Pradhan Mantri Jan Arogya Yojna – Free Healthcare Benefits to the Underprivileged.

The second component under Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojna or PM-JAY as it is popularly known. The Hon’ble Prime Minister of India, Narendra Modi, launched this programme on 23 September 2018 at Ranchi, Jharkhand. Except West Bengal, NCT of Delhi and Odisha, it has been implemented in all States and territories. For rural areas and cities, the homes included shall be defined on the basis of deprivation and employment criteria identified in the 2011 Socioeconomic Castes Census: (SECC 2011).

PM-JAY is fully funded by the Government and cost of implementation is shared between the Central and State Governments in the ratio of 60:40 and the premium per family is Rs.1052/year. PM-JAY was earlier known as the National Health Protection Scheme (NHPS) before being rechristened. The existing programme, called Rashtriya Swasthya Bima Yojana(RSBY), launched in 2008, was replaced by it. Therefore, family members which were included in the RSBY but did not show up in the SECC 2011 database shall also be covered by the PM-JAY coverage.

PM-JAY is the most comprehensive health insurance guarantee scheme in the world funded by the government. In India, it offers cover of up to INR 5 lakhs per family annually for hospital stays at primary and tertiary care institutions enrolled in empanelling hospitals. A total of 1.96 crore hospital admissions worth Rs. 24,315 crores have been authorized through a network of approximately 23,000 Empanelled Health Care Providers (EHCPs).

There are local health schemes in some states. However, a common health card, ‘Ayushman Card’ with logos of both Ayushman Bharat and state government health schemes can be used for both central and state health schemes.

Key Features of PM-JAY:

Over 12 crore poor and vulnerable entitled families (approximately 55 crore beneficiaries) are eligible for these benefits. At the point of service, i.e.,the hospital, PMJAY provides the beneficiary with a cashless access to health care services.

PM-JAY envisions to help mitigate catastrophic expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year. It includes hospital costs such as diagnostic tests and medicines for a period of up to 3 days or 15 days after hospitalisation. The size of families, age and gender are not restricted.

All pre–existing conditions are covered from day one.

AB-PMJAY provides treatment corresponding to a total of 1669 procedures under 26 different specialties including chronic diseases like Cancer, Diabetes, Heart Disease and other non-communicable diseases and renal and corneal transplant.

The size of families, age and gender are not restricted.

Services include approximately 1,929 procedures covering all the costs related to treatment, including but not limited to drugs, supplies, diagnostic services, physician’s fees, room charges, surgeon charges, OT and ICU charges etc.

The health care provided in public hospitals is subsidised to the same extent as that of privately operated hospitals

The RSBY had a family cap of five members. However, PMJAY has been designed in such a way that there is no limit to the size of the family or the age of the members, based on the lessons learnt from these schemes. Moreover, from the very first day, preexisting diseases are covered. This means that, from the day they are enrolled in this programme, any eligible person who has a serious medical condition prior to being covered by PMJAY will be able to receive treatment for all those conditions under this scheme as soon as possible.

Detailed list of criteria for eligibility under AB-PMJAY as per SECC 2011 automatically included:

– Households without shelter

– Destitute/ living on alms

– Manual scavenger families

– Primitive tribal groups

– Legally released bonded labour

Transgender individuals can access health insurance through Ayushman Bharat TG Plus, which includes gender reassignment surgery as part of the Ayushman Bharat Yojana’s health benefit package.

The guidelines for empanelment of hospitals under AB-PMJAY can be accessed on PMJAY website

Benefit Cover Under PM-JAY

Benefit cover under various Government-funded health insurance schemes in India have always been structured on an upper ceiling limit ranging from an annual cover of INR 30,000 to INR 3,00,000 per family across various States which created a fragmented system. For the specific secondary and tertiary care conditions, PMJAY provides cashless cover to each eligible family per year for an amount up to INR 5,00,000.

State/UT

Ayushman cards issued#

Authorized Hospital Admissions

Value of authorized hospital admissions

(in Rs)

Andaman and Nicobar Islands

33,844

651

16,011,653

Andhra Pradesh*

11

1,245,956

35,454,214,219

Arunachal Pradesh

22,726

1,812

31,559,579

Assam

12,420,824

252,251

3,749,546,919

Bihar

6,869,237

287,389

2,770,023,718

Chandigarh

63,524

11,406

81,696,009

Chhattisgarh

13,240,939

1,551,997

15,108,847,365

Dadra and Nagar Haveli | Daman and Diu

416,028

67,444

455,095,733

Goa

21,867

10,282

331,417,452

Gujarat

7,641,318

2,426,337

36,636,319,474

Haryana

2,616,418

290,815

3,588,146,295

Himachal Pradesh

1,075,101

96,035

1,077,353,995

Jammu and Kashmir

4,794,200

200,034

1,860,995,910

Ladakh

93,516

1,615

18,187,716

Jharkhand

8,992,890

867,385

8,767,034,692

Karnataka

9,782,602

1,581,386

17,576,957,813

Kerala

6,621,730

2,478,238

19,135,502,001

Lakshadweep

1,636

1

1,800

Madhya Pradesh

24,791,352

853,881

12,140,065,052

Maharashtra

7,162,216

479,528

12,416,017,419

Manipur

313,634

36,759

453,214,817

Meghalaya

1,655,716

287,303

2,210,910,884

Mizoram

356,647

55,878

576,271,260

Nagaland

258,083

19,194

277,952,667

Puducherry

250,454

6,184

31,688,824

Punjab

7,021,511

756,583

8,631,451,965

Rajasthan*

1,336,147

7,809,870,450

Sikkim

36,667

4,012

37,808,637

Tamil Nadu

24,727,508

3,102,787

38,240,413,903

Tripura

1,255,479

99,404

670,014,773

Uttar Pradesh

14,189,874

769,531

7,965,274,653

Uttarakhand

3,973,158

308,192

3,960,546,591

West Bengal@

17,636

170,981,470

Undefined&

762,296

122,244

903,192,165

Irregularities in PMJAY Scheme – CAG Report

According to the CAG audit (audit No. 11 of 2023), there have been numerous anomalies with the PMJAY programme. The same mobile number “9999999999” has been used to register 7,49,820 beneficiaries for insurance, 1,39,300 beneficiaries under the same mobile number “8888888888,” and 96,046 beneficiaries under the same mobile number “9000000000.” Additionally, the investigation stated that at least 20 phone numbers were used repeatedly to register 10,000 and 50,000 individuals.

The number of family members among the 43,197 beneficiaries has been incorrectly represented as being between 11 and 201. The article also claims that 403 people who are thought to be deceased have received payments from the government totaling Rs 1.1 crore.

Also, 7.87 crore beneficiaries (73%) were enlisted in the programme initially out of a target of 10.74 crore (November 2022) eligible beneficiaries according to the SECC survey’s initial results. Subsequently, according to NFSA statistics, the CAG claimed that the government had increased this target to Rs 12 crore.

The Union Ministry of Health and Family Welfare clarified on August 17 that “under AB PM-JAY, hospitals are allowed to initiate request for pre-authorization upto three days post the date of admission in the hospital. In some cases, the patients got admitted and before their pre-authorization was raised, they died during the treatment. In such cases, the date of death is same as the admission date or earlier.”

 

 

Links

https://mera.pmjay.gov.in/

https://nha.gov.in/PM-JAY

https://web.umang.gov.in/landing/department/pradhan-mantri-jan-arogya-yojana.html

https://www.pib.gov.in/PressReleasePage.aspx?PRID=1738169

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