakh per family, per year. So, PMJAY will benefit urban workers’ families in the occupational category present as per the Socio-Economic Caste Census 2011. Further, any family enrolled under the Rashtriya Swasthaya Bima Yojana will benefit from the PM Jan Arogya Yojana as well.
In the urban areas, those who can avail of the government-sponsored scheme consist mainly of:
- 1. Washerman / chowkidars.
- 2. Rag pickers.
- 3. Mechanics, electricians, repair workers.
- 4. Domestic help.
- 5. Sanitation workers, gardeners, sweepers.
- 6. Home-based artisans or handicraft workers, tailors.
- 7. Cobblers, hawkers and others providing services by working on streets or pavements.
- 8. Plumbers, masons, construction workers, porters, welders, painters and security guards.
- 9. Transport workers like drivers, conductors, helpers, cart or rickshaw pullers.
- 10. Assistants, peons in small establishments, delivery boys, shopkeepers and waiters.
Benefits of this scheme:
Government-funded health insurance schemes in India have always been based on an upper ceiling limit and varied between an annual cover of INR30,000 to INR3,00,000 per family across various States, creating a fragmented system so PM-JAY provides cashless cover of up to INR5,00,000 to each eligible family per annum for listed secondary and tertiary care conditions. The cover under the scheme includes all the expenses incurred for the following components of the treatment.
- Medical examination, treatment, and consultation
- Medicine and medical consumables
- Non-intensive and intensive care services
- Diagnostic and laboratory investigations
- Medical implant services (where necessary)
- Accommodation benefits
- Food services
- Complications arising during treatment
- Post-hospitalization follow-up care up to 15 days
The benefits of INR 5,00,000 are on a family floater basis which means that it can be used by one or all members of the family. The RSBY had a family cap of five member so However, based on learning from those experiences, Ayushman Bharat Yojana was designed in such a way that there is no cap on family size and age of members. In addition, pre-existing diseases are cover from the very first day. This means that any eligible person suffering from any medical condition before being covered by PM-JAY will now be able to get treatment for those medical conditions under the scheme.
Some critical Disease Cover:
Some Critical Disease are Cover under this scheme, they are:
- Coronary artery bypass grafting
- Double valve replacement
- Carotid angioplasty
- Pulmonary valve replacement
- Skull base surgery
- Laryngopharyngectomy with gastric pull-up
- Anterior spine fixation
- Tissue expander for disfigurement following burns
How to apply for this scheme?
There is no special Ayushman Bharat Yojana procedure pertaining to PMJAY this is because PMJAY applies to all beneficiaries as identified by the SECC 2011 and those who are already part of the RSBY scheme. However, here’s how you can check if you are eligible to be a beneficiary of PMJAY. So,You can check your name by these methods:
- Common Service Centres (CSC)– Beneficiaries can check their eligibility by visiting the nearby Common Service Centres Apart from these CSCs, beneficiaries can also collect the information form the impaneled hospitals.
- Helpline No.- The second method is the helpline numbers. The government has also provided helpline no. to help the beneficiaries. So they can call and contact the customer care centers for help, The helpline numbers are-
- 14555 & 1800111565
- Online Method- the last and very popular method is the online methods. So, beneficiaries have to visit the official website of NHA (National Health Authority) for Ayushman Bharat Yojana.
- Beneficiaries have to start by visiting https://mera.pmjay.gov.in.
- They have to click on the “Am I Eligible” tab on the homepage so they can check their name in the list.
- Now they have to enter their mobile no. and captcha code in provided fields.
- Beneficiaries can select their state and category.
After entering the mobile no. and captcha code OTP will be generate and beneficiaries have to enter this OTP in the space provided.
They can either search by name, by mobile no., by Ration card no., or by RSBY URN number. After selecting the category, they have to enter the required information such as mobile no (search by mobile no.), Ration card no. (in case of selecting search by ration card no.), name, father’s name, mother’s name, spouse’s name, gender, age, area, district, town/village, pin code (search by name), and RSBY URN number so Once the beneficiaries have filled the required details they have to click the “Search”, button and result appear on the screen. If the name of the beneficiary will be there in the list, then it will also be reflected on the screen and vice-versa.
26 states and union territories accepted the scheme except four states: Delhi, Odisha, West Bengal and Telangana. More than a lakh (100,000) people have taken benefit of the scheme till October 2018. By 26th November more than 825,000 e-cards had been generated and there was a push to recruit more private hospitals to the scheme. Three had already been signed up: Cygnus Sonia Hospital in Nangloi, Dr. Shroff’s Charity Eye Hospital and Cygnus MLS Super-Speciality Hospital and so many more are in queues.
There have been media reports of widespread misuse of the Ayushman Bharat scheme by unscrupulous private hospitals through submission of fake medical bills. Under the Scheme, surgeries have been claimed to be performed on persons who had been discharged long ago and dialysis has been shown as performed at hospitals not having kidney transplant facility. There are at least 697 fake cases in Uttarakhand State alone, where fine of Rs one crore has been imposed on hospitals for frauds under the Scheme. However, unlike the earlier RSBY (Rashtriya Swasthya Bima Yojana) era, plagued by lax monitoring of insurance fraud, AB-PMJAY involves a robust information technology infrastructure overseeing transactions and locating suspicious surges across the country.
Many hospitals have been blacklisted and the constantly evolving fraud-control system will play a major role in streamlining the scheme as it matures. Initial analysis of high-value claims under PMJAY has revealed that a relatively small number of districts and hospitals account for a high number of these, and some hint of an anti-women bias, with male patients getting more coverage. Despite all efforts to curb foul-play, the risk of unscrupulous private entities profiteering from gaming the system is clearly present in AB-PMJAY.