Ayushman Bharat Pradhan Mantri Jan Arogya Yojana UPSC

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana

The Pradhan Mantri Jan Arogya Yojana (PMJAY) popularly known as Ayushman Bharat Yojana Scheme is the flagship scheme by the Government of India. It is essentially a health insurance scheme to cater to the poor, lower section of the society and the vulnerable population. The scheme offers financial protection in case of hospitalization due to medical emergencies. On this note, let us understand about the scheme in detail. 

What is Ayushman Bharat Pradhan Mantri Jan Arogya Yojana ? 

Considered as one of the biggest healthcare schemes in the world, Ayushman Bharat Yojana aims to cover more than 50 crore Indian citizens. It is designed especially for the economically weaker sections of the country. The PMJAY was launched in September 2018 providing health insurance coverage of a maximum sum insured amount of Rs.5 lakh. 

The government health insurance scheme covers most of the medical treatment costs, medicines, diagnostics and pre-hospitalisation expenses. Additionally, the scheme offers cashless hospitalisation services through the Ayushman Bharat Yojana e-card which you can use to get healthcare services at any of the empanelled hospitals across the country. Beneficiaries of the scheme can avail hospitalisation for necessary treatment by showing their PMJAY e-card. 

What is covered under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana ? 

With the intention to provide accessible healthcare to the poor and needy, the Ayushman Bharat Yojana Scheme offers coverage of up to Rs.5 lakh per family per year for secondary and tertiary hospitalisation care. 

The health insurance under AB-PMJAY includes hospitalization costs of beneficiaries and includes the below components: 

• Medical examination, consultation and treatment. 

• Pre-hospitalisation. 

• Non-intensive and intensive care services. 

• Medicine and medical consumables. 

• Diagnostic and laboratory services. 

• Accommodation. 

• Medical implant services, wherever possible. 

• Food services. 

• Complication arising during treatment. 

• Post-hospitalisation expenses for up to 15 days. 

• COVID-19 (Coronavirus) treatment. 

What is not covered under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana ? 

Similar to other types of health insurance policies, the Ayushman Bharat Yojana Scheme has some exclusions. 

Below components are not covered under the scheme: 

• Out-Patient Department (OPD) expenses. 

• Drug rehabilitation. 

• Cosmetic surgeries. 

• Fertility treatments. 

• Individual diagnostics. 

• Organ transplant.

Features of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana :

• Coverage of Rs.5 lakh per family per annum for secondary and tertiary care across public and private hospitals. 

• Approximately 50 crore beneficiaries (over 10 crore poor and vulnerable entitled families) are eligible for the scheme. 

• Cashless hospitalisation. 

• Covers up to 3 days of pre-hospitalisation expenses such as medicines and diagnostics. 

• Covers up to 15 days of post-hospitalisation expenses which include medicines and diagnostics. 

• No restriction on the family size, gender or age. 

• Can avail services across the country at any of the empanelled public and private hospitals. 

• All pre-existing conditions covered from day one. 

• The scheme includes around 1400 medical procedures. 

• Includes costs for diagnostic services, drugs, room charges, 

physician’s fees, surgeon charges, supplies, ICU and OT charges. 

• Public hospitals are reimbursed at par with private hospitals. 

Eligibility criteria for rural and urban population 

The scheme has been launched to cover the bottom 40% of poor and economically weaker sections of the country. This was based on the deprivation and occupational criteria of the Socio-Economic Caste Census 2011 for rural and urban areas. The eligibility is designed with pre-conditions so that only the underprivileged people of the society benefit from the initiative. PMJAY Rural: The 71st round of the National Sample Survey Organisation reveals that a staggering 85.9% of rural households do not have access to any healthcare insurance or assurance. Additionally, 24% of rural families access healthcare facilities by borrowing money. PMJAY’s aim is to help this sector avoid debt traps and avail services by providing yearly assistance of up to Rs. 5 lakh per family. The scheme will come to the aid of economically disadvantaged families as per data in the Socio-Economic Caste Census 2011. Here too, households enrolled under the Rashtriya Swasthya Bima Yojana (RSBY) will come under the ambit of the PM Jan Arogya Yojana.In the rural areas, the PMJAY health cover is available to: 

1. Those living in scheduled caste and scheduled tribe households; 

2. Families with no male member aged 16 to 59 years; 

3. Beggars and those surviving on alms; 

4. Families with no individuals aged between 16 and 59 years; 

5. Families having at least one physically challenged member and no able-bodied adult member; 

6. Landless households who make a living by working as casual manual labourers; 

7. Primitive tribal communities; 

8. Legally released bonded labourers; 

9. Families living in one-room makeshift houses with no proper walls or roof; 

10. Manual scavenger families 

PMJAY Urban: According to the National Sample Survey Organisation (71st round), 82% of urban households do not have access to healthcare insurance or assurance. Further, 18% of Indians in urban areas have addressed healthcare expenses by borrowing money in one form or the other. 

Pradhan Mantri Jan Arogya Yojana helps these households avail healthcare services by providing funding of up to Rs. 5 lakh per family, per year. PMJAY will benefit urban workers’ families in the occupational category present as per the Socio-Economic Caste Census 2011. Further, any family enrolled under the Rashtriya Swasthaya Bima Yojana will benefit from the PM Jan Arogya Yojana as well.In the urban areas, those who can avail of the government-sponsored scheme consist mainly of: 

1. Washerman / chowkidars; 

2. Rag pickers; 

3. Mechanics, electricians, repair workers; 

4. Domestic help; 

5. Sanitation workers, gardeners, sweepers; 

6. Home-based artisans or handicraft workers, tailors; 

7. Cobblers, hawkers and others providing services by working on streets or pavements; 

8. Plumbers, masons, construction workers, porters, welders, painters and security guards;

9. Transport workers like drivers, conductors, helpers, cart or rickshaw pullers; 

10. Assistants, peons in small establishments, delivery boys, shopkeepers and waiters. 

People not entitled for the Health Cover under Pradhan Mantri Jan Arogya Yojana: 

1. Those who own a two, three or four-wheeler or a motorised fishing boat; 

2. Those who own mechanised farming equipment; 

3. Those who have Kisan cards with a credit limit of Rs.50000; 

4. Those employed by the government; 

5. Those who work in government-managed non-agricultural enterprises; 

6. Those earning a monthly income above Rs.10000; 

7. Those owning refrigerators and landlines; 

8. Those with decent, solidly built houses; 

9. Those owning 5 acres or more of agricultural land.