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Pradhan Mantri Jan Arogya Yojana: Scheme under the Ayushman Bharat 

Introduction

The Ayushman Bharat Campaign was launched by the government with the intention of improving healthcare in the country and providing primary health to its citizens. Two schemes are covered under this campaign. One of them is Pradhan Mantri Jan Arogya Yojana.

Pradhan Mantri Jan Arogya Yojana was a scheme that was launched under the Ayushman Bharat in the year 2018 in the district of Ranchi by Shri Narender Modiji, the PM of India. The scheme was formerly known as the National Health Protection Mission. The scheme provides a cover of INR 5 Lakh for every family for a year for hospitalization of tertiary and secondary treatments across private and public hospitals in India to greater than 10.75 crores of families across India.

These families form the lower 40% of the population of India. The Government gives the full expense of the scheme, and the cost is jointly shared by State and Central Governments.

Features of PMJAY

Thousands of people die in India each year as a result of a lack of medical care. Most of these individuals were poor and could not afford the high medical expenditures. Poor people will receive free medical treatment as a result of the implementation of this project.

The scheme and its features have been discussed below in detail-

  1. PM-JAY is the world's largest government-funded assurance/health insurance scheme. All applicants who have enrolled in the scheme will be able to obtain a medical insurance scheme worth INR 5 lakhs. This sum is for one fiscal year.
  2. People living in both rural and urban areas will be able to enrol in this scheme if they meet the other eligibility criteria. Beneficiaries from villages and urban settlements have been identified in proportions of 85% and 60%, respectively. Only patients admitted to empanelled hospitals will be able to receive cashless and paperless treatment.
  3. The scheme will be implemented throughout the country. The central government has highlighted some implementation methods for ease of operation. Each state will be able to select the mode of implementation that best suits its needs.
  4. It pays for up to three days of the period before hospitalization and up to fifteen days after hospitalization expenses, for example, medications and diagnostics.
  5. This sum is meant to cover all secondary and most tertiary care expenses.
  6. There are no restrictions on the age, size, or gender of the family.
  7. Already existing conditions are covered from the start.
  8. A three-tier model is used to implement the scheme throughout the country.
  9. The AB-PMJAY is implemented by the National Health Authority throughout the country. The SHAs or the State Health Agencies have been established to ensure the effective implementation of AB-PMJAY at the state/territorial level.
  10. District Implementation Units, or DIUs, have been established to ensure on-the-ground coordination among scheme stakeholders and smooth implementation.

Eligibility

There are certain prerequisites attached on the basis of which it is decided who the persons that can claim the benefit are. In rural locations, the qualifying criteria are mostly determined by the person's income, lifestyle, and other deprivations. In urban regions, it is determined by each individual's employment.

Rural Communities

Those rural communities which satisfy any one of the given below conditions will become eligible-

  • Landless households whose primary source of income is manual casual labour
  • Families with no adult members aged 16 to 59
  • Households of SC/ST
  • Families with only one room and Kucha walls and roof
  • Female-headed households with no adult male member aged 16 to 59
    Families in rural areas with one or more of the following characteristics: households without shelter, homeless, living on charity, manual scavenger families, primitive tribal groups, and legally released bonded labour.

For Metropolitan Areas

In Metropolitan Areas, if any one of the below-mentioned conditions is satisfied, then they become eligible for the scheme.

  • Domestic helper
  • Sweeper, maali, tailor, sanitation worker
  • Beggar
  • Street vendors, hawkers, or any other service provider who works on the streets
  • Ragpicker
  • Plumber, welder, labourer, construction worker, security guard, painter, mason, and other jobs
  • Driver, transport employee, conductor, a rickshaw puller, cart puller
  • Mechanic, repairman, electrician, and assembler
  • Washerman , chowkidar
  • Peon in a small establishment, delivery boy, shop employee, waiter, attendant, assistant

Exclusions

The following are excluded from the scheme-

  • Families who pay income tax or professional tax
  • Households with a Kisan card with a credit limit greater than INR 50000.
  • Any member of the family whose earnings are greater than INR 10000 per month
  • Government employee
  • Households with non-agricultural enterprises that have been registered with the government
  • Any member who possesses over 2.5 acres of irrigated land and 1 piece of irrigation equipment or owns 5 acres or more of irrigated land for at least two crop seasons or has at least 7.5 acres of land and at least one irrigation system
  • Families who own a motorized wheeler or fishing boat

Hospitalization Under the Ayushman Bharat Scheme

If you are a beneficiary of the Ayushman Bharat Yojana and you or a member of your family requires hospitalization, the PM Ayushman Yojana will cover all pre and post-hospitalization costs, as well as in-patient costs. The process is completely cashless, and there is no need to pay anything because the centre and state are shared 60:40.

This scheme provides PAN-India coverage with cashless hospitalization benefits to all PMJAY-enrolled families at empanelled public and private hospitals. Various Ayushman Mitras are assigned to various empanelled hospitals to assist patients during their hospitalization. They will check the documents and qualifying criteria and provide a letter with a QR code.

This QR code is scanned and validated to see whether the beneficiary is eligible for PMJAY scheme benefits. The government has made numerous initiatives to assist the underprivileged who are unable to handle their healthcare expenditures by providing free hospitalization benefits through the PMJAY plan.

Diseases Covered in PMJAY

Some critical diseases are covered in this scheme. They are as follows :

  • Surgery of skull
  • Prostrate cancer
  • Pulmonary valve replacement
  • Fixation of the anterior spine
  • Replacement of double valve
  • Gastric pull-up with laryngopharyngectomy
  • Bypass surgery of coronary artery
  • Carotid angioplasty with stent

Diseases Not Covered In PMJAY

There are some diseases that are not covered in PMJAY. They are as follows :

  • Transplant of organs
  • Procedure related to cosmetics
  • OPD
  • Drug rehabilitation program
  • Any procedure related to fertility
  • Diagnostics for evaluation of individuals

Expenses or Services Covered under the Scheme

The following type of expenses or services are covered under the scheme-

  • Services for Intensive and Non-Intensive Care
  • Pre Hospitalization expenses
  • Lab Investigation and Diagnosis
  • Medicines and medical consumables
  • Expenses related to treatment, medical examination, and consultation
  • Post Hospitalization expenses for the next 15 days after hospitalization
  • Treatment and testing for Covid-19
  • Food-related services
  • Complications that arise during treatment
  • Benefit of accommodation

Difficulties in Adopting PMJAY

Cooperation of States:

Because health is a state responsibility and states are expected to contribute 40% of the scheme's funding, it is critical to streamline and harmonize the existing state health insurance schemes to PMJAY. PMJAY has not been implemented in West Bengal or Odisha.

The Cost Burden:

Costs are a point of contention between providers and the government, and many for-profit hospitals see the government's proposals as unworkable.

Unnecessary Treatment:

The 2017 National Health Policy proposed a fee for the "strategic purchasing" of services from secondary and tertiary hospitals. Contracts with healthcare providers who will receive financial compensation should clearly state that they must strictly adhere to notified guidelines and standard treatment protocols in order to avoid unnecessary treatment.

Inadequate Health Resources:

Because the public sector's health capacities are inadequate, partnerships and coalitions with private sector providers are required.

In such cases, the provision of services can only be guaranteed if the providers are held accountable for their actions.

How to Get Yourself Enrolled in the PMJAY Scheme?

Those people whom the government identified as beneficiaries were automatically enrolled under the scheme. For this, the government issued them a PMJAY card, and they can use this card to get a cashless treatment done at the hospitals.

The following documents need to be submitted for PMJAY registration-

  • Contact Details
  • Certificate of identification and age
  • Income Proof
  • Caste Certificate
  • Document for current family status

Procedure to File a Claim Under PMJAY

The PMJAY scheme is a welfare program that aims to provide quality medical care to the poor in times of medical emergency. It is a government-funded program that functions similarly to a group health insurance plan and provides free coverage. The government launched this scheme to help the poor, and with the progress that the scheme has made, the potential for growth is high.

The PMJAY claim procedure is straightforward-

  • You must identify the accredited hospitals that provide PMJAY treatment. Admit yourself to the hospital and present your PMJAY health card as identification.
  • After some paperwork was completed to verify the insured's identity, treatments would be permitted on a cashless basis.
  • You would not have to pay for your own medical expenses because the scheme would cover them.

How to Get Your Ayushman Card Online

You must have an Ayushman card to benefit from the Ayushman Bharat Yojana or the PMJAY scheme. Without this card, authorities may have difficulty identifying those who fall under the plan.

People who are covered by the scheme or are eligible for benefits under the Ayushman Bharat scheme may not receive the advantages associated with it. You can get the Ayushman Card for the PMJAY online. To successfully download your Ayushman card, follow the steps below:

  • Go to PMJAY's official website and fill in your personal information.
  • Enter your Aadhaar card number and select approve beneficiary
  • Now, enter the password and pin number into the CSC wallet.
  • It will take you to the website's home page.
  • The download option is visible. Place it in front of your golden card and click on it.
  • The Ayushman card has been downloaded.

With the Ayushman card, you can obtain insurance services at any empanelled public or private hospital.

Benefits of the PMJAY Scheme

The scheme helps in improving the healthcare of many families across India. Some of the benefits of the scheme have been given below-

  • The Pradhan Mantri Jan Arogya Yojana card holder is entitled to a number of perks. Beneficiaries from the weaker parts of society can have access to high-quality healthcare without facing too many financial troubles as a result of unintended or long-term vital medical procedures.
  • Standard mediclaim coverage excludes pre-existing ailments, internal congenital disorders, and mental health issues.
  • A solid IT foundation underpins the system-
    IT assists with beneficiary identification, the maintenance of treatment records, the processing of claims, the resolution of grievances, and so on.
    Both the national and state levels have a fraud detection, prevention, and control system, which is crucial for combating fraud.
  • The initiative has the potential to spark major changes in India's healthcare sector.
  • The system compels hospitals to meet a specific level.
  • Insurers and third-party administrators will have access to the vast new market created by the plan.

Achievements of the PMJAY Scheme

Beneficiary households have saved about INR 13000 crores in one year since the scheme's inception. There is more to the scheme's effective execution. Private hospitals in various tier II and III cities have seen higher foot traffic as they have completed more than 60% of their goal treatment.

Furthermore, the plan has produced numerous employment in the healthcare industry, with over 50000 positions created in 2018. This figure is projected to rise as the government aims to develop 1.5 lakh Health and Wellness Centres (HWC) by 2022.

Frequently Asked Questions

What is the coverage under Pradhan Mantri Jan Arogya Yojana?

The scheme provides a cover of INR 5 Lakh per family per year for hospitalization of secondary and tertiary care across public and private hospitals in India to more than 10.75 crores of families across India.

Which type of medical or healthcare services are not covered under the Pradhan Mantri Jan Arogya Yojana?

Different healthcare services such as organ transplants, cosmetic surgeries, fertility treatment, and drug rehabilitation are not covered under the Pradhan Mantri Jan Arogya Yojana.

Which was the campaign under which the Pradhan Mantri Jan Arogya Yojana was launched?

Pradhan Mantri Jan Arogya Yojana was a scheme that was launched under the Ayushman Bharat program in 2018 in Ranchi by the Prime Minister of India with the view to provide the benefits of health insurance to people who have low incomes.

What are the documents required for applying to get enrolled in the PMJAY Scheme?

The following documents need to be submitted to apply for the scheme-

  • Contact Details
  • Certificate of identification and age
  • Income Proof
  • Caste Certificate
  • Document for current family status

What are the different expenses or services that are covered under the scheme?

The different expenses or services that are covered under the scheme include expenses related to treatment, medical examination, and consultation, Pre Hospitalization and post-hospitalization expenses, Services for Intensive and Non-Intensive Care, Food-related services, Lab Investigation and Diagnosis, Medicines and medical consumables, etc.

Can hospitals charge beneficiaries money for treatment under PMJAY?

No, hospitals cannot charge until the beneficiary has spent all of his or her INR 5 lakhs.

Are there any diseases that are not covered by the scheme?

There are some diseases that are not covered in PMJAY. These are transplants of organs, procedures related to cosmetics, OPD services, drug rehabilitation programs, any procedure related to fertility, and diagnostics for the evaluation of individuals.

What are the minimum and maximum ages for participation in the PMJAY scheme?

This scheme has no age restrictions or limits on the number of persons in a family who can be covered.

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