Ayushman Bharat, a flagship scheme of the Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to "leave no one behind."
Ayushman Bharat is an attempt to move from a sectoral and segmented approach to health service delivery to a comprehensive need-based health care service. This scheme aims to undertake path-breaking interventions to holistically address the healthcare system (covering prevention, promotion, and ambulatory care) at the primary, secondary, and tertiary levels. Ayushman Bharat adopts a continuum of care approach, comprising two inter-related components, which are -
1. Health and Wellness Centres (HWCs)
2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)
Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) was launched on 23rd September 2018 in Ranchi, Jharkhand by the Hon’ble Prime Minister of India, Shri Narendra Modi.
AB PM-JAY is the largest health assurance scheme in the world which aims at providing a health cover of ₹ 5,00,000 per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries) that form bottom 40% of the Indian population. The households included is based on the deprivation and occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. PM-JAY is fully funded by the Government and the cost of implementation is shared between the Central and State Governments.
AB PM-JAY provides cashless cover of up to ₹ 5,00,000/- to each eligible family per annum for listed secondary and tertiary care conditions. The cover under the scheme includes all expenses incurred on the following components of the treatment:
Medical examination, treatment, and consultation
Pre-hospitalization
Medicine and medical consumables
Non-intensive and intensive care services
Diagnostic and laboratory investigations
Medical implantation services (where necessary)
Accommodation benefits
Food services
Complications arising during treatment
Post-hospitalization follow-up care up to 15 days
The benefits of ₹ 5,00,000/- are on a family floater basis which means that it can be used by one or all members of the family. Under AB PM-JAY, there is no cap on family size or the age of members. In addition, pre-existing diseases are covered from the very first day. Any eligible person suffering from any medical condition before being covered by PM-JAY will now be able to get treatment for all those medical conditions as well under this scheme right from the day they are enrolled.
Out of the total seven deprivation criteria for rural areas, PM-JAY covered all such families who fall into at least one of the following six deprivation criteria and automatic inclusion(Destitute/ living on alms, manual scavenger households, primitive tribal group, legally released bonded labour) criteria:
Only one room with kucha walls and kucha roof
No adult member between ages 16 to 59
Households with no adult male member between ages 16 to 59
Disabled member and no able-bodied adult member
SC/ST households
Landless households deriving a major part of their income from manual casual labour
Urban Beneficiaries
For urban areas, the following 11 occupational categories of workers are eligible for the scheme:
Ragpicker
Beggar
Domestic worker
Street vendor/ Cobbler/hawker / other service provider working on streets
Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and other head-load worker
The Arogya Mitra searches the available list of beneficiaries using details such as name, location, ration card number, mobile number, or the RSBY URN of the beneficiary. After this, the beneficiary is searched for in the BIS. The individual is identified and the scanned valid ID documents are then uploaded.
To get a PMJAY e-card for themselves and their family, a potential beneficiary needs to visit either a hospital or a Community Service Centre (CSC) for identification and follow the steps mentioned below:
Step 1: Potential AB-PMJAY beneficiaries are to submit the PM letter/ RSBY URN/ RC Number/ Mobile Number - The operator (commonly known as the Arogya Mitra) searches the available list of beneficiaries. The operator does this by entering details such as name, location, Ration Card number, mobile number, or even RSBY URN of the beneficiary.
Step 2: Search in the BIS Application - The operator searches for the potential beneficiary in the entitled SECC, RSBY, State Health Scheme, Additional Data Collection Drive databases.
Step 3: Individual Identification - The identification process is carried out if the name is found in the list. For this, documents like Aadhaar or any government ID and a Ration Card or an alternative family ID are required to validate against the details available in the system. Scanned documents are then uploaded.
Step 4: Family Identification - The Arogya Mitra then identifies the family records through the ration card and the scanned documents are then uploaded. The Arogya Mitra then submits the individual and family records to the trust/insurance company for approval.
Step 5: Approval or Rejection - The Health insurance company or trust may then approve or recommend rejection for the submitted beneficiaries. The cases that are recommended for rejection will be finally verified for approval or rejection by the State Health Agency (SHA).
Step 6: E-card Issuance - On approval by SHA/insurance company/trust, an e-card will be issued to the beneficiary.
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Will beneficiaries have to pay anything to get covered under this scheme?
No. All eligible beneficiaries can avail free services for secondary and tertiary hospital care for identified packages under PM-JAY at public hospitals and empaneled private hospitals. Beneficiaries will have cashless and paperless access to health services under PM-JAY.
What is the enrollment process? Is there any time period for enrollment?
PM-JAY is an entitlement based mission. There is no enrollment process. Families who are identified by the government on the basis of deprivation and occupational criteria using the SECC database both in rural and urban areas are entitled for PM-JAY.
Will a card be given to the beneficiary?
A dedicated PM-JAY family identification number will be allotted to eligible families. Additionally, an e-card will also be given to beneficiary at the time of hospitalization.
Are Already existing illnesses covered under this scheme?
Yes. All existing medical conditions / Illnesses are covered under this scheme.
Are Benefits available for New born child under this scheme?
Yes. New born child can be provided treatment under this scheme. They can also be added into beneficiary family after providing necessary documents.
Are RSBY cardholders covered under the scheme?
Any family that has an active RSBY card as of 28 February 2018 is covered under the Ayushman Bharat Pradhan mantra Jan Arogya Yojana.
Can benefits under this scheme be available without Aadhar Card?
Yes. Aadhar card is not mandatory for availing services under this scheme.
What Who Is Aarogya Mitra?
An Ayushman Mitra (AM) is a certified frontline health service professional who is present at each of the EHCP and serves as a first contact point for beneficiaries. They will help in processing documents for Beneficiary identification as well as complete claim process along with Medical Coordinator. They are available at Ayushman Bharat Kiosk in every EHCP to assist patients.
How does Claim Submission process work?
Once patient is discharged from the EHCP, the claim submission process is initiated by raising request on online portal with patient’s discharge summary along with other necessary clinical notes and investigation reports. EHCP is required to submit claims within 24 hours of discharge of patient.
What Is Pradhan Mantri Jan Arogya Yojana(PM-JAY)?
Pradhan Mantri Jan Arogya Yojana(PM-JAY) is a pioneering initiative of Prime Minister Modi to ensure that the poor and vulnerable population is provided health coverage. This initiative is part of the Government’s vision to ensure that its citizens – especially the poor and vulnerable groups have universal access to good quality hospital services without anyone having to face financial hardship as a consequence of using health services.
What Health Services Are Available Under PM-JAY?
The health services covered under the program include hospitalization expenses, daycare surgeries, follow-up care, pre and post-hospitalization expense benefits, and newborn child/children services. The comprehensive list of services is available on the website.
Where Can Beneficiaries Avail Of Services Under PM-JAY?
Services under the scheme can be availed at all public hospitals and empaneled private healthcare facilities. Empanelment of the hospitals under PM-JAY will be conducted through an online portal by the state government. Information about empaneled hospitals will be made available at through different means such as government website, mobile app. Beneficiaries can also call the helpline number at 14555. Regular updates will also be provided through ASHAs, ANM and other specific touch points This information will be activated shortly.
Will Beneficiaries Have To Pay Anything To Get Covered Under This Scheme?
No. All eligible beneficiaries can avail free services for secondary and tertiary hospital care for identified packages under PM-JAY at public hospitals and empaneled private hospitals. Beneficiaries will have cashless and paperless access to health services under PM-JAY.
How Are The Beneficiaries Identified?
The beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC (Socio-Economic Caste Census) database for rural areas and 11 occupational criteria for urban areas. In addition, RSBY beneficiaries in states where RSBY is active are also included.
Can Those Families Whose Names Are Not On The List Avail The Benefits Under PM-JAY?
In this phase, no additional new families can be added under PM-JAY. However, the names of additional family members can be added for those families whose names are already on the SECC list.
What Is The Maximum Time Required For Approval Of Claim Submission Requests?
Once all claims documents are submitted, the claim must be approved within 15 days to SHA for final approval and payment processing. SHA will make payment of claims within 15 days after being authenticated by their internal team.
Who Are The Members Of Various Grievance Committees?
AB PMJAY has a three-tier grievance redressal structure to ensure the timely redressal of grievances. This section of the guidelines lays down these structures, their constitution, and their functions. District Grievance Redressal Committee (DGRC) – will be constituted by the SHA in each district and this is chaired by Head of the District or District Magistrate or District Collector or Deputy Commissioner. The State Grievance Redressal Committee (SGRC) is chaired by CEO of SHA / State Nodal Agency (SNA). The SGRC shall perform all functions related to handling and resolution of all grievances received either directly or escalated through the DGRC. The National Grievance Redressal Committee (NGRC) will be chaired by Deputy CEO of National Health Agency (NHA). The NGRC shall act as the final Appellate Authority at the national level. The NGRC shall only accept appeals and petitions against the orders of the SGRC of a State. The decision of NGRC will be final.
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Frequently Asked Questions
Ayushman Bharat, a flagship scheme of the Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to "leave no one behind."
Ayushman Bharat is an attempt to move from a sectoral and segmented approach to health service delivery to a comprehensive need-based health care service. This scheme aims to undertake path-breaking interventions to holistically address the healthcare system (covering prevention, promotion, and ambulatory care) at the primary, secondary, and tertiary levels. Ayushman Bharat adopts a continuum of care approach, comprising two inter-related components, which are -
1. Health and Wellness Centres (HWCs)
2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)
Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) was launched on 23rd September 2018 in Ranchi, Jharkhand by the Hon’ble Prime Minister of India, Shri Narendra Modi.
AB PM-JAY is the largest health assurance scheme in the world which aims at providing a health cover of ₹ 5,00,000 per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries) that form bottom 40% of the Indian population. The households included is based on the deprivation and occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. PM-JAY is fully funded by the Government and the cost of implementation is shared between the Central and State Governments.
