Ayushman Bharat Yojana

Ayushman Bharat Yojana

Ayushman Bharat Yojana is the world’s largest health insurance scheme that provides a health insurance cover of Rs 5 lacs to each Indian family who is eligible.

The scheme caters to nearly 50 crore beneficiaries and provides them access to tertiary and secondary care hospitalization, which is 40% of the Indian poor and vulnerable families. Ayushman Bharat Yojana eligibility is divided among the households in both rural and urban areas, which are categorized based on the occupational and deprivation criteria of Socio-Economic Caste Census 2011.

It was launched with a vision to help mitigate exorbitant medical expenses that push close to 6 Crore Indians towards poverty annually.

Before it was rechristened the scheme was termed as the National Health Protection Scheme. It subsumed the current Rashtriya Swasthya Bima Yojana that was launched in 2008. It also covers the families that were covered under RSBY but are not present in the SECC 2011 database. This scheme is funded by the Indian Government.

Pvt Health Insurance Ayushman Bharat Yojana
Maximum sum insured of up to Rs. 3crore Maximum sum insured of up to Rs. 5Lakh
Free health check – up No free health check – ups
Pre – hospitalization up to 60 days & post – hospitalization up to 180 days Pre – hospitalization up to 3 days & post – hospitalization up to 15 days
Most plans cover 20+ critical illnesses, including lung cancer, stroke, paralysis, etc. Only 9 critical illnesses are covered, excluding lung cancer, stroke, paralysis, etc .
OPD expenses, including doctor consultation costs, covered OPD cover not covered
Home treatment covered Home treatment not covered
Plans start from Rs. 7/days* Premiums fully paid by the government
No claim bonus granted for every claim – free year No claim bonus is not granted
Tax benefits available up to Rs. 1lakh No tax benefits available
Single private hospital room available Single private hospital room may or may not be available

Key Features of Ayushman Bharat PM-JAY

A well-defined cover of Rs. 5lakh will be provided to every eligible family, every year.
The beneficiaries will be permitted to avail primary, secondary, and tertiary healthcare services from any of the empanelled public or empanelled private hospitals.
The benefits will be entirely cashless and portable. This means that neither would the beneficiary have to wait for reimbursements, nor would their location impact their ability to access healthcare.
The beneficiaries would be identified on the basis of the same deprivation criteria which were used while conducting the socio-economic caste census. This would help determine their entitlement.
The principle of cooperative federalism would be strictly followed by giving adequate flexibility to the states in terms of expenditure incurred.
The payments would be made on a package basis. The total costs, specific services and procedures which can be included in the package would be defined by the government in charge.
An Ayushman Bharat National Health Protection Mission Council would be set up to facilitate coordination between the central and state governments. This apex body would be chaired by the Union minister for health and family welfare. To know more about Ayushman Bharat Yojana (आयुष्मान भारत योजना), please refer to official website.
An Ayushman Bharat National Health Protection Mission Council would be set up to facilitate coordination between the central and state governments. This apex body would be chaired by the Union minister for health and family welfare. To know more about Ayushman Bharat Yojana (आयुष्मान भारत योजना), please refer to official website.
Each state would be asked to create a health agency in order to seamlessly implement the scheme.
An inter-operable and robust IT platform would be designed under the leadership of NITI Aayog, to make sure that all transactions under the plan remain paperless and scalable

10 Benefits Cover under PM-JAY

Most of the Government-funded medical insurance schemes offer a limit cover up to Rs 3Lakh only. However, Ayushman Bharat Yojana or PM-JAY provides cover up to Rs 5Lakh along with cashless medical treatment facility to the beneficiaries in both public and private hospitals in India. Each family in India who fit the Ayushman Bharat Yojana eligibility criteria can avail this sum insured for defined secondary as well as tertiary care conditions.

This scheme recompenses all the expenses incurred on the following medical treatments.

  • Medical examination, treatment and consultation
  • Pre-hospitalization expenses
  • Post-hospitalization follow-up care up to 15 days
  • Diagnostic procedures and lab investigation charges
  • Cost of Medicine and medical consumables expenses are covered
  • Non-intensive and intensive care services
  • Accommodation benefits
  • Medical implantation services (where necessary)
  • Food services
  • Treatment resulting in complications
  • All out-of-pocket expenses incurred during the hospitalisation process would be covered.
  • Irrespective of whether the hospital is public or empanelled private, the insurance provided would be in a completely cashless format.
  • A transport allowance would be paid to the beneficiary, which will cover the cost of travel during the pre and post hospitalisation period.
  • Daycare treatment facilities would be made available within the insurance package.

PMJAY Critical Illness Coverage

It helps the families by giving access to healthcare services and also offers assistance for day care procedures, including pre-existing illnesses. The scheme covers nearly 1,350 medical packages at both public and private network hospitals across India.

List of Critical Diseases covered under Ayushman Bharat Health Scheme

Some of the Critical illnesses that the policy covers are as follows:

  • Double valve replacement
  • Prostate cancer
  • Coronary ABG
  • Carotid angioplasty with stent
  • Anterior spine fixation
  • Pulmonary valve replacement
  • Skull base surgery
  • Laryngopharyngectomy
  • Tissue expander for disfigurement in case of burns

Ayushman Bharat Health Scheme has limited exclusions, which are as follows:

  • Drug rehabilitation programme
  • OPD expenses
  • Organ transplants
  • Cosmetic procedures
  • Fertility related procedures

Registration

  • Empanel all individuals and families in the catchment area and update this database regularly when there is a new entrant into this area, or someone exits.
  • Facilitate identification and registration of beneficiaries/ families for Pradhan Mantri Jan Arogya Yojana as per laid down criteria.
  • Ensure that every family and individual have been allotted and are aware of their unique Health ID – which would also be used to seek services under various programmes such as RCH/ RNTCP/ NVBDCP etc and support beneficiaries to seek services under the PMJAY.
  • Link the unique health ID with the AADHAAR ID at the back end in line with the current statute and Supreme Court directions.
  • Identify and merge duplicates by verifying IDs.
  • Create a longitudinal health record of each empanelled individual.

Service Delivery

  • Record all services that are delivered at the HWC under different programmes.
  • Enable follow up of services that individual patients are receiving by recording relevant parameters, diagnostic results, medication given etc.
  • Send SMS/ reminders to individuals about the follow up visits.
  • Facilitate clinical decision making for the service providers (based on standard treatment protocols).
  • Track and support upward and downward referrals to support continuity of care.
  • Ability to print key summary and prescription based on individual’s requirement.
  • Ability to provide standardized prescription, discharge summary and/or referral note which can be scanned/photographed or printed and uploaded as per requirement.
  • Capture, store and transmit images to support teleconsultation, referral and follow up.

Management of Service Delivery

  • Capture service delivery coverage and measure health outcomes using population-based analytics.
  • Generate work plans for the teams with alert and reminder feature for services providers to support scheduling of appointments, follow up home visits and outreach activities.
  • Use the service delivery data to validate use of services and enable Direct Bank Transfers to beneficiaries wherever required.
  • Support Birth and death registrations and disease surveillance.
  • Capture record of other preventive and promotive services delivered, like vector control etc.
  • z Send appropriate IEC/BCC messages.

Logistics

  • 1. Support Inventory management and regular supply of medicines, vaccines and consumables by linking with DVDMS – Drugs and Vaccines Delivery Management Systems.
  • Support biomedical equipment maintenance of all equipment by maintaining database for equipment at HWC.

Capacity Building

  • Provide Job aids (in the form of flow charts or audio/ video aids) for continuous learning and support of the primary health care team.
  • Support access to Massive open online courses (MOOC) and use of platform such as ECHO for regular capacity building and problem solving for HWC teams both at SHC and PHC level.

Reporting and Monitoring

  • Generate population-based analytics reports for routine monitoring and to assess performance of health care providers.
  • Support in generating performance matrix for all service providers, calculating incentives from the service transaction data in the system.

What is the process to get an Ayushman card?

There is no special registration procedure pertaining to Ayushman Bharat Scheme. All the beneficiaries under PMJAY are either a part of RSBY Scheme or are identified by the SECC 2011. Mentioned below is how you can check your eligibility as a PM-Jay beneficiary. Visit the official website and click on Am I Eligible Provider your mobile number and the CAPTCHA code and click Generate OTP Then select your state and search by mobile number/HHD number/name/ ration card number Based on the results that appear in search you can check if your family is covered under Ayushman Bharat Scheme On the other hand, if you want to check your eligibility under PMJAY you check the Empanelled Health Care Provider or dial the PMJAY helpline number i.e. 14555 or 1800-111-565

Documents Required to Apply For Ayushman Bharat Yojana Scheme

  • Age & Identity Proof (Aadhaar Card/PAN Card)
  • Contact details (mobile, address, email)
  • Caste certificate.
  • Income certificate (maximum annual income to be only up to Rs. 5lakh
  • Document proof the current status of the family to be covered (Joint or nuclear)

What are the documents that should be considered for addition of a family member in ayushman Bharat Pmjay scheme?

Documents Required to Apply For Ayushman Bharat Yojana Scheme:

  • Identity and Age Proof (Aadhaar Card/PAN Card)
  • Details of your mobile number, email address and residential address.
  • Caste certificate.
  • Income certificate.
  • Documents stating your current family status.

What are the benefits of PMJAY Scheme?

Ayushman Bharat Yojana benefits include health insurance coverage of up to INR 5lakh per family, annually. Here, all the pre-existing illnesses are covered without any waiting period.