Ayushman Bharat – Pradhan Mantri Jan Arogya Yojna (PMJAY)

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Ayushman Bharat or PMJAY is a scheme of National Health Protection Mission Council. It is a social health insurance scheme for the general citizens of India.

Ayusham Bharat scheme was announced in the 2018-19 budget and subsequently approved by the Cabinet on 21st March 2018. As announced by our Prime Minister Hon’ble Shri. Narendra Modi on 15th August 2018, this scheme will be rolled out from 25th September 2018, on the birth anniversary of Shri. Pandit Deendayal Upadhyay.

Features of Ayushman Bharat

  • Scheme provides a health cover of Rs. 5 Lakh per family per year like family floater health coverage.
  • Scheme will cover more than 10 crore families belonging to the poor and vulnerable population as per Socio-Economic Caste Census (SECC) of 2011.
  • There are approximately 50 crore beneficiaries and it is considered as the world’s largest health protection scheme.
  • The cover will be for almost all the secondary and tertiary care procedure i.e. scheme will mostly cover all the diseases and treatment procedure. The government recently released the list of 1354 treatments packages covering 23 different types of diseases including heart ailments, knee and hip implants, brain tumor, epilepsy surgery etc.
  • All the pre-existing diseases are covered from the first day of the policy along with pre and post medical hospitalization expenses.
  • There will be no restriction on the family size, gender and age in the scheme to ensure nobody is left out of the benefits of the scheme.
  • Cashless and paperless treatment is available at all public and empanelled private hospitals.
  • Hospitals are not allowed to charge any additional amount of money from beneficiaries for the treatments.
  • Ayushman Bharat will subsume the on-going centrally sponsored schemes i.e. Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).
  • Aadhaar card is not mandatory to avail of benefit but beneficiaries need to carry a prescribed ID to receive free treatment at the hospital.

Official Website – https://www.pmjay.gov.in/

Beneficiaries Covered Under Ayushman Bharat

For identifying beneficiaries under the scheme, Government has decided to use the latest Socio-Economic Caste Census (SECC) data as a source/base data for validation of beneficiary families. The categories in rural and urban that will be covered under the scheme are given as follows:

For Rural

Total deprived Households targeted for the scheme who belong to one of the six deprivation criteria amongst D1, D2, D3, D4, D5 and D7:

  • Only one room with kucha walls and kucha roof (D1)
  • No adult member between age 16 to 59 (D2)
  • Female-headed households with no adult male member between age 16 to 59 (D3)
  • Disabled member and no able-bodied adult member (D4)
  • SC/ST households (D5)
  • Landless households deriving a major part of their income from manual casual labour (D7)

Following families are automatically covered under the scheme: –

  • Households without shelter
  • Destitute/ living on alms
  • Manual scavenger families
  • Primitive tribal groups
  • Legally released bonded labour

For Urban

Occupational categories of workers: –

  • Rag picker
  • Beggar
  • Domestic worker
  • Street vendor/ cobbler/ hawker/ other service provider working on streets
  • Construction worker/ plumber/ mason/ labour/ painter/ welder/ security guard/ coolie and another head-load worker
  • Sweeper/ sanitation worker / mali
  • Home-based worker/ artisan/ handicrafts worker / tailor
  • Transport worker/ driver/ conductor/ helper to drivers and conductors/ cart puller/ rickshaw puller
  • Shop worker/ assistant/ peon in small establishment/ helper/ delivery assistant / attendant/ waiter
  • Electrician/ mechanic/ assembler/ repair worker
  • Washer-man/ chowkidar

Other Features of Ayushman Bharat

  • There is no need to fill an application form or go through any registration process for taking benefit of the scheme. The Department will identify the beneficiaries and dispatch letter to them with a unique
  • At the national level to manage, an Ayushman Bharat National Health Protection Mission Agency (AB-NHPMA) would be put in place.
  • States/ UTs would be advised to implement the scheme by a dedicated entity called the State Health Agency (SHA). They can either use an existing Trust/ Society/ Not for Profit Company/ State Nodal Agency (SNA) or set up a new entity to implement the scheme.
  • States/ UTs can decide to implement the scheme through an insurance company or directly through the Trust/ Society or use an integrated model.
  • Any private hospital with a capacity of more than 10 beds can apply for empanelment under Ayushman Bharat scheme.
  • Each empanelled hospital will have an ‘Ayushman Mitra’ to assist patients and will coordinate with beneficiaries and the hospital. They will run a help desk, check documents to verify the eligibility, and enrolment to the scheme.
  • To control costs, the payments for treatment will be done on the package rate (to be defined by the Government in advance) basis. However, hospitals with NABH/NQAS accreditation can be incentivized for higher package rates subject to the procedure and cost
  • Cost for the scheme shall be shared between Central and State Government in the ratio of 60:40 for all the states and union territory, 90:10 for Northeast states and 100:0 for the state of Jammu and Kashmir, Himachal and Uttarakhand.

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