Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

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Introduction: Ayushman Bharat, a flagship initiative by the Government of India, was launched under the recommendations of the National Health Policy 2017. The objective was to achieve Universal Health Coverage (UHC) and contribute to the Sustainable Development Goals (SDGs), aligning with the principle of “leaving no one behind.” The scheme represents a paradigm shift from a fragmented healthcare delivery system to a comprehensive, need-based service.

The initiative incorporates a continuum of care approach and is designed to cover prevention, promotion, and curative health services across primary, secondary, and tertiary levels. Ayushman Bharat comprises two major components:

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

Launch of AB-PMJAY:

The Pradhan Mantri Jan Arogya Yojana (PM-JAY) was officially launched on September 23, 2018, in Ranchi, Jharkhand, by the Hon’ble Prime Minister of India, Shri Narendra Modi. It is currently the world’s largest health assurance program, aiming to provide financial protection for secondary and tertiary healthcare services.

Key Features of PM-JAY:

The scheme provides health insurance coverage of up to ₹5,00,000 per family per year for secondary and tertiary care hospitalization. It targets over 10.74 crore underprivileged families, amounting to around 50 crore beneficiaries, which forms the bottom 40% of India’s population.

The eligibility criteria for inclusion in PM-JAY are based on deprivation and occupational parameters identified in the Socio-Economic Caste Census (SECC) 2011 for rural and urban areas. The scheme is entirely funded by the Government, with costs shared between the Central and State Governments.

Benefits of AB-PMJAY:

The PM-JAY scheme offers cashless health coverage of up to ₹5,00,000 per year to each eligible family for a wide range of medical treatments. The benefits cover:

1. Medical Services:
   • Examination, consultation, and treatment for a variety of medical conditions.
   • Pre-hospitalization expenses.
   • Diagnostic tests and laboratory investigations.
   • Intensive and non-intensive care services.
   • Post-hospitalization care for up to 15 days.
2. Medical Consumables:
   • Coverage of medicines, implants, and necessary medical equipment.
3. Additional Benefits:
   • Food and accommodation services during hospitalization.
   • Complications arising during treatment are also covered.
4. Flexibility in Coverage:
   • Benefits are provided on a family floater basis, allowing any family member to avail the full ₹5,00,000 if needed.
   • There is no restriction on family size or the age of members.
   • Pre-existing medical conditions are covered from the very first day of enrollment.

Eligibility Criteria for Beneficiaries

Rural Beneficiaries:

In rural areas, households falling under the following six deprivation criteria are eligible for PM-JAY:

1. Families living in a single-room house made of kucha walls and kucha roofs.
2. Households with no adult members aged between 16 to 59 years.
3. Families without an adult male member aged between 16 to 59 years.
4. Families with at least one disabled member and no able-bodied adult member.
5. Scheduled Caste (SC) or Scheduled Tribe (ST) households.
6. Landless households deriving their major income from manual labor.

Additional automatic inclusion criteria include:

• Destitute families or those surviving on alms.
• Manual scavengers.
• Primitive tribal groups.
• Legally released bonded laborers.

Urban Beneficiaries:

In urban areas, individuals working in the following 11 occupational categories are eligible:

1. Ragpickers and beggars.
2. Domestic workers.
3. Street vendors, cobblers, hawkers, and similar service providers.
4. Construction workers, plumbers, masons, painters, welders, and laborers.
5. Sanitation workers, sweepers, and gardeners.
6. Home-based artisans, handicrafts workers, and tailors.
7. Transport workers, drivers, conductors, cart pullers, and rickshaw pullers.
8. Workers in small establishments, including assistants, peons, and delivery agents.
9. Electricians, mechanics, repair workers, and assemblers.
10. Washers and launderers.
11. Watchmen and chowkidars.

Exclusions:

The following groups are not eligible for benefits under PM-JAY:

1. Families owning a two-wheeler, three-wheeler, or four-wheeler vehicle or a motorized fishing boat.
2. Owners of mechanized farming equipment.
3. Individuals with Kisan credit cards with a limit of ₹50,000 or more.
4. Government employees and those working in non-agricultural government-managed enterprises.
5. Households earning a monthly income above ₹10,000.
6. Families with refrigerators and landline phones.
7. Families living in pucca houses or owning over 5 acres of agricultural land.

Application Process for PM-JAY

Offline Enrollment:

To get a PM-JAY e-card, eligible beneficiaries need to visit either a hospital or a Community Service Centre (CSC) for identification and follow these steps:

1. Submission of Beneficiary Information:
   • Provide details like the PM letter, RSBY URN, Ration Card number, or mobile number to the Arogya Mitra (the operator managing the application process).
2. Search in the BIS Application:
   • The operator searches through databases like SECC, RSBY, State Health Schemes, or Additional Data Collection drives to confirm eligibility.
3. Individual Identification:
   • Valid government ID (Aadhaar or PAN card) and Ration Card or family ID are used to validate the beneficiary’s identity. Scanned copies of these documents are uploaded.
4. Family Identification:
   • The operator verifies family details using the ration card or similar documents. Scanned records are submitted to the trust or insurance company for approval.
5. Approval or Rejection:
   • The submitted applications are reviewed by the health insurance company or trust. Rejected cases undergo further verification by the State Health Agency (SHA).
6. Issuance of E-card:
   • Once approved, an e-card is issued to the beneficiary, enabling them to avail of PM-JAY benefits.

Required Documents:

The following documents are necessary to complete the enrollment process:

1. Proof of identity (Aadhaar Card or PAN Card).
2. Address proof.
3. Contact details (mobile number and email).
4. Caste certificate (if applicable).
5. Income certificate.
6. Proof of family structure (joint or nuclear family status).
7. Aadhaar Card (mandatory for identification).

Conclusion:

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY) is a revolutionary scheme aimed at addressing healthcare inequities and ensuring quality medical services for the underprivileged. By providing cashless and comprehensive healthcare coverage, it relieves financial stress on economically vulnerable families. Furthermore, the scheme’s emphasis on inclusivity ensures that even those with pre-existing medical conditions receive treatment without delay. This ambitious program is not only a step toward universal health coverage but also a significant stride in building a healthier and more equitable India.