Benefits of Ayushman Bharat & Pradhan Mantri Jan Arogya Yojana (PM-JAY Scheme)

Are you aware that amongst the top 5% people in India, 98% receive some medical attention before they die, however, over 38% of citizens who belong to the bottom 25% never receive any health care during their lifetimes? They are too poor to afford a hospital stay, even for life-threatening diseases. More than six crores are forced to step below the poverty line.

The relevance of health insurance and its substantial benefits have often been discussed at length. The COVID-19 pandemic has merely reiterated the undeniable importance of medical coverage. That being said, how many times have we seen our local or central governments making it a top priority? 

In 70+ years of our independent history, despite some genuine efforts, it’s difficult to think of many large-scale and well-organised attempts at expanding healthcare coverage for all sections of the society, with a particular focus on the vulnerable population. That changed in September 2018, when Ayushman Bharat and Pradhan Mantri Jan Arogya Yojana (PM-JAY Scheme) were launched by the Central Government of India (GOI).

Let’s briefly understand what Ayushman Bharat and Pradhan Mantri Jan Arogya Yojana are all about, the eligibility criteria, inclusions, exclusions and explore their transformational benefits.

The Ayushman Bharat & Pradhan Mantri Jan Arogya Yojana (PM-JAY Scheme)

  • Ayushman Bharat is a health insurance flagship scheme of the Government of India.
  • It was launched after recommendations from the National Health Policy 2017.
  • Aims to achieve the vision of Universal Health Coverage (UHC) with an underlining commitment to leave no one behind.
  • Moves from sectoral/segmented approach of medical service delivery to comprehensive need-based health care.
  • Comprises of two components: Health and Wellness Centres (HWCs) + Pradhan Mantri Jan Arogya Yojana (PM-JAY, earlier known as the National Health Protection Scheme or NHPS). 
  • PM-JAY was introduced on 23rd September 2018, and it is the largest health assurance scheme in the world fully funded by the Government with nearly 50 crore beneficiaries. 
  • The cost of implementation is shared between the state and central governments. 
  • Provides a health cover of 5 lakh rupees/family/year for secondary and tertiary care hospitalisation to more than 10.74 crore low-income families from the bottom 40% of the population.

PM-JAY Scheme Eligibility & Inclusions

  • The eligibility in the PM-JAY scheme relies on the deprivation and occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban parts of the country, respectively. 
  • Rural area families must satisfy at least one of the following six criteria: 
  • Living in one room with kuccha walls and roof.
  • No adult member between ages 16-59.
  • Households with no adult male members between ages 16-59.
  • Disabled member and no able-bodied adult.
  • SC/ST households.
  • Landless households deriving considerable income from manual casual labour. 
  • Destitutes, manual scavenger households, primitive tribes and legally released bonded labour are automatically included.
  • Urban area occupational categories of eligible workers:
  • Ragpickers.
  • Beggars.
  • Domestic workers. 
  • Street vendors.
  • Cobblers/hawkers.
  • Other service providers working on the streets.
  • Construction workers.
  • Plumbers/Masons/Painters/Welders.
  • Security guards.
  • Coolies and other head-load workers.
  • Sweepers/Sanitation workers.
  • Malis.
  • Home-based workers.
  • Artisans/Handicrafts workers.
  • Tailors.
  • Transport workers/Drivers/Conductors/Helper to drivers.
  • Cart/Rickshaw pullers.
  • Shop workers/Assistants.
  • Peons in small establishments.
  • Helpers/Delivery assistants.
  • Attendants/Waiters.
  • Electricians/Mechanics/Assemblers/Repair workers.
  • Washer-men.
  • Chowkidars.

Pradhan Mantri Jan Arogya Yojana Household & Other Exclusions

  • Government employees and the ones working in government-run non-agricultural enterprises.
  • Kisan cardholders with 50,000+ Rupees as the credit limit. 
  • Owners of 5+ acres agricultural land, mechanised farming equipment, motorised fishing boats, two/three/four-wheelers, landline phones and refrigerators.
  • Individuals earning 10,000+ Rupees every month, paying income or professional tax or residing in properly built stable houses.
  • OPD expenses, drug rehabilitation, cosmetic surgeries, fertility treatments, individual diagnostics and organ transplants are also excluded.

Ayushman Bharat Yojana Benefits

  • Cashless access to medical services from empanelled public or private hospitals all over the nation without restrictions based on your family’s size, members’ age or gender.
  • Takes care of all pre-existing conditions from day one.
  • Covers expenses incurred on medical examinations, treatments, consultations, medicines/medical consumables, non-intensive/intensive care services, diagnostic/laboratory investigations, medical implantation services, accommodation benefits and food services. 
  • Up to 3 days of pre-hospitalisation + 15 days of post-hospitalisation coverage. 
  • 1,393 procedures cover all treatment costs, including (not limited to) expenses on various supplies, drugs, diagnostic services, doctors’ fees, surgeons’ charges and room/OT/ICU charges.
  • Critical illnesses cover Prostate cancer, Coronary artery bypass grafting, Carotid angioplasty with stent and Skull base surgery.
  • COVID-19 treatment and hospitalisation are also covered. 
  • Helps in reducing out-of-pocket expenditures as hospitals are directed not to charge extra from all PM-JAY beneficiaries.

Affordable healthcare remains an unfulfilled need for most Indians, in spite of the rise in income levels and standards of living. 

Less than 20% have medical insurance, and only 5% claim to have appropriate insurance covers fit for their age, family status and location. 8 out of 10 individuals manage medical expenses out of their pockets through savings and other means. With medicare inflation in double digits, the situation is unlikely to improve soon. 

Securing health insurance for yourself, and your loved ones is no longer a matter of choice, but more of an urgency. 

The Pradhan Mantri Jan Arogya Yojana may not be the perfect solution for everybody’s healthcare needs. Yet, it is undoubtedly improving the quality of life for the weaker sections of our society.

“Portability” has been highlighted as an excellent advantage of the PM-JAY scheme. It allows you to utilise quality and affordable medicare not only at the place of registration but in any part of the country. 

Ayushman Bharat and Pradhan Mantri Jan Arogya Yojana have already benefitted one crore Indians with multiple milestones on the way. If you think you are qualified for the PM-JAY scheme and wish to confirm the eligibility, please reach out to www.pmjay.gov.in or the toll-free call centre at 14555/ 1800111565 for more details.

Alternatively, at Quickinsure, you may compare health insurance policies by going through quotes from all established insurers.Sources: www.india.gov.in, www.pmjay.gov.in, www.livehindustan.com, www.pmmodiyojana.in, www.indiatoday.in, www.nhp.gov.in, Nielson, The Pioneer, World Health Organization, Bloomberg Quint, Livemint, YouTube.com, and multiple other information channels.

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