Ayushman Bharat: Pradhan Mantri Jan Arogya Yojana (PMJAY)
AYUSHMAN BHARAT (PMJAY): Introduction
Government of India launched Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AYUSHMAN BHARAT (PMJAY)) on 23.09.2018. Ayushman Bharat, a flagship scheme of Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). It has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to “leave no one behind.”
Ayushman Bharat is an attempt to move from sectoral and segmented approach of health service delivery to a comprehensive need-based health care service. This scheme aims to undertake path breaking interventions to holistically address the healthcare system (covering prevention, promotion and ambulatory care) at the primary, secondary and tertiary level.
AYUSHMAN BHARAT (PMJAY): Components
Ayushman Bharat adopts a continuum of care approach, comprising of two inter-related components, which are:
- Health and Wellness Centres (HWCs)
- Pradhan Mantri Jan Arogya Yojana (PMJAY)
- Health and Wellness Centers (HWCs)
In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres. These centres are to deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people. They cover both, maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.
Health and Wellness Centers are envisaged to deliver an expanded range of services to address the primary health care needs of the entire population in their area, expanding access, universality and equity close to the community. The emphasis of health promotion and prevention is designed to bring focus on keeping people healthy by engaging and empowering individuals and communities to choose healthy behaviours and make changes that reduce the risk of developing chronic diseases and morbidities.
- Pradhan Mantri Jan Arogya Yojana (PMJAY)
The second component under Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojna or PMJAY as it is popularly known. This scheme was launched on 23rd September, 2018 in Ranchi, Jharkhand by the Hon’ble Prime Minister of India, Shri Narendra Modi.
Ayushman Bharat PMJAY is the largest health assurance scheme in the world which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries) that form the bottom 40% of the Indian population. The households included are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. PMJAY was earlier known as the National Health Protection Scheme (NHPS) before being rechristened. It subsumed the then existing Rashtriya Swasthya Bima Yojana (RSBY) which had been launched in 2008. The coverage mentioned under PMJAY, therefore, also includes families that were covered in RSBY but are not present in the SECC 2011 database. PMJAY is fully funded by the Government and cost of implementation is shared between the Central and State Governments.
AYUSHMAN BHARAT (PMJAY): Key Features
- PMJAY is the world’s largest health insurance/ assurance scheme fully financed by the government. AYUSHMAN BHARAT (PMJAY) is a centrally sponsored scheme. It is entirely funded by Government and the funding is shared between Centre and State governments as per prevailing guidelines of Ministry of Finance.
- AYUSHMAN BHARAT (PMJAY) provides health coverage up to Rs. 5 lakh per family per year for secondary and tertiary hospitalization.
- AYUSHMAN BHARAT (PMJAY) is an entitlement based scheme. This scheme covers poor and vulnerable families based on deprivation and occupational criteria as per the Socio-Economic Caste Census SECC 2011 database. Over 10.74 crore poor and vulnerable entitled families (approximately 50 crore beneficiaries) are eligible for these benefits. All such beneficiary families under RSBY that do not feature in the targeted groups as per SECC data, are also covered under AYUSHMAN BHARAT (PMJAY). At present, there is no proposal to extend the coverage of AYUSHMAN BHARAT (PMJAY).
- AYUSHMAN BHARAT (PMJAY) provides cashless and paperless access to services for the beneficiary at the point of service in any (both public and private) empanelled hospitals across India. In other words, a beneficiary from one State can avail benefits from an empanelled Hospital anywhere in the Country.
- Under PMAJY, the States are free to choose the modalities for implementation. They can implement the scheme through insurance company or directly through the Trust/ Society or mixed model.
- There is no restriction on family size, ensuring all members of designated families specifically girl child and senior citizens get coverage.
- A well-defined Complaint and Public Grievance Redressal Mechanism, has been put in place through which complaints/ grievances are registered, acknowledged, escalated for relevant action, resolved and monitored.
- AYUSHMAN BHARAT (PMJAY) has created a robust IT system for implementation and role of real time transaction data.
- At National level, National Health Authority (NHA) has been set up as an attached office to Ministry of Health and Family Welfare to manage the implementation of the scheme.
- The details of package, operational guidelines and key features are available at www. Ayushman Bharat (PMJAY).gov.in
- AYUSHMAN BHARAT (PMJAY) provides cashless treatment to the entitled beneficiaries at empanelled hospitals. No money is released to the beneficiary and payment is made directly to the hospitals by State Health Agency (SHA) in case of Trust Mode, and by Insurance company in case of Insurance mode.
- Under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-AYUSHMAN BHARAT (PMJAY)), all public hospitals (Community Health Centre and above), in the States implementing AYUSHMAN BHARAT (PMJAY), are deemed empanelled. Hospitals belonging to Employee State Insurance Corporation (ESIC) may also be empanelled based on the bed occupancy ratio parameter. All National institutes run by Ministry of Health & Family Welfare as well as Institute of National Importance are part of the empanelled healthcare provider network for AYUSHMAN BHARAT (PMJAY). As far as private hospitals are concerned, they are empanelled by State Health Agencies of respective States. For empanelment, guidelines have been issued to all the States laying down the detailed criteria and process.
- PMJAY envisions to help mitigate catastrophic expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year.
- It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.
- All pre–existing conditions are covered from day one.
- Public hospitals are reimbursed for the healthcare services at par with the private hospitals.
- Medical examination, treatment and consultation
- Services include approximately 1,393 procedures covering all the costs related to treatment, including but not limited to:
- Pre-hospitalization
- Medicine and medical consumables
- Non-intensive and intensive care services
- Diagnostic and laboratory investigations
- Medical implantation services (where necessary)
- Accommodation benefits
- Food services
- Complications arising during treatment
- Post-hospitalization follow-up care up to 15 days
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