Ayushman Bharat Scheme

Eligibility Of Pradhan Mantri Ayushman Bharat Yojana

The government believes that only a healthy India can succeed in global competition. In order to ensure affordable healthcare services to all classes of people, a number of government-sponsored health schemes have been introduced in recent years. Alongside, the government has also come up with the Pradhan Mantri Ayushman Bharat health insurance scheme.

What is Ayushman Bharat health insurance?

Ayushman Bharat is a health protection scheme to provide health insurance to citizens. It provides insurance coverage of up to Rs.5 lakh on a family floater basis to beneficiaries every year in order to receive primary, secondary, and tertiary healthcare services. The scheme was earlier referred to as AB-NHPS as it is an initiative under the existing (NHPS). Currently, it is known as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). The government plans to distribute this scheme through national insurance companies. The scheme subsumes the existing senior citizen health insurance scheme as well as the Rashtriya Swasth Bima Yojna.

Features and benefits of the scheme

• A cover of up to Rs.5 lakh is available for the beneficiary family every year.
• The scheme can be utilised to get primary, secondary, and tertiary healthcare services.
• The benefits of the scheme can be availed at any government hospital or empanelled private hospital.
• The eligibility of beneficiaries targeted towards the poor, deprived rural families and identified occupational category of urban workers’ families based on the Socio-Economic Caste Census (SECC) 2011 data.
• Package model will be followed to make payments. The package will be defined by the government-in-charge in terms of payment of total costs, specific services, and procedures.
• An Ayushman Bharat National Health Protection Mission will be established for effective coordination between the Central and the state governments.
• The scheme covers about 40% of the country’s population who are poor and vulnerable.
• All expenses incurred by the beneficiary from his pocket during the hospitalisation will also be covered.
• The cost incurred during the pre and post-hospitalisation period will be covered.
• The insurance provides cashless hospitalisation facility.
• Daycare treatment expenses are covered by the scheme.
• The insurance scheme covers all pre-existing health conditions. Follow-up of medical examinations upto 15 days are also covered to ensure that the patients have recovered completely.

Ayushman Bharat Yojana Eligibility criteria for rural families

There are six deprivation criteria to identify the rural families that are eligible for the benefits of the scheme. They are:

• Families that do not have an earning adult member aged between 16 and 59 years.
• Households headed by female members having no adult male members aged between 16 and 59 years.
• Households with a single room having makeshift walls and roof.
• Households belonging to the Scheduled Castes and Scheduled Tribes categories.
• Households that have disabled members with no able members offering support.
• Landless households with manual labour as their basic source of income.

In addition, the following households are automatically eligible:

• Destitute families who rely on alms.
• Families of manual scavengers.
• Households without proper shelter.
• Families of bonded labour.
• Primitive and particularly vulnerable tribal groups.

Eligibility criteria for urban families

An urban family must belong to one of the listed occupational categories to be eligible for the scheme:

• Street vendors, cobblers, and hawkers.
• Domestic workers.
• Rag pickers and beggars.
• Construction site workers, plumbers, masons, painters, welders, and security guards.
• Coolies.
• Sweepers, sanitation workers, and gardeners.
• Transport workers such as conductors, drivers, cart pullers, and others.
• Artisans, home-based workers, handicraft workers, and tailors.
• Washermen and watchmen.
• Electricians, mechanics, repair workers, and assemblers.
• Peons, helpers, shop workers, delivery assistants, attendants, and waiters.

Eligibility criteria for hospitals

Similar to setting eligibility criteria for beneficiaries, the government has framed eligibility criteria for a hospital to be empanelled. The criteria are:

• The hospital must be registered with state health agencies.
• Qualified medical and nursing staff must be available 24/7.
• The hospital must have a minimum of 10 in-patient beds.
• The medical facility must have an accessible washroom.
• An interoperable IT system should be in place to manage data.
• A complete record of Ayushman Bharat patients must be maintained and shared with the government as per the requirement.
• Ambulance and other emergency services must be available.
• A dedicated medical officer should be appointed to take care of AB-NHPS operations.
• There should be a blood bank and testing laboratory in the vicinity.
• The medical facility must have all the equipment and technical necessities.
• The hospital must have facilities such as regulated water, electricity, and bio-medical waste disposal.

Frequently Asked Questions

Will a newborn baby be covered under the PMJAY when there are five members in a family who have already availed of PMJAY benefits? 

Yes, there is no limit of family size under the PMJAY. The newborn baby will be provided care under the PMJAY provided the benefit limit is not exhausted. The newborn baby should be added to the PMJAY scheme with at least one PMJAY verified beneficiary.

Does the scheme entitle a beneficiary for admission to only the general ward?

Yes. When a beneficiary wants an upgrade in the room, then all expenses for treatment will not be covered under the PMJAY scheme. However, admission to ICU for specified packages is allowed.

Does a beneficiary need to pay for medicines he/she receives under this scheme?

No, a beneficiary does not have to pay for the medicines he/she receives for the treatment. Under the PMJAY, medicines will be included in the package for the duration of treatment, including up to 15 days after discharge from the hospital.

What is the meaning of post-hospitalisation expenses under the PMJAY?

Post-hospitalisation expenses are the expenses incurred by the patient from the date of discharge up to 15 days for medicines, consultation, diagnostics and post-operative care. Also in the case of surgery, any post-operative complication and re-admission linked to the treatment are to be covered under the earlier package cost.

What is the meaning of pre-hospitalisation expenses under the PMJAY?

Pre-hospitalisation expenses mean the expenditure incurred by the beneficiary of the scheme up to 3 days before getting admitted to the hospital. However, it is applicable only to the expenses made in the same hospital where treatment under the PMJAY is initiated. The expenditure may be related to consultation, diagnostics, medications, etc., and inclusive in the package.

What are the services that are excluded under the PMJAY?

Any outpatient care, cosmetic treatments, drug rehabilitation, fertility treatment and organ transplants are not covered under the PMJAY.

BIS PROCESS FLOW

• A potential beneficiary may visit either an empanelled hospital or a designated Kiosk or center for his/her identification.

• Beneficiary needs to come with preferably Aadhaar Card or any other photo based individual Government ID like Voter ID card, PAN card etc. along with family ID like Ration Card, State identified family ID, etc.

• Pradhan Mantri Arogya Mitra (PMAM) or Kiosk / Center Operator will search a beneficiary name/family using different ways/parameters.

• Upon identification of beneficiary in BIS Application, beneficiary will be asked to submit either Aadhaar Number (preferable) or any other photo based individual Govt. ID for individual identification/verification.

• PMAM or Kiosk / Center Operator will perform an online authentication using Aadhaar or enter details in case of Non-Aadhaar Verification and also validate beneficiary's mobile number. A photo of the beneficiary will also be collected (in case of Non-Aadhaar verification)

• Beneficiary will also have to submit a family ID document (e.g. Ration Card) for establishing his relationship in the family. The operator will also scan and upload the family ID document submitted by the beneficiary.

• The Operator then submits the 'record' to the approving authorities for further verification and approval. The approving authority can either be an Insurance company or Trust as the case may be.

• The record can then be approved or recommended for rejection by these authorities. If the record is recommended for rejection, then the approving authority will specify the reason and SHA will take a final decision on the recommended records.

• Approved beneficiary records are assigned an AB-PMJAY ID. These records are considered as 'verified beneficiaries'.