Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Overview

Ayushman Bharat, a flagship initiative of the Government of India, was launched in line with the recommendations of the National Health Policy 2017 to achieve the vision of Universal Health Coverage (UHC). The scheme is a transformative step aimed at meeting the Sustainable Development Goals (SDGs) and adhering to the principle of “leaving no one behind.”

The scheme seeks to shift from a fragmented and segmented approach to health service delivery to a comprehensive, need-based healthcare system. It introduces groundbreaking interventions to address healthcare comprehensively, encompassing prevention, promotion, and ambulatory care at primary, secondary, and tertiary levels. Ayushman Bharat adopts a continuum of care approach through two interconnected components:

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 officially launched on September 23, 2018, by the Hon’ble Prime Minister of India, Shri Narendra Modi, in Ranchi, Jharkhand.

Key Features of PM-JAY

AB PM-JAY is the largest health assurance scheme in the world, aiming to provide health coverage of ₹5,00,000 per family annually for secondary and tertiary care hospitalization. It targets over 10.74 crore poor and vulnerable families (approximately 50 crore beneficiaries), which constitute the bottom 40% of the Indian population. The beneficiaries are identified based on the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas.

The scheme is entirely funded by the government, with the implementation costs shared between the Central and State Governments.

Benefits of PM-JAY

The scheme provides cashless health cover of up to ₹5,00,000 per family per year for listed secondary and tertiary care conditions. The coverage includes all expenses incurred on various components of treatment, such as:

• Medical examination, treatment, and consultation.
• Pre-hospitalization expenses.
• Medicines and consumables.
• Non-intensive and intensive care services.
• Diagnostic and laboratory investigations.
• Medical implantation services (where required).
• Hospital accommodation benefits.
• Food services during hospitalization.
• Complications arising during treatment.
• Post-hospitalization follow-up care for up to 15 days.

Family Floater Benefit

The ₹5,00,000 benefit is available on a family floater basis, meaning any family member(s) can use the entire sum insured.

• No cap on family size or age: All family members are eligible for benefits, irrespective of their age or number.
• Pre-existing conditions covered: Diseases or conditions existing prior to enrollment are covered from day one of joining the scheme.

Eligibility Criteria

Rural Beneficiaries

Families in rural areas are covered if they meet at least one of the following six deprivation criteria or are included under automatic inclusion criteria, such as:

1. Living in a single room with kucha walls and roof.
2. No adult member aged 16-59 years in the household.
3. Households without an adult male member aged 16-59 years.
4. Households with a disabled member and no able-bodied adult member.
5. Scheduled Caste (SC) or Scheduled Tribe (ST) households.
6. Landless households earning primarily through manual casual labor.

Automatic Inclusion Categories:

• Destitute or those living on alms.
• Manual scavenger households.
• Primitive tribal groups.
• Legally released bonded laborers.

Urban Beneficiaries

In urban areas, individuals from the following 11 occupational categories are eligible:

1. Ragpickers.
2. Beggars.
3. Domestic workers.
4. Street vendors, cobblers, hawkers, and other street service providers.
5. Construction workers, plumbers, masons, laborers, painters, welders, and other manual workers.
6. Sweepers, sanitation workers, and gardeners (mali).
7. Home-based workers, artisans, and handicrafts workers, including tailors.
8. Transport workers such as drivers, conductors, and helpers to drivers or conductors.
9. Shop workers, assistants, peons, helpers, delivery assistants, and waiters.
10. Electricians, mechanics, assemblers, and repair workers.
11. Washermen and chowkidars.

Exclusions

The following groups are not eligible under PM-JAY:

1. Owners of two-wheelers, three-wheelers, four-wheelers, or motorized fishing boats.
2. Owners of mechanized farming equipment.
3. Individuals holding Kisan Credit Cards with a credit limit of ₹50,000 or above.
4. Government employees.
5. Individuals working in non-agricultural government-managed enterprises.
6. Those earning a monthly income exceeding ₹10,000.
7. Households owning refrigerators or landline phones.
8. Families residing in pucca (well-built) houses.
9. Owners of five acres or more of agricultural land.

Application Process

Offline Enrollment Process

Beneficiaries can visit a hospital or a Community Service Centre (CSC) for identification and enrollment. The steps are as follows:

1. Submission of Basic Information:
   • Potential beneficiaries submit details such as their name, location, ration card number, mobile number, or RSBY Unique Registration Number (URN) to an Arogya Mitra, who searches the beneficiary database.
2. Search in BIS Application:
   • The operator verifies details in databases, including SECC, RSBY, State Health Schemes, and Additional Data Collection Drives.
3. Individual Identification:
   • Beneficiaries provide documents like Aadhaar cards or any government ID for verification. Ration cards or family IDs are required to confirm family details. These documents are scanned and uploaded.
4. Family Identification:
   • The operator identifies family records, scans and uploads related documents, and submits them to the trust/insurance company for approval.
5. Approval or Rejection:
   • The insurance company or trust reviews the application. Cases recommended for rejection are further verified by the State Health Agency (SHA) for final approval or rejection.
6. Issuance of E-Card:
   • Upon approval by the SHA or insurance company, an e-card is issued to the beneficiary.

Documents Required

To enroll in the PM-JAY scheme, the following documents are required:

1. Age and identity proof (Aadhaar Card or PAN Card).
2. Proof of address.
3. Contact details (mobile number and email address).
4. Caste certificate (if applicable).
5. Income certificate.
6. Proof of family structure (joint or nuclear family).
7. Aadhaar Card for biometric authentication.

Key Highlights of PM-JAY

1. Accessibility:
   • Beneficiaries can avail of cashless treatment in empaneled hospitals across the country.
   • The scheme covers a wide range of secondary and tertiary care conditions, including critical treatments like cancer and organ transplants.
2. No Age or Family Size Restrictions:
   • Entire families, irrespective of size or age, are eligible.
3. Pre-Existing Conditions Covered:
   • Patients can receive treatment for illnesses existing before enrollment.
4. Wide Reach:
   • Covering 50 crore people, PM-JAY aims to bring quality healthcare within reach of the underprivileged.
5. Zero Financial Burden:
   • The scheme ensures that beneficiaries do not face financial difficulties due to hospitalization.

Conclusion

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana is a revolutionary step towards ensuring universal health coverage in India. By targeting the bottom 40% of the population, it strives to eliminate barriers to healthcare access for millions of underprivileged families. The scheme not only reduces the financial burden of medical expenses but also strengthens the overall healthcare infrastructure in the country. With its comprehensive coverage, cashless benefits, and inclusivity, PM-JAY is paving the way for a healthier and more equitable India.