The Government of India announced an ambitious health insurance scheme named Ayushman Bharat or Pradhan Mantri Jan Aarogya Yojana (PM-JAY in short) during the February budget this year and officially rolled it out in September 2018. This scheme is the new one which replaces the earlier Ayushman Bharat-National Health Protection Mission (AB-NHPM) and Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PMRSSM).
The government-funded scheme aims to benefit poor families in the country who will, under the PM-JAY scheme, get access to quality health facilities and services anywhere in India and not necessarily only in one’s own State. Citizens who fall within the scope of certain occupational categories of urban workers’ families will also benefit. The government also stated that this scheme is going to be cashless and paperless and is an entitlement one, with no formal enrollment process required and no premiums required to be paid.
Personal ID will also not be required to get treatment at a hospital. Thus, treatment cannot be denied for the non-possession of an Aadhar Card or for not producing it during the claim settlement process.
Benefits of PM-JAY
- Government provides health insurance cover of up to Rs. 5,00,000 per family per year.
- More than 10.74 crore poor and vulnerable families (approximately 50 crore beneficiaries) covered across the country.
- All families listed in the SECC database as per defined criteria will be covered. No cap on family size and age of members.
- Priority to girl child, women and and senior citizens.
- Free treatment available at all public and empaneled private hospitals in times of need.
- Covers secondary and tertiary care hospitalization.
- 1,350 medical packages covering surgery, medical and day care treatments, cost of medicines and diagnostics.
- All pre-existing diseases covered. Hospitals cannot deny treatment.
- Cashless and paperless access to quality health care services.
- Hospitals will not be allowed to charge any additional money from beneficiaries for the treatment.
- Eligible beneificiares can avail services across India, offering benefit of national portability. Can reach out for information, assistance, complaints and grievances to a 24X7 helpline number – 14555
- Help India progressively achieve Universal Health Coverage (UHC) and Sustainable Development Goals (SDG).
- Ensure improved access and affordability, of quality secondary and tertiary care services through a combination of public hospitals and well measured strategic purchasing of services in health care deficit areas, from private care providers, especially the not-for profit providers.
- Significantly reduce out of pocket expenditure for hospitalization. Mitigate financial risk arising out of catastrophic health episodes and consequent impoverishment for poor and vulnerable families.
- Acting as a steward, align the growth of private sector with public health goals.
- Enhanced used to of evidence based health care and cost control for improved health outcomes.
- Strengthen public health care systems through infusion of insurance revenues.
- Enable creation of new health infrastructure in rural, remote and under-served areas.
- Increase health expenditure by Government as a percentage of GDP.
Enhanced patient satisfaction.
- Improved health outcomes.
- Improvement in population-level productivity and efficiency
- Improved quality of life for the population
List of Medical Specialties
The following is the list of the Specialties for which medical financial aid is provided under the Ayushman Bharat Scheme:
- Cardio-vascular surgery.
- Cardio-thoracic surgery.
- Obstetrics & Gynaecology.
- General Surgery.
- Neurosurgery Interventional Neuroradiology.
- Plastic & reconstructive.
- Burns management.
- Oral and Maxillofacial Surgery.
- Paediatric medical management.
- Paediatric cancer.
- Paediatric surgery.
- Medical packages.
- Emergency Room Packages (Care requiring less than 12 hrs stay) .
- Mental Disorders Packages.
How to check eligibility
Know if you are eligible at: PM – Jan Arogya Yojana eligibility check page. You need to enter a valid mobile number. On getting a six-digit One-Time Password (OTP) you can then use the search criteria.
You can use the search features to know if you are an eligible beneficiary for PM-JAY using any of these:
- With Mobile number/Ration Card Number. This data was collected during an additional data drive earlier this year by Gram Sabhas all over India.
- With Socio-Economic Caste Census (SECC) Name: You can search using your details as per the SECC database such as Name, Father’s Name, Gender, State etc. Even now, if no results are displayed, then the user should contact a nearby Ayushmaan Mitra (the person at the Help Desk of a hospital.)
- With RSBY URN : Additionally, all active families that are enrolled under Rashtriya Swasthya Bima Yojna (RSBY) till 31st March 2018 that do not feature in the targeted groups as per SECC data will be included as well and can identify if they are eligible for PM-JAY using their RSBY URN (Unique Relationship Number).
On the successful completion of the search, you have the option to receive a text message with the Household Id number (known as HHID number)/RSBY URN for future purposes on your mobile phone by clicking the “Get SMS” button and entering your mobile number. [Note: This mobile number can be different from the mobile number used in the first step for getting the OTP.]
How to file and settle claims
There will be a dedicated official person known as “Ayushmaan Mitra” at a Help Desk to guide the patient to coordinate the entire process, coordinating between the beneficiary and the hospital. It is proposed to have some kind of QR code for a beneficiary. This code will be scanned and then eligibility checked via the Beneficiary Identification System (BIS) for which guidelines are provided by the Government.
Being a paperless scheme, all claims will be settled via online mode. The claim will be raised to the insurance agency or the Trust, as the case may be, who will then scrutinize and review the documents. Within 15 days of the claim being filed, the payment will be made electronically.
It should be noted that for each medical package, it is mandatory to submit/upload details of specific Pre and Post-op Investigations for pre-authorization/claims’ settlement purposes. The costs for such investigations will, though, form part of the approved package cost.
At the State level, there is a helpline number for each State, namely 104, which will be accessible to all citizens. Citizens can also call for information, assistance, complaints and grievances to a 24X7 helpline number: 14555.