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

Overview

Ayushman Bharat, a flagship initiative of the Government of India, was introduced as part of the National Health Policy 2017. The primary goal of this scheme is to achieve Universal Health Coverage (UHC), aligning with the global Sustainable Development Goals (SDGs) and the principle of “leaving no one behind.” This comprehensive program focuses on addressing healthcare needs holistically, moving away from a segmented approach to a more unified and inclusive system of health service delivery.

Ayushman Bharat seeks to reform the healthcare system by addressing healthcare needs across all levels—primary, secondary, and tertiary. It emphasizes prevention, health promotion, and ambulatory care. The scheme consists of two major components:

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

PM-JAY, also known as Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana, was officially launched on September 23, 2018, in Ranchi, Jharkhand, by the Honorable Prime Minister of India, Shri Narendra Modi.

Key Features of AB PM-JAY

1. World’s Largest Health Assurance Scheme
   • The scheme provides health coverage of ₹5,00,000 per family annually for secondary and tertiary care hospitalization.
   • Over 10.74 crore poor and vulnerable families, accounting for approximately 50 crore individuals, are covered under this initiative. These families represent the bottom 40% of the Indian population.
2. Selection Criteria
   • Families are selected based on the Socio-Economic Caste Census 2011 (SECC 2011), ensuring inclusion of deprived households in both rural and urban areas.
   • The cost of implementation is shared between the Central and State Governments.
3. Cashless and Paperless Service
   • Beneficiaries receive cashless treatment at empaneled hospitals.
   • The scheme is entirely paperless, simplifying administrative processes and ensuring easy access.

Benefits of AB PM-JAY

The scheme provides a comprehensive health cover of ₹5,00,000 per family per year on a family floater basis, meaning any member of the family can utilize the entire coverage amount if required. Here are the benefits included under PM-JAY:

1. Pre-Hospitalization Expenses
   • Coverage includes medical consultations, diagnostic tests, and medication costs incurred prior to hospitalization.
2. In-Patient Hospitalization Services
   • Non-Intensive and Intensive Care Services: Covers general hospital stays and specialized care.
   • Diagnostic and Laboratory Investigations: Ensures necessary tests are included.
   • Medical Implants: Expenses for prosthetics and other implants, if required.
3. Post-Hospitalization Expenses
   • Follow-up consultations and treatment for up to 15 days after discharge.
4. Other Benefits
   • Food Services: Ensures nutrition for patients during their hospital stay.
   • Accommodation: Covers hospital room expenses.
   • Treatment of Complications: Addresses unforeseen complications during treatment.
5. Pre-Existing Diseases Covered
   • Coverage starts from the first day of enrollment, including pre-existing medical conditions.

Eligibility Criteria

The eligibility criteria for AB PM-JAY differ for rural and urban beneficiaries, as outlined below:

Rural Beneficiaries

PM-JAY covers families that fall under at least one of the following six deprivation categories or meet automatic inclusion criteria:

1. Families living in one-room homes with kucha walls and kucha roofs.
2. Households with no adult member aged between 16 and 59 years.
3. Families with no adult male member aged between 16 and 59 years.
4. Families with disabled members and no able-bodied adult members.
5. Scheduled Caste (SC) and Scheduled Tribe (ST) households.
6. Landless households that derive their income primarily from manual casual labor.

Automatic inclusion categories include:

• Destitutes or those living on alms.
• Manual scavenger households.
• Primitive tribal groups.
• Legally released bonded laborers.

Urban Beneficiaries

In urban areas, families falling under one of the following 11 occupational categories are eligible:

1. Ragpickers.
2. Beggars.
3. Domestic workers.
4. Street vendors, cobblers, hawkers, and other service providers.
5. Construction workers, plumbers, masons, painters, welders, security guards, coolies, and other head-load workers.
6. Sweepers, sanitation workers, and gardeners (mali).
7. Home-based workers, artisans, handicrafts workers, and tailors.
8. Transport workers such as drivers, conductors, and rickshaw pullers.
9. Shop workers, assistants, peons in small establishments, delivery assistants, and attendants.
10. Electricians, mechanics, assemblers, and repair workers.
11. Washermen and chowkidars.

Exclusions

The following categories of individuals are not eligible for AB PM-JAY:

1. Owners of two, three, or four-wheelers or motorized fishing boats.
2. Those owning mechanized farming equipment.
3. Individuals with Kisan Credit Cards having a credit limit of ₹50,000 or more.
4. Government employees or those employed in non-agricultural enterprises managed by the government.
5. Individuals earning a monthly income exceeding ₹10,000.
6. Owners of refrigerators and landlines.
7. Families living in well-built houses.
8. Owners of 5 acres or more of agricultural land.

Application Process

The process for enrolling in PM-JAY involves the following steps:

Offline Procedure

1. Initial Search: An Arogya Mitra searches the list of beneficiaries using details like name, location, ration card number, mobile number, or RSBY URN.
2. BIS Application Search: The beneficiary’s information is verified in various databases, including SECC, RSBY, State Health Scheme, and others.
3. Individual Identification: Beneficiaries must provide documents like Aadhaar or other government ID for validation.
4. Family Identification: Ration card and other family ID documents are used to verify family details.
5. Approval or Rejection: The health insurance company or trust verifies the application and either approves or rejects it.
6. E-Card Issuance: Upon approval, a PM-JAY e-card is issued to the beneficiary.

Required Documents

To apply for AB PM-JAY, beneficiaries need the following documents:

1. Age and identity proof (e.g., Aadhaar card or PAN card).
2. Proof of address.
3. Contact details (mobile number and email).
4. Caste certificate.
5. Income certificate.
6. Family status proof (whether joint or nuclear family).

Conclusion

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana is a transformative step toward achieving universal health coverage in India. By addressing the healthcare needs of the most vulnerable sections of society, this scheme ensures that financial constraints do not hinder access to quality medical care. Its cashless, paperless, and inclusive approach makes it a significant milestone in the country’s journey toward equitable healthcare. With its wide coverage and robust implementation framework, AB PM-JAY is set to improve health outcomes for millions of Indians, fostering a healthier and more prosperous nation.