Eligibility Criteria and Latest Status of AB-PMJAY Scheme 2024

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana 2024

The AB-PMJAY 5 lakh insurance scheme has specific eligibility criteria that apply to Central category families. This scheme, known as Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), is the largest publicly funded health assurance program in the world. It provides health coverage of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization to approximately 55 crore beneficiaries, representing 12 crore families belonging to the bottom 40% of India’s population.

To ensure that all eligible beneficiaries receive free healthcare under the scheme, States/UTs now have the flexibility to use digitized databases of similar socio-economic profiles for beneficiary identification. Additionally, many States/UTs have expanded the beneficiary base under AB-PMJAY at their own expense.

AB-PMJAY operates on a cashless and paperless basis, eliminating the need for reimbursement. Beneficiaries can seek treatment at any of the empanelled hospitals across the country. These empanelled healthcare providers receive payment based on specified Health Benefit Packages (HBPs) with standardized rates. The cost of the HBPs covers all treatment-related expenses, including drugs, supplies, diagnostic services, physician fees, room charges, surgeon charges, OT and ICU charges, among others. Currently, there are 27,742 empanelled hospitals under the scheme as of 15.01.2024.

The delivery of healthcare services under AB-PMJAY is designed to be cashless and paperless due to the demographic characteristics of the beneficiary population and the scale of the scheme.

In collaboration with the National Health Authority, the Ministry of Home Affairs (MHA) is implementing the Ayushman CAPF scheme for 40 lakh serving personnel and their dependents in Central Armed Police Forces (CAPF). The benefits and entitlements under Ayushman CAPF are determined by MHA. Reimbursement for healthcare services obtained in non-empanelled hospitals is only allowed in emergency situations for Ayushman CAPF beneficiaries.

States/UTs have the flexibility to implement AB-PMJAY through trust, insurance, or hybrid modes. In the insurance/hybrid mode, insurance companies are brought onboard by the respective State Health Agencies (SHAs) responsible for implementing the scheme. SHAs pay premiums to these insurance companies based on the discovered price during the tender process. Detailed information on the engagement of insurance companies, payments made, and claims submitted and settled by the States/UTs over the past five years is available on a policy year-wise basis.

Significant efforts have been made to create Ayushman cards, with approximately 10 crore cards created during 2022-23 alone. The Aapke Dwar Ayushman 3.0 campaign has been launched, introducing a self-verification feature that allows beneficiaries to create Ayushman cards for themselves and their families. Additionally, the ‘Ayushman Bhava’ campaign, initiated by the Hon’ble President of India on 13.09.2023, aims to ensure widespread creation of Ayushman cards across the country. Ayushman card creation is also offered as one of the on-spot services under the ‘Viksit Bharat Sankalp Yatra’, resulting in the creation of over 2.78 crore Ayushman cards. The awareness of the scheme has significantly increased over the years, as evidenced by the growing number of Ayushman cards.

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Central Govt Ayushman Bharat 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. Ayushman Bharat adopts a continuum of care approach, comprising of two inter-related components.

PM-JAY Hospitals (HWCs)

In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres. These centres 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 behaviours and make changes that reduce the risk of developing chronic diseases and morbidities.

PM-JAY Launched in 2018

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 12 crores poor and vulnerable families (approximately 55 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.

Highlights of PM-JAY Scheme

PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government.
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. Over 12 crore poor and vulnerable entitled families (approximately 55 crore beneficiaries) are eligible for these benefits. PM-JAY provides cashless access to health care services for the beneficiary at the point of service, that is, the hospital. PM-JAY envisions to help mitigate catastrophic expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year. It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines. There is no restriction on the family size, age or gender. All pre–existing conditions are covered from day one. 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 1,929 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.

Benefits of the PM-JAY Scheme

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 INR3,00,000 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.

• Medical consultation and treatment
• Pre-hospitalization
• Medicine and medical consumables
• Non-intensive and intensive care services
• Diagnostic and laboratory investigations
• Medical implantation services (where necessary)
• Accommodation benefits
• Food services
• Complications arising during treatment
• Post-hospitalization follow-up care up to 15 days