PM-JAY is a health insurance scheme that provides financial protection to poor and vulnerable families against catastrophic health expenditures, covering medical and hospitalization expenses for secondary and tertiary care. It is a cashless and paperless scheme that aims to reduce out-of-pocket healthcare expenses and ensure that nobody is left behind due to lack of financial resources.

Who is eligible for PM-JAY?

The PM-JAY scheme covers eligible families identified as per the Socio-Economic Caste Census (SECC) 2011 database. The eligible families include those living below the poverty line and identified as deprived households, as well as families with at least one of the following criteria: rural households with no male member aged 16 to 59 years; households with a disabled member and no able-bodied adult member; SC/ST households; and landless households who depend on manual labor for their livelihood.

What is the coverage amount under PM-JAY?

The PM-JAY scheme provides a health cover of up to Rs. 5 lakhs per family per year, covering hospitalization expenses, pre- and post-hospitalization expenses, and day care procedures for listed packages. The coverage amount is on a family floater basis, meaning the total sum insured can be used by any family member for medical treatment.

Which medical treatments are covered under PM-JAY?

PM-JAY covers over 1,500 medical and surgical procedures, including cancer treatment, neurosurgery, cardiology, and organ transplant. The scheme also covers pre-existing diseases and newborn child services. The full list of covered treatments is available on the PM-JAY website.

How can I check if I am eligible for PM-JAY?

To check if you are eligible for PM-JAY, you can visit the PM-JAY website or use the PM-JAY mobile app. You can also visit any of the empanelled hospitals to get yourself registered under the scheme.

How can I avail the benefits of PM-JAY?

To avail the benefits of PM-JAY, you need to visit any of the empanelled hospitals and present your PM-JAY e-card or other identification proof. The hospital will verify your eligibility under the scheme and provide cashless treatment for the covered medical procedures. You can also call the PM-JAY helpline number (14555) for any assistance related to the scheme.

Can I use my PM-JAY e-card at any hospital?

You can use your PM-JAY e-card at any of the empanelled hospitals under the scheme. The empanelled hospitals are listed on the PM-JAY website and mobile app. If you receive treatment at a hospital that is not empanelled under the scheme, you may not be able to avail the cashless benefit, and you may need to pay the medical expenses upfront and claim reimbursement later.

How can I enroll for PM-JAY?

The eligible families are automatically enrolled under PM-JAY based on the SECC 2011 database. However, if you think you are eligible but not enrolled, you can visit the PM-JAY website or mobile app and register yourself. You can also visit any of the empanelled hospitals to get yourself registered under the scheme.

Is PM-JAY available in all states in India?

Yes, PM-JAY is available in all states and union territories in India. The scheme is implemented by the National Health Authority (NHA).

Pradhan Mantri Jan Arogya Yojana (PM-JAY)

What exactly is the Pradhan Mantri Jan Arogya Yojana?

The Pradhan Mantri Jan Arogya Yojana (PMJAY), often known as the Ayushman Bharat program, is a health insurance program for low-income and backward-class households. The PMJAY plan is India's largest Universal Health Coverage (UHC) scheme, providing health insurance coverage of Rs.5 lakhs to about 50 crore participants, or 10.74 crore impoverished households.

Eligibility of PMJAY

Beneficiaries for the plan are chosen based on occupational and deprivation criteria from the 2011 Socio-Economic Caste Census (SECC) conducted in rural and urban regions. As a result, the PMJAY plan can only cover qualifying families and individuals. So, the PMJAY qualifying conditions are as follows:

Families enrolled in the Rashtriya Swasthya Bima Yojana (RSBY) program, which launched in 2008.
Individuals who fall under the SC/ST category would be covered under PMJAY even if they are not in the SECC database
Poor homes with no male members between the ages of 16 and 59.
Beggars who rely on alms
Poor households with no members between the ages of 16 and 59. Households with at least one physically challenged member but no healthy adult
Families that do not own property and rely on informal labour to make ends meet
Bonded labourers who have been legally released
Families of manual scavengers
Traditional tribal communities
Individuals who live in one-room makeshift dwellings with no permanent walls or ceiling

In the urban areas, coverage under the PMJAY scheme can be availed by following-

Rag pickers, Washermen, Chowkidars, Domestic help, gardeners, sanitation workers, etc.

There are no restrictions on the scheme's entry age, number of members covered, or exit age for eligible beneficiaries.

Individuals who own any type of vehicle, have mechanized farming equipment, are employed by the government, have a Kisan card with an Rs.50,000 limit, earn Rs.10,000 or more per month, work in government-managed non-agricultural enterprises, own refrigerators, and landlines, 5 acres of agricultural land, or live in decently built houses are not eligible for the PMJAY scheme.

Ayushman Bharat, a flagship plan of the Government of India, is an attempt to transition from a sectoral approach to health service delivery to a need-based health care service. This project intends to implement initiatives to address the healthcare system holistically (prevention, promotion, and ambulatory care) at the primary, secondary, and tertiary levels. Ayushman Bharat uses a continuum of care strategy that includes two interconnected components.

1 Health and Wellness Centres (HWCs)- The Government of India announced in February 2018 the development of 1,50,000 Health and Wellness Centres (HWCs) by revamping existing Sub Centres and Primary Health Centres. These centres will provide Comprehensive Primary Health Care (CPHC), bringing healthcare closer to people's homes. They include free vital medications and diagnostic services, as well as maternity and child health care and non-communicable diseases.

The goal of health and wellness centres is to provide a wider range of services to meet the primary healthcare requirements of the local population as a whole, increasing accessibility, universality, and equity near the community. The goal of health promotion and prevention is to keep people healthy by motivating and enabling people to make healthy decisions and alter their lifestyles in order to lower their chance of contracting chronic illnesses and morbidities.

2 Pradhan Mantri Jan Arogya Yojana (PM-JAY)- PM-JAY is the largest health assurance scheme in the world, providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crore poor and vulnerable families. It is fully funded by the Government and the cost of implementation is shared between the Central and State Governments.

How to register for PMJAY?

The government has automatically registered identified beneficiaries in the PMJAY plan. A health card has been provided to designated families, and by showing the card at the time of hospitalisation, they can get cashless treatments. You can determine your eligibility for the plan by visiting a Common Service Centre (CSC), phoning the helpline number 14555 or 1800 111 565, or visiting the official PMJAY website.

Following documents, you need to submit for applying for PMJAY-

Certified document with your identification and age
Income certificate
Caste certificate
Document to show your current family status
Contact details

How do you file a claim under PMJAY?

The PMJAY claim procedure is quite simple.

You must locate an impaneled hospital that provides PMJAY treatments.

When you are admitted to the hospital, present your PMJAY health card as identification.

You would not have to pay for your own medical expenditures since the system would cover them.

The PMJAY plan is a welfare program that attempts to give quality medical care to the needy and poor in times of medical emergency.

Benefits Covered Under PM-JAY

Benefits coverage under different government-funded health insurance plans in India has traditionally been organised on an upper ceiling limit varying from INR30,000 to INR3,000,000 per family across several States, resulting in a fragmented system. PM-JAY offers cashless coverage of up to INR5,00,000 per year to each qualified household for designated secondary and tertiary care conditions. The scheme's coverage includes all fees incurred on the following therapy components.

Medical examination, treatment, and advice
Pre-hospitalization
Medicine and medical supplies
Services for non-intensive and intensive care
Laboratory and diagnostic testing
Services for medical implantation (where necessary)
Accommodation advantages
Catering services
Complications that occur during treatment
Follow-up treatment after hospitalisation for up to 15 days

Conclusion

The AB-PMJAY provides a once-in-a-lifetime chance to enhance the health of hundreds of millions of Indians while also eliminating a key cause of poverty. However, significant hurdles must be solved in order for these advantages to be realised by the Indian people for the plan to make a lasting contribution to India's development towards UHC. To do this, the scheme's success will be dependent on addressing the Indian system's existing and interconnected structural shortcomings, including public and private sector governance, stewardship, quality control, and health system organisation. This will need extensive change, intervention, and leadership at all levels of the system.

References: NHA Website

Author - Kunjal Jain