PM Jan Arogya Yojana – 5 Lakh Health Cover for Your Family

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a Centrally Sponsored Scheme having central sector component under Ayushman Bharat Mission anchored in the Ministry of Health and Family Welfare (MoHFW). It is an umbrella of two major health initiatives, namely Health and wellness Centres and National  Health Protection Scheme.

Health and Wellness Centres

Under this 1.5 lakh existing sub centres will bring health care system closer to the homes of people in the form of Health and wellness centres. These centres will provide comprehensive health care, including for non-communicable diseases and maternal and child health services.


List of Services to be provided at Health & Wellness Centre

• Pregnancy care and maternal health services
• Neonatal and infant health services
• Child health
• Chronic communicable diseases
• Non-communicable diseases
• Management of mental illness
• Dental care
• Eye care
• Geriatric care Emergency medicine

National Health Protection Mission (AB-PMJAY)

Benefits

• AB-PMJAY provides a defined benefit cover of Rs. 5 lakh per family per year. This cover will take care of almost all secondary care and most of tertiary care procedures.
• To ensure that nobody is left out (especially women, children and elderly) there will be no cap on family size and age in the scheme.
• The benefit cover will also include pre and post-hospitalisation expenses. All pre-existing conditions will be covered from day one of the policy. A defined transport allowance per hospitalization will also be paid to the beneficiary.
• Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.
• The beneficiaries can avail benefits in both public and empanelled private facilities. All public hospitals in the States implementing AB-PMJAY, will be deemed empanelled for the Scheme. Hospitals belonging to Employee State Insurance Corporation (ESIC) may also be empanelled based on the bed occupancy ratio parameter. As for private hospitals, they will be empanelled online based on defined criteria.
• To control costs, the payments for treatment will be done on package rate (to be defined by the Government in advance) basis. The package rates will include all the costs associated with treatment. For beneficiaries, it will be a cashless, paper less transaction. Keeping in view the State specific requirements, States/ UTs will have the flexibility to modify these rates within a limited bandwidth.

Eligibility criteria

• AB-PMJAY is an entitlement based scheme with entitlement decided on the basis of deprivation criteria in the SECC database.
• The different categories in rural and urban areas include
  • families having only one room with kucha walls and kucha roof;
  • families having no adult member between age 16 to 59;
  • female headed households with no adult male member between age 16 to 59;
  • disabled member and no able bodied adult member in the family;
  • SC/ST households;
  • landless households deriving major part of their income from manual casual labour,
  • Families in rural areas having any one of the following: households without shelter, destitute, living on alms, manual scavenger families, primitive tribal groups, legally released bonded labour.
  • For urban areas, 11 defined occupational categories are entitled under the scheme – Occupational Categories of Workers, Rag picker, Beggar, Domestic worker, Street vendor/ Cobbler/hawker / Other service provider working on streets, Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/, Coolie and another head-load worker, Sweeper/ Sanitation worker / Mali, Home-based worker/ Artisan/ Handicrafts worker / Tailor, Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller, Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter, Electrician/ Mechanic/ Assembler/ Repair worker, Washerman/ Chowkidar.

As per the SECC 2011, the following beneficiaries are automatically excluded:

• Households having motorized 2/3/4 wheeler/fishing boat
• Households having mechanized 3/4 wheeler agricultural equipment
• Households having Kisan Credit Card with credit limit above Rs. 50,000/ –
• Household member is a government employee
• Households with non – agricultural enterprises registered with government
• Any member of household earning more than Rs. 10,000/ – per month
• Households paying income tax
• Households paying professional tax
• House with three or more rooms with pucca walls and roof
• Owns a refrigerator
• Owns a landline phone
• Owns more than 2.5 acres of irrigated land with 1 irrigation equipment
• Owns 5 acres or more of irrigated land for two or more crop season
• Owning at least 7.5 acres of land or more with a t least one irrigation equipment

Process of availing care under PM-JAY

Implementation Strategy

At the national level to manage, a National Health Agency has been set up. States/ UTs are advised to implement the scheme by a dedicated entity called State Health Agency (SHA).

Major Impact

In-patient hospitalization expenditure in India has increased nearly 300% during last ten years. (NSSO 2015). More than 80% of the expenditure are met by out of pocket (OOP). Rural households primarily depended on their ‘household income / savings’ (68%) and on ‘borrowings’ (25%), the urban households relied much more on their ‘income / saving’ (75%) for financing expenditure on hospitalizations, and on ‘(18%) borrowings. (NSSO 2015). Out of pocket (OOP) expenditure in India is over 60% which leads to nearly 6 million families getting into poverty due to catastrophic health expenditures. AB-PMJAY will have major impact on reduction of Out Of Pocket (OOP) expenditure on ground of:

• Increased benefit cover to nearly 40% of the population, (the poorest&the vulnerable)
• Covering almost all secondary and many tertiary hospitalizations. (except a negative list)
• Coverage of 5 lakh for each family, (no restriction of family size)

This will lead to increased access to quality health and medication. In addition, the unmet needs of the population which remained hidden due to lack of financial resources will be catered to. This will lead to timely treatments, improvements in health outcomes, patient satisfaction, improvement in productivity and efficiency, job creation thus leading to improvement in quality of life.

Expenditure involved

The expenditure incurred in premium payment will be shared between Central and State Governments in specified ratio as per Ministry of Finance guidelines in vogue. The total expenditure will depend on actual market determined premium paid in States/ UTs where AB-PMJAY will be implemented through insurance companies. In States/ UTs where the scheme will be implemented in Trust/ Society mode, the central share of funds will be provided based on actual expenditure or premium ceiling (whichever is lower) in the pre-determined ratio.

Number of Beneficiaries

AB-PMJAY will target about 10.74 crore poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data covering both rural and urban. The scheme is designed to be dynamic and aspirational and it would take into account any future changes in the exclusion/ inclusion/ deprivation/ occupational criteria in the SECC data.

States/Districts covered

AB-PMJAY will be rolled out across all States/UTs in all districts with an objective to cover all the targeted beneficiaries.