Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

SCHEME OBJECTIVE:To provide cashless quality medical care to beneficiaries under the scheme for catastrophic illnesses requiring hospitalization for surgeries and therapies under identified specialty services through network of health care providers.

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY):Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched by Government of India from 23rd September, 2018. AB-PMJAY was launched in the Maharashtra in integration with Mahatma Jyotirao Phule Jan Arogya Yojna and was implemented on mixed Insurance and Assurance Mode.

Beneficiaries under Pradhan Mantri Jan Arogya Yojana: The households included are based on the automatic inclusion, deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. There are 83.72 lakh families in state. This data is frozen hence additional families cannot be added. However new members in existing families can be added.

Key Features of PM-JAY

PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government.

It provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empanelled hospitals in India.
PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government.
Over 12 crore poor and vulnerable entitled families (approximately 55 crore beneficiaries) are eligible for these benefits.
PM-JAY provides cashless access to health care services for the beneficiary at the point of service, that is, the hospital.
PM-JAY envisions to help mitigate catastrophic expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year.
It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.
There is no restriction on the family size, age or gender.
All pre–existing conditions are covered from day one.
Benefits of the scheme are portable across the country i.e. a beneficiary can visit any empanelled public or private hospital in India to avail cashless treatment.
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.
Public hospitals are reimbursed for the healthcare services at par with the private hospitals.

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) is a scheme to provide health cover or health insurance of up to INR 5 lakh per family per year for certain beneficiaries. Like ABDM, it is also implemented by the National Health Authority. AB PM-JAY is leveraging the platform of ABDM, so that its delivery becomes more efficient and transparent. Similarly, any other such scheme or health programme can leverage the common building blocks or design of ABDM so that its efficiency can improve. The integration of ABDM with AB PM-JAY is like its integration with any other digital health system such as the one of NIKSHAY (antiTB programme), CoWIN (COVID vaccination portal), hospitals, etc. Apart from this integration, both the schemes have different goals. Thus, they are two different schemes being implemented by the same authority/office. However, AB PM-JAY has digital linkages with ABDM which enables effective quality and continuum of care.

Eligibility Criteria

Urban : For Urban area, 11 occupational criteria are identified as Rag pickers, Beggars, Domestic workers, Street vendors, Cobbler, hawkers, Construction workers, Plumbers, Masons, Painters, Welders, Sweepesrs Sanitation workesr, Mali, Home-based workers, Artisans, Handicrafts workers, Tailors, Transport workers, Drivers, Conductors, Helpers, Rickshaw pullers, Shop workers, Assistants, Peons, Attendants, Waiters, Electricians, Mechanics, Assemblers, Repair workers, Washer-men, Chowkidar.
Rural : Rural Criteria for rural area are from D1 to D7 which include families with only one room with kachha wall and kachha roof, No adult member between age 16 to 59, Female headed household s with no adult members between age 16 to 59, Disabled member and no able bodied adult member, SC/ST households, Landless households deriving major part of income from manual casual labour. Automatically Included category includes Households without shelter, Destitute-living on alms, Manual Scavenger Families, Primitive Tribal Groups and Legally released Bonded Labour.

Benefits

Ayushman Bharat PM-JAY provides a health cover of Rs. 5 lakhs per family per policy year for secondary and tertiary care hospitalization in any of empaneled hospitals across the country.
The benefit is available to each and every member of the family on floater basis.
The RSBY had a family cap of five members. However, based on learnings from those schemes, PM-JAY has been designed in such a way that there is no cap on family size or age of members
In addition, pre-existing diseases are covered from the very first day. This means that 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.
PMJAY beneficiary gets benefit of 1209 Medical and Surgical procedures (Additional 213 Medical and Surgical procedures) with 183 follow up procedures. There are 131 government reserved procedures out of 996 MJPJAY procedures and additional 37 government reserved procedures for PMJAY 1209 procedures.