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Introduction

In a country with 1.2 billion people, providing quality healthcare to everyone is a challenge. Healthcare infrastructure gets a major chunk of the annual budget. In spite of that, thousands of citizens from rural India lack basic healthcare facilities. Timely medical care is a right for all citizens and the government should strive constantly to make it available for all its citizens.

Ayushman Bharat (also known as Pradhan Mantri Jan Arogya Yojana), a landmark scheme by the Government of India, has been initiated, as proposed by the National Health Policy 2017, to attain Universal Health Coverage (UHC) in India. This program was planned to achieve the Sustainable Development Goals (SDGs) and to reinforce its pledge to 'Leave No One Behind.'

Ayushman Bharat aims at moving from a sectoral and segmented approach to the provision of health services to an integrated, need-based national healthcare system. This scheme adopts pioneering interventions to address the health care system holistically (covering prevention, promotion and outpatient care) at primary, secondary and tertiary levels. Ayushman Bharat adopts a range of healthcare approaches, consisting of two inter-dependent concepts, which are-

Health and Wellness Centres (HWCs)

In February 2018, the Government of India declared the establishment of 1,50,000 Health and Wellness Centres (HWCs) by converting established Sub-Centres and Primary Health Centres. Such centres are built to provide Integrated Primary Health Care (CPHC) taking health services closer to people's homes. Which provide all maternal and infant safety care and non-communicable disorders, including free prescription medicines and medical facilities.

Health and Wellness Centres are expected to provide a broader variety of resources to meet the primary health care needs of the local population in their region, through availability, universality and community-based equity. The aim of health promotion and prevention is to concentrate on maintaining citizens healthier by educating and encouraging individuals and families to adopt healthier lifestyles and to make improvements that decrease the likelihood of contracting chronic diseases and morbidities.

Pradhan Mantri Jan Arogya Yojana (PMJAY)

On 23rd September 2018, our Hon’ble Prime Minister of India, Shri Narendra Modi launched this largest health assurance scheme in the world, Pradhan Mantri Jan Arogya Yojana (PMJAY), in Ranchi Jharkhand.

Pradhan Mantri Jan Arogya Yojana offers insurance benefits of Rs.5 lakhs per family each year for secondary and tertiary treatment with hospitalization. This program protects more than 10.74 crores of deprived and vulnerable households. That is around bottom 40% of the entire population, which approximates to about 50 crore people. The scheme is fully funded by the Government and the cost of implementation is shared between the state and central governments.

Salient features of PMJAY

  • PMJAY is the world's largest healthcare coverage and insurance scheme fully financed by the government.
  • It provides Rs. 5 lakhs per family each year for secondary and tertiary treatment and hospitalization through public and private empanelled hospitals in India.
  • Over 10.74 crore poor and vulnerable eligible families (approximately 50 crore beneficiaries) are eligible for these benefits.
  • PMJAY offers cashless hospitalization for the beneficiaries at various hospitals enrolled under the scheme.
  • PMJAY aims to help reduce the crippling expenditure required for healthcare that pushes around 6 crore Indians into poverty per year.
  • It covers the charges for diagnostics and medications for up to 3 days of pre-hospitalization and 15 days of post-hospitalization.
  • There is no limit on the number of members per family or their age or gender.
  • All pre-existing illnesses are protected from day one.
  • The benefits of the scheme are portable across the country, i.e. the beneficiary can visit any public or private hospital in India for cashless treatment.
  • Coverage includes about 1,393 treatments along with all treatment-related expenses, including but not restricted to medications, equipment, laboratory facilities, hospital bills, space charges, surgical charges, OT and ICU charges, etc.
  • Hospitals are then reimbursed for clinical care at the same level as commercial facilities.

What are the benefits offered under the PMJAY scheme?

The beneficiaries of the PMJAY scheme can avail cashless cover of Rs.5 lakhs to avail treatment at empanelled hospitals for the following healthcare procedures:

  • Medical examinations, treatment and consultation cost
  • Pre-hospitalisation expenses
  • Medical and surgical equipment costs
  • Non-intensive and non-critical care facilities
  • Diagnosis and laboratory investigations
  • Health implantation wherever necessary
  • Cost for lodging and food costs
  • Any complications that occur during diagnosis
  • Post-hospitalization follow-up for up to 15 days
  • Covid-19 Treatment costs

Critical Diseases or Illnesses Covered Under PMJAY scheme

Ayushman Bharat Yojana covers treatment for various critical illnesses too. Here is the list:

  • Prostate cancer
  • Double valve replacement
  • Coronary artery bypass graft
  • COVID-19
  • Pulmonary valve replacement
  • Skull base surgery
  • Anterior spine fixation
  • Laryngopharyngectomy with gastric pull-up
  • Tissue expander for disfigurement following burns
  • Carotid angioplasty with stent

What is not covered under the PMJAY scheme?

PMJAY is similar to other insurance schemes. It too does not cover a few specific components of the treatment or expenses incurred. The below aspects are not covered under the scheme:

  • Out-Patient Department (OPD) expenses
  • Drug rehabilitation
  • Cosmetic surgeries
  • Fertility treatments
  • Individual diagnostics
  • Organ transplant

Who is eligible to get the benefits under the PMJAY scheme?

There are 2 segments under the PMJAY Scheme; PMJAY Rural and PMJAY Urban. 

PMJAY Rural

The Socio-Economic Caste Census 2011 (SECC 2011) ranked rural households on the basis of their socio-economic standing. These households were rated based on 7 poverty standards on the basis of their status. As such, the program extends to those applicants that fall into at least one the following six deprivation category which generally covers destitutes, manual scavenger households, beggars, primitive tribal communities and bonded labourers:

  • Kutcha house with just one room
  • No adult family member in the age range of 16 and 59 years of age
  • No adult male in the age range of 16 and 59 years of age
  • Consists of disabled individual and non-disabled family members
  • SC & ST households
  • Landless families for whom the key sources of revenue are by manual casual labor

PMJAY Urban

Under the program, urban households are classified on the basis of occupation. Below are 11 job groups of employees qualifying for the Ayushman Bharat Yojana scheme:

  • Beggar
  • Domestic worker
  • Ragpicker
  • Cobbler/Street Vendor/Hawker/Other service providers on the street.
  • Plumber/Construction Worker/Mason/Painter/Labour/Welder/Security Guard/Coolie
  • Sweeper/Mali/Sanitation Worker
  • Artisan/Handicrafts Worker/Tailor/Home-based Worker
  • Driver/Transport Worker/Conductor/Cart or Rickshaw Pullers/Helper to Drivers or Conductors
  • Shop Workers/Peon in Small Establishment/Assistant/Helper/Attendant/Delivery Assistant/Waiter
  • Mechanic/Electrician/Repair Worker/Assembler
  • Chowkidar/Washer-man

Who is not eligible to get the benefits of the PMJAY Scheme?

  • Those who have mechanised farming equipment
  • Who owns a two, three or four-wheeler
  • Those who hold a Kisan card
  • Government employees
  • Those who own a motorised fishing boat
  • Those who are earning more than Rs. 10,000 per month
  • Those who are working in government-run non-agricultural enterprises
  • Those who own more than 5 acres of agricultural land
  • Those who own landline phones or refrigerators
  • All who live in decently constructed houses

What are the documents required to get cashless treatment under the PMJAY Scheme?

Patients need to submit the following documents: 

  • Identity and Age Proof (Aadhaar Card/PAN Card)
  • Personal details like mobile number, email address and residential address.
  • Caste certificate
  • Income certificate
  • Documents supporting your current family status

How to check if I am eligible for benefits under the PMJAY scheme?

You can check if you are eligible for the scheme by logging on to the PMJAY official portal.

  • On the portal, you have an option called ‘Am I Eligible’. Click on that. 
  • You will be required to enter your mobile number to generate an OTP. 
  • Once you enter the OTP, you will be taken to the next page where you need to enter your State name
  • Then you need to search your details by entering your HHD Number or details like your name, father’s name, district, village/town, pincode, etc.
  • Once you have entered all the necessary details, it will show if you are eligible for the scheme or not.

FAQs on Ayushman Bharat (PMJAY)

1. How to enroll for the PMJAY Scheme?

This scheme does not have a separate enrolment process. Persons requiring medical treatment can approach their nearest empanelled hospital and avail the necessary treatment. They can submit their income document and identity document to get cashless treatment. The hospital will later get a reimbursement from the government.

2. What are the health services available under PMJAY?

The PMJAY scheme provides for hospitalization costs, day-treatment, follow-up care, pre-and post-hospital expenditures and unborn child / child services. A complete selection of programs can be found on the official website.

3. Where can beneficiaries avail of services under PMJAY?

Treatment under the scheme will be provided in both public hospitals and private health facilities. Registration of hospitals under PMJAY will be carried out through the state government's online platform. Data on registered hospitals should be made accessible via a variety of means, such as the government website and smartphone apps. Beneficiaries can also call the helpline number at 145555. Regular notifications will also be given via ASHAs, ANMs and other unique touch points.

4. Are beneficiaries required to pay anything to get treatment under this scheme?

No. All eligible recipients may use free secondary and tertiary hospital care services for identified PMJAY packages in public hospitals and covered private hospitals. Beneficiaries will have access to PMJAY health services without cash or documents.

5. How do I get enrolled under the scheme?

PMJAY is a scheme based on entitlement. There is no registration procedure. Families defined by the State on the basis of poverty and occupational requirements, using the SECC database, in both rural and urban areas, are qualified for PMJAY.

EndNote

A strong healthcare system is the backbone of any country. India has taken this mammoth initiative to make sure that it’s citizens are able to avail high class medical care without any cost or hassles.

Latest & Update Ayushman Bharat Scheme News

Ayushman Bharat Yojana Launched in the Union Territory of Jammu & Kashmir21 Jan 2021

Prime Minister Narendra Modi launched his flagship Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in Jammu and Kashmir. Nearly 225 government hospitals and 35 private hospitals in the union territory are covered under the scheme. As per this scheme...

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Prime Minister Narendra Modi launched his flagship Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in Jammu and Kashmir. Nearly 225 government hospitals and 35 private hospitals in the union territory are covered under the scheme. As per this scheme, eligible citizens of Jammu and Kashmir can enjoy free healthcare facilities up to Rs. 5 lakhs. This is a universal free healthcare scheme that helps to provide medical care for people belonging to the economically weaker sections of the society.

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