Ayushman Bharat Pradhan mantri Jan Arogya Yojana(PM-JAY)

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Ayushman Bharat Pradhan mantri Jan Arogya Yojana(PM-JAY)

Ayushman Bharat, a flagship scheme of Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to “leave no one behind.”

The Scheme Ayushman Bharat is an attempt to move from sectoral and segmented approach of health service delivery to a comprehensive need-based health care service. This scheme aims to undertake path breaking interventions to holistically address the healthcare system (covering prevention, promotion and ambulatory care) at the primary, secondary and tertiary level. Scheme adopts a continuum of care approach, comprising of two inter-related components, which are –

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


1)Health and Wellness Centers (HWCs)
In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centers (HWCs) by transforming the existing Sub Centers and Primary Health Centers. These centers are to deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people. They cover both, maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.

Health and Wellness Centers are envisaged to deliver an expanded range of services to address the primary health care needs of the entire population in their area, expanding access, universality and equity close to the community. The emphasis of health promotion and prevention is designed to bring focus on keeping people healthy by engaging and empowering individuals and communities to choose healthy behaviors and make changes that reduce the risk of developing chronic diseases and morbidity.

2)Pradhan Mantri Jan Arogya Yojana (PM-JAY)
The second component under Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojna or PM-JAY as it is popularly known. This scheme was launched on 23rd September, 2018 in Ranchi, Jharkhand by the Hon’ble Prime Minister of India, Shri Narendra Modi.

Ayushman Bharat PM-JAY is the largest health assurance scheme in the world which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries) that form the bottom 40% of the Indian population. The households included are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. PM-JAY was earlier known as the National Health Protection Scheme (NHPS) before being rechristened. It subsumed the then existing Rashtriya Swasthya Bima Yojana (RSBY) which had been launched in 2008. The coverage mentioned under PM-JAY, therefore, also includes families that were covered in RSBY but are not present in the SECC 2011 database. PM-JAY is fully funded by the Government and cost of implementation is shared between the Central and State Governments.

About  PM-JAY

Scheme Name: Pradhan Mantri Jan Arogya Yojana(PM-JAY) under Ayushman Bharat

Launched on 23-Sep-2018

Benefits: 5 Lakhs Hospitalization coverage to each family in India

Benefit Cover Under Ayushman Bharat Pradhan mantri Jan Arogya Yojana(PM-JAY)

Benefit cover under various Government-funded health insurance schemes in India have always been structured on an upper ceiling limit ranging from an annual cover of INR30,000 to INR 3,00,000 per family across various States which created a fragmented system. PM-JAY provides cashless cover of up to INR5,00,000 to each eligible family per annum for listed secondary and tertiary care conditions. The cover under the scheme includes all expenses incurred on the following components of the treatment.

1)Medical examination, treatment and consultation
2)Pre-hospitalization
3)Medicine and medical consumables
4)Non-intensive and intensive care services
5)Diagnostic and laboratory investigations
6)Medical implantation services (where necessary)
7)Accommodation benefits
8)Food services
9)Complications arising during treatment
10)Post-hospitalization follow-up care up to 15 days

The benefits of INR 5,00,000 are on a family floater basis which means that it can be used by one or all members of the family. The RSBY had a family cap of five members. However, based on learning from those schemes, PM-JAY has been designed in such a way that there is no cap on family size or age of members. from the very first day, pre-existing diseases are covered . 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.

Features of Ayushman Bharat Pradhan mantri Jan Arogya Yojana(PM-JAY)

  1. 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.
  2. PM-JAY provides cashless access to health care services for the beneficiary at the point of service, that is, the hospital.
  3. It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.
  4. There is no restriction on the family size, age or gender.
    from day one, all pre–existing conditions are covered.

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 1,393 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
Ayushman Bharat

How to Check Eligibility of PM-JAY

Before going to treatment we need to check our eligibility in the official website of PMJAY. If the data will appear in the website then we will be able to avail the benefits of PMJAY.

Steps to Check the Eligible in PM-JAY

Open the URL https://mera.pmjay.gov.in/search/login

Enter Mobile Number

Enter the captcha code

Click On Generate OTP

In the next screen, Enter the OTP and authenticate,

In the Next screen Select State

Select Search by HHD or Search by Name

If you select Search by HHD, Then enter your food security card number then search the data

If you select Search by Name, The enter Name, Father Name, Mother Name, Age, Gender, District, Town, Pincode then click on Search

If your data found, then it will show in the rights side panel

Click on family details

It will show all the beneficiary details

click on information button

Then a popup box will appear showing your eligibility for the scheme PMJAY.



 

Watch the video on how to check the eligibility to avail benefit under PMJAY



How to check Empanelled Hospitals of PM-JAY

Open the official website https://pmjay.gov.in/

Go to Menu, Click on Find Hospital

in the Next screen select state, District, Hospital Type, Specialty, Hospital Name, empanellment Type

Enter captcha code and click on search button to search hospital details.

Milestones of PM-JAY

12-Mar-2018 : Cabinet Approval
27-Mar-2018 : CEO Appointed
11-May-2018 : NHA Incorporated
14-Jun-2018 : Ministers Conclave
15-Aug-2018 : PM Announces Ayushman Bharath PM-JAY Launch
23-Sep-2018 : Ayushman Bharat PM-JAY Launched
23-Sep-2019 : 10.39 Lakh E-cards issued

Expansion of coverage by States under PM-JAY and convergence Various States have been implementing their own health insurance/assurance schemes over the past couple of decades. Most of these schemes provide cover for tertiary care conditions only. The benefit cover of these schemes is mostly available within the State boundaries except some smaller States have empanelled a few hospitals outside the State boundaries. Very few States had converged their schemes with the erstwhile RSBY scheme and many of them were operating independently. This was due to the lack of flexibility in the design of the RSBY,  which although initially helped in quick scale-up but became a challenge over a period of time and offered limited flexibility to the States.

Even though these schemes were targeting the poor and vulnerable, there were large variations across States in terms of eligibility criteria and databases. Few States were using the food subsidy database while some others had created a separate database for their welfare schemes.

The primary objectives for launching PM-JAY were to ensure comprehensive coverage for catastrophic illnesses, reduce catastrophic out-of-pocket expenditure, improve access to hospitalisation care, reduce unmet needs, and to converge various health insurance schemes across the States. PM-JAY will also establish national standards for a health assurance system and is providing national portability of care. At the implementation level, the States are given the flexibility to use their own database if they were already implementing a health insurance/ assurance scheme and were covering more families than those eligible as per the SECC 2011 database. However, such States shall ensure that all families eligible as per the SECC data are covered and not denied benefits.


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

The National Health Authority (NHA) has entered into a partnership with the Employee’s State Insurance Corporation (ESIC). This synergy between Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB PM-JAY)and Employees State Insurance Scheme (ESIS) will create an ecosystem wherein ESIC beneficiaries will be able to access services at ABPM-JAY empanelled hospitals and vice versa.

The convergence between PM-JAY and ESIC is a landmark initiative for the development of health systems in the country. This will leverage the presence of an established network of quality services providers under PM-JAY alongside fixed health benefit packages, thereby standardizing services across schemes. Further, it will create higher demand for health services at ESIC empanelled hospitals that may be currently underutilized. This will support in improvement of infrastructure and facilities of such facilities, via utilization of funds reimbursed under PMJAY.

In the initial phase, a pilot is being conducted in Ahmednagar, Maharashtra and Bidar,
Karnataka wherein ESIC beneficiaries of these districts will be able to access PM-JAY services in PM-JAY empanelled hospitals. The beneficiaries will be eligible for all 1,393 secondary and tertiary packages under the scheme and the initiative will be scaled up to 102 districts with a plan of eventually extending coverage across the country.

Key Benefits of AB PM-JAY and ESIS convergence:

ESIC beneficiaries will get access to healthcare providers under AB PM-JAY
AB PM-JAY beneficiaries will be able to avail services in ESIC empanelled hospitals.
Beneficiaries of ESIC can use their ESIS card to access free treatment at AB PM-JAY
empanelled hospitals.
Similarly, beneficiaries of AB PM-JAY can use their PM-JAY card to access free treatment at
ESIC empanelled hospitals.
For more information beneficiaries can call ESIC tollfree number: 1800 112 526/ 1800 113 839

 

Online Login

Hospitals List under PM-JAY

Beneficiary Identification

Visit Official Website

FAQs on PM-JAY

What if patient produces PMJAY card late and wants to get treatment under PMJAY at the time of discharge? e.g. patient party has produced card after 4 days post admission.?

The hospital must develop a mechanism to identify PMJAY beneficiaries at the time of registration itself. However, a provision is made in the TMS to register the patient, back dated, up to 5 days  maximum. Hence, treatment can be facilitated to patients who have produced the card before discharge and hospital should ensure no extra money is collected from the beneficiary.

What is the minimum duration of hospitalization that qualifies to be blocked under medical
packages?
Minimum of 24 hours stay is required and the rationale for hospitalization should be provided by the hospital through clinical documents. The diagnosis needs to match the listed packages under PMJAY.

If the patient is admitted for medical case and requires a surgery, how should the case be
tackled?
Medical and Surgical packages cannot be booked together. All surgical packages include expenditure related to pre and post-operative care. Hence, the hospital shall cancel the pre-auth and generate a new pre-auth request for required surgery. Surgical package under the scheme covers 3 days pre and 15 days post hospitalization expenses.

What is the definition of pre-hospitalization expenses under PMJAY?
This is the expenditure incurred by the beneficiary of the scheme up to 3 days before getting admitted in the hospital (Applicable only to the expenses made in same hospital where treatment under PMJAY is initiated). The expenditure may be related to diagnostics, consultation and medications etc. and inclusive in the package

How to implement 3-day pre-hospitalization cashless benefit?
The hospital can register the beneficiary in the TMS when he visits hospital for the treatment. If the beneficiary needs admission, pre-auth can be raised and expenses incurred by the beneficiary till then (up to 3 days) shall be considered inclusive in the package. Incase if he does not need hospitalization or daycare procedure as under PMJAY scheme, then pre-hospitalization expenses will be borne by the patient.

How to implement 15 days post-hospitalization cashless benefit?
Hospital must procure required medications and provide to the beneficiary. In case if diagnostic evaluation and follow-up visits are needed within 15 days post discharge, it should be done free of cost by the hospital.

Which brand of implants or chemotherapy drugs to be used?
It is up to the hospital to choose the brand meeting the specifications laid down by concerned authorities and patient should be ensured free and good quality treatment. The patient should not be charged any additional money for drugs or implants on the pretext of better quality.

Is booking of multiple medical packages allowed?
Booking of multiple medical packages is not allowed under PMJAY.

Is booking of multiple surgical packages allowed?
Yes, booking of multiple surgical packages is allowed. However, PPD and CPDs shall perform
the due diligence while approving and processing such claims.

What is meant by pre-auth enhancement in medical cases?
For medical cases the first day would be on auto approved mode. In case extension of stay is
required, the PMAM/MEDCO need to seek enhancement through the TMS. Enhancement request may be approved maximum up to 5 days at a time and the same process may be repeated, if required.

What should be done if hospital treat patient before getting pre-auth approval?
The hospital must develop a mechanism to identify PMJAY beneficiaries at the time of
registration itself.
1. For Packages requiring pre-auth, mandatory pre-Authorization need to be sought before
initiating treatment.
2. In case of emergency, telephonic pre-Authorization can be sought, and treatment can be
initiated. However, all the required documentation needs to be uploaded within 24 hours.
When pre-auth is already initiated and later found that an additional surgery to be done.
What should be done in this case?
The pre-auth raised earlier needs to be cancelled and same should be intimated to PPD. After
intimation new package can be blocked.

Is uploading of mandatory document compulsory while raising pre-auth?
While initiating the Pre-Auth, uploading of all mandatory documents for the selected package
is compulsory. If the patient is registered without Bio-metric Authorization, patient’s
photograph is also required.