Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana

Syllabus subtopic: Welfare Schemes for Vulnerable Sections of the population by the Centre and States and the Performance of these Schemes; Mechanisms, Laws, Institutions and Bodies constituted for the Protection and Betterment of these Vulnerable Sections.

Prelims and Mains focus: about the move and its significance; about PMJAY and its objectives

News: India is aiming to plug significant gaps in providing healthcare in smaller cities and towns under the ambitious Ayushman Bharat programme by signing up hospitals operated by state-run companies and Indian Railways.

Background

• The PMJAY, launched in September 2018, aims to provide health insurance for secondary and tertiary hospitalization to over 100 million poor and vulnerable families, which would total around 500 million beneficiaries.

• Since its launch, over 7.8 million patients have availed of insurance services under the scheme at over 21,271 hospitals across the country, information on the PMJAY website showed as of Saturday.

• However, a research conducted by PMJAY for April-July last year showed that there was disparity in where these services were availed of, based on the disease burden and socio-economic status.

About the move

It has been decided that all public hospitals should be empanelled under AB-PMJAY (Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana) in order to expand its coverage.

Why?

• The government’s push to get public hospitals empanelled is due to a lack of secondary and tertiary healthcare facilities in poorer regions.

• A number of hospitals in smaller cities— including those run by state-run enterprises—are under-utilized, even though there is strong demand for their services in these regions especially because of the insurance programme.

AB-PMJAY

• Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a Centrally Sponsored Scheme having central sector component under Ayushman Bharat Mission anchored in the Ministry of Health and Family Welfare (MoHFW).

• It is an umbrella of two major health initiatives, namely Health and wellness Centres (HWCs) and National Health Protection Scheme (NHPS).

1. Health and Wellness Centres (HWCs)

Under this 1.5 lakh existing sub centres will bring health care system closer to the homes of people in the form of Health and wellness centres. These centres will provide comprehensive health care, including for non-communicable diseases and maternal and child health services.

List of Services to be provided at Health & Wellness Centre

• Pregnancy care and maternal health services
• Neonatal and infant health services
• Child health
• Chronic communicable diseases
• Non-communicable diseases
• Management of mental illness
• Dental care
• Eye care
• Geriatric care Emergency medicine

2. National Health Protection Mission (PM-JAY)

Benefits

• AB-PMJAY provides a defined benefit cover of Rs. 5 lakh per family per year. This cover will take care of almost all secondary care and most of tertiary care procedures.

• To ensure that nobody is left out (especially women, children and elderly) there will be no cap on family size and age in the scheme.

• The benefit cover will also include pre and post-hospitalisation expenses. All pre-existing conditions will be covered from day one of the policy. A defined transport allowance per hospitalization will also be paid to the beneficiary.

• Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.

• The beneficiaries can avail benefits in both public and empanelled private facilities. All public hospitals in the States implementing AB-PMJAY, will be deemed empanelled for the Scheme. Hospitals belonging to Employee State Insurance Corporation (ESIC) may also be empanelled based on the bed occupancy ratio parameter. As for private hospitals, they will be empanelled online based on defined criteria.

• To control costs, the payments for treatment will be done on package rate (to be defined by the Government in advance) basis. The package rates will include all the costs associated with treatment. For beneficiaries, it will be a cashless, paper less transaction. Keeping in view the State specific requirements, States/ UTs will have the flexibility to modify these rates within a limited bandwidth.

Eligibility criteria

• AB-PMJAY is an entitlement based scheme with entitlement decided on the basis of deprivation criteria in the SECC database.

• The different categories in rural and urban areas include
  • families having only one room with kucha walls and kucha roof;
  • families having no adult member between age 16 to 59;
  • female headed households with no adult male member between age 16 to 59;
  • disabled member and no able bodied adult member in the family;
  • SC/ST households;
  • landless households deriving major part of their income from manual casual labour,
  • Families in rural areas having any one of the following: households without shelter, destitute, living on alms, manual scavenger families, primitive tribal groups, legally released bonded labour.
  • For urban areas, 11 defined occupational categories are entitled under the scheme - Occupational Categories of Workers, Rag picker, Beggar, Domestic worker, Street vendor/ Cobbler/hawker / Other service provider working on streets, Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/, Coolie and another head-load worker, Sweeper/ Sanitation worker / Mali, Home-based worker/ Artisan/ Handicrafts worker / Tailor, Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller, Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter, Electrician/ Mechanic/ Assembler/ Repair worker, Washerman/ Chowkidar.

As per the SECC 2011, the following beneficiaries are automatically excluded:

• Households having motorized 2/3/4 wheeler/fishing boat
• Households having mechanized 3/4 wheeler agricultural equipment
• Households having Kisan Credit Card with credit limit above Rs. 50,000/ -
• Household member is a government employee
• Households with non - agricultural enterprises registered with government
• Any member of household earning more than Rs. 10,000/ - per month
• Households paying income tax
• Households paying professional tax
• House with three or more rooms with pucca walls and roof
• Owns a refrigerator
• Owns a landline phone
• Owns more than 2.5 acres of irrigated land with 1 irrigation equipment
• Owns 5 acres or more of irrigated land for two or more crop season
• Owning at least 7.5 acres of land or more with a t least one irrigation equipment.