Health Insurance

Ayushman Bharat Yojana Mystery Revealed in 2021

Ayushman Bharat Yojana

Overview about Ayushman Bharat Yojana

In 2017 as recommended by National Health Policy, the Government of India had launched a flagship health scheme called Ayushman Bharat Yojana. The motive of this scheme, Ayushman Bharat Yojana has the intent to meet the Sustainable Development Goals (SGDs). This was the vision of Universal Health Coverage (UHC) which is to “leave no one behind”.

The reason behind the Ayushman Bharat Yojana, to form a health care ecosystem that is separate from the previous sectoral segmented approach to a completely need-based health care system.

This scheme has been specially designed to take care of the health issue from the first step to till cure. This scheme covers primary stages like prevention, promotion, and ambulance care and it takes care of the secondary and tertiary levels also.

Ayushman Bharat Yojana

Ayushman Bharat Yojana comprises two interrelated schemes to take care of the health ecosystem.

  1. Health and Wellness Centers (HWCs)
  2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Health and Wellness Centers 

The motive of these health and wellness centers is to bring the health ecosystem nearer to common people’s homes to take the benefit. So, in 2018 February month the GOI had announced the creation of a 1,50,000 (One Lakh Fifty Thousand) health and wellness center. All these centers are newly transformed from the existing old sub-health centers and primary health centers.

Both the centers cover all types of including child care to maternity care and non-communicable diseases. They also give free medicines and diagnostic services to the people.

The motive of the health and wellness centers is to give primary health care services to the entire population of that area. By encouraging this type of facilities this main objective was to keep people healthy and engaging so that people will be safe from developing chronic diseases and morbidities.

Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Pradhan Mantri Jan Arogya Yojana was launched on 23 September 2018 in Ranchi, Jharkhand. This scheme was inaugurated by the Hon’ble prime Minister of India, Shri Narendra Modi. This scheme is popularly known as PM-JAY.

This scheme is a complete health insurance package with Rs. 5 Lakh coverage from primary to the tertiary health issue. This is the world’s largest health insurance which covers 50% of the population of India. This data comes from the census of 2011.

This scheme was previously known as National Health Protection Scheme (NHPS). This scheme is completely governed and funded by the Government of India and implementation costs are borne by both the Central and State government.

What are the Key Features of Pradhan Mantri Jan Arogya Yojana (PM-JAY?)

  • It is the largest health insurance scheme operated by the Government
  • Gives Rs. 5 Lakhs health coverage per family per year in public and private tie-up hospitals in India
  • According to census 2011 around 50 beneficiaries can avail this health service
  • PM-JAY scheme gives you cashless benefits for the beneficiary at the point of service in the hospital
  • PM-JAY scheme helps from the expensive medical expenses
  • Under this scheme one can avail of 3 days pre-hospitalization and 15 days post-hospitalization expenses.
  • The best part of this scheme is there are no checkpoints like family size, age, or gender
  • Any type of pre-existing conditions also covered from day one
  • You can port the benefits of this scheme across India. To avail of this benefit, you have to visit any public or private tie-up hospitals
  • As per official data this scheme can cover approximately 1393 health-related costs during treatment
  • In public hospitals, they reimbursed for the total health care services at par with private hospitals

What is the Benefits Cover under Pradhan Mantri Jan Arogya Yojana (PM-JAY?)

  • Beneficiary can get the health examination, consultation, and treatment under this scheme
  • Includes pre-hospitalization for 3 days and post-hospitalization expenses for 15 days
  • Receives free medicine and medical consumables
  • Includes Intensive and non-intensive care facilities in the hospital
  • Benefits of diagnostics and laboratory investigations
  • Includes benefits of medical implantation services
  • Includes accommodation and food services without any additional cost
  • Includes services during complications during medical treatment
  • All pre-existing health issues are covered under this scheme

All the benefits mentioned above come under this scheme and up to Rs. 5 lakhs coverage for the whole family per year. This is a floater health insurance so; if a family member reimbursed Rs. 2 lakhs during the first policy month then the rest Rs. 3 lakhs is available for the whole family for the rest policy year.

Any person who is already suffering from any medical condition can get the benefits of treatment after enrolling himself under this Pradhan Mantri Jan Arogya Yojana (PM-JAY) scheme.

Who are the Eligible Beneficiaries of the Ayushman Bharat Yojana?

When this scheme was launched the main purpose of this scheme was to cater to the bottom 40% of people who are not eligible to take health care insurance. If you calculate the actual number then it will be around 10.74 crore households.

 As per Socio-Economic Caste Census 2011 (SECC 2011) survey, this is eligible for both rural and urban area people who fall under the criteria.

Pradhan Mantri Jan Arogya Yojana (PM-JAY) has identified the potential target families who can be the beneficiaries of this scheme. In rural areas government has made seven deprivation criteria from (D1 to D7) but in urban areas, they are categorized as per their occupation category. 

Beneficiaries from Rural Area

     D1- People with one room with kucha wall and kucha roof

     D2- No adult member in the family between ages 16 to 59

     D3- No male adult member in the family between ages 16 to 59

     D-4-Householdwith disabled member and no able-bodied adult member

     D-5- People who belong to SC/ST category

     D-7- Landless People derives a major part of their income from manual casual labor

Beneficiaries from Urban Area

In urban areas below mentioned 11 categories people are eligible for the scheme.

  1. Domestic worker
  2. Beggar
  3. Ragpicker
  4. Mali/Sweeper/Sanitation worker
  5. Chowkidar/Washer-man
  6. Tailor/Artisan/Home-based worker and Handicraft worker
  7. Cobbler/Street vendor/hawker and other service providers on streets
  8. Helper/Attendant/Assistant/Waiter/Shop worker/Peon in small establishment/Delivery Assistant
  9. Welder/Mason/Coolie/Painter/Labour/construction worker/helper to drivers and conductors/Rickshaw puller and Cart puller
  10. Repair worker/Electrician/Mechanic/Assembler
  11. Plumber/Security Guard and other head-load workers

Apart from this PMJAY scheme, many states are already having their health schemes to give the benefits. But all the states are ensured to give the benefits to the according to the above criteria.

Pradhan Mantri Jan Arogya Yojana (PM-JAY) Packages and Rates for Beneficiaries

Sometimes hospitals are overcharged for the treatments in the hospital, so check that charges all the impaneled health care service providers are paid as per specific package rate decided by the government.

All packages include all expenses attached with the treatment including pre and post-hospitalization costs. The treatment packages are covered 24 specialties treatments including major surgeries like oncology, cardiovascular surgery, neurosurgery, and cardiothoracic. 

To take as a sample daycare package includes below benefits for beneficiaries:

  • Registration cost and General ward bed charges
  • Boarding and Nursing charges
  • Medicines and Drugs charges
  • Anesthetists, Surgeons, Consultant and medical Practitioner’s fees
  • Includes the cost of Prosthetic devices or implants
  • All pathology and radiology tests
  • Blood transfusion, Oxygen, Anesthesia, O.T. Charges, and cost of surgical appliances
  • Food of Patient
  • Pre and Post hospitalization expenses. 
  • If any other expenses related to the treatment of the patient

In some cases, the expense is too high because of the severity of the disease. In these cases, hospitals can be paid a higher amount after valid verification.

IF a surgical condition is not mentioned in the package then the impaneled hospital takes prior approval and fixes the rate from the insurer/SHA before giving the treatment to the patient up to a limit of Rs. 1,00,000.

Awareness and Communication about Pradhan Mantri Jan Arogya Yojana (PM-JAY)

After all this effort the main thing is to spread awareness about the scheme to the eligible people. To encourage the beneficiaries’ government has initiated it through various modes like TV, radio, hoarding, leaflets, and booklets are important to communication medium to reach across the eligible audience.

To spread this awareness government has dedicated 30th April 2018 named as “Ayushman Bharat Diwas”. To spread this awareness there are approximately 3 lakh villages covered by ASHA & ANMs and Gram Sevak volunteers. 

The government has dedicated a specific website having full details about the scheme to various stakeholders.

Grievance Redressal

During the cashless treatment and in the time of reimbursement there might be some issue arise, so to address this type of issue and giving justice to the beneficiary without compromising in the quality of treatment the Grievance Redressal comes into effect.

It is a three-tier Grievance Redressal Committee structure set up at the National, State, and district levels to resolve this type of issue.

You can submit your complaints through a letter or online portal which is developed by NHA. There are some other ways like SMS, telephone call, e-mail and by Fax, complaints can also be registered.

The Nationwide Call Center number is 14555/1800111565 for Grievance Redressal.

The timeline for addressing the issue is 30 days after the complaint is registered.

The partnership between National Health Authority (NHA) and Employee’s State Insurance Corporation (ESIC)

After the formation of Ayushman Bharat Yojana, the National Health Authority (NHA) and the Employee’s State Insurance Corporation (ESIC) has tied up to make an ecosystem wherein both beneficiaries will be able to get the medical services at impaneled hospitals.

This agreement between PM-JAY and ESIC was a landmark initiative to develop a better health ecosystem in the country. By this policy and through the established hospital network people will get better health benefits packages.

Key Benefits of AYUSHMAN BHARAT PM-JAY and ESIS Tie-Up

  • ESIC beneficiaries will be benefited from healthcare providers under AB PM-JAY
  • AB PM-JAY beneficiaries will access health services in ESIC impaneled hospitals across the country
  • Beneficiaries of ESIC can get free treatment at AB PM-JAY impaneled hospitals by showing their ESIS card
  • Beneficiaries of AB PM-JAY can get free medical treatment at ESIC impaneled hospitals by using their PM-JAY card
  • You can get more information by calling ESIC toll free number: 1800 112 526/ 1800 113 839

Conclusion

Ayushman Bharat Yojana was a historic announcement for our health ecosystem. Through this health scheme, approximately 40% of the poor and vulnerable people of India will be benefited.

Every year nearly 6 crore Indians are pushed into poverty due to the catastrophic expenditure on medical treatment. It is fully funded by the Government of India and infrastructure cost-shared by both Central and State governments.

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