Ayushman Bharat Scheme – Check Eligibility, Advantages, & Coverage!

Ayushman Bharat Yojana, sometimes referred to as the National Health Protection Scheme, is an initiative that seeks to create a new India that is strong, content, and healthy. As of September 4, 2018, it has been operating in Uttar Pradesh as a test project. Its first objective is to build a nationwide network of health and wellness infrastructure to deliver comprehensive primary healthcare services. Its second objective is to provide insurance coverage to at least 40% of India’s population, which is largely excluded from secondary and tertiary care services.

This government-sponsored flagship program seeks to give disadvantaged 10 crore households (about 50 crore people – 40% of the country’s population) an annual health cover of up to Rs. 5 lakhs based on the caste census & Socio-Economic database.

What do you understand by the Ayushman Bharat Scheme?

Ayushman Bharat, as its name indicates, is primarily a health protection program that seeks to offer health insurance to almost 10 crore participants. Every year, disadvantaged families would be given coverage of up to Rs. 5 lakhs for any type of basic, intermediate, or tertiary healthcare services. It is designed to combine the Rashtriya Swasthya Bima Yojana with the present Senior Citizen Health Insurance Scheme.

National insurance firms will be used to implement the Ayushman Bharat plan. The state & central governments will each pay their fair share of the costs associated with paying premiums. Ayushman Bharat, which is a National Health Protection Scheme, is frequently referred to as AB-NHPS.

Important Elements of the Ayushman Bharat Scheme

  • Every qualified household would receive a clear cover of Rs. 5 lakhs each year.
  • The scheme holder will be able to access secondary, primary, and tertiary health-related services from any public or commercial institutions that have been accredited.
  • The advantages will be completely portable and cashless. It means that neither the beneficiary’s ability to get healthcare nor the timing of reimbursements would be impacted by their location.
  • There will be the same deprivation conditions applied during the socioeconomic caste census will be utilised to identify the recipients. This would make it easier to assess their eligibility.
  • Giving the states enough latitude in terms of spending would rigorously adhere to the cooperative federalism ideal.
  • The payments would be made in a series of instalments. The responsible government would establish the overall expenditures, certain services, and processes that may be included in the package.
  • To enhance cooperation between the federal and state governments, the Ayushman Bharat National Health Protection Mission Council would be established. The union minister for health and family welfare would serve as the head of this organisation. Please visit the official website to learn more about the Ayushman Bharat Yojana.
  • To enhance cooperation between the federal and state governments, the Ayushman Bharat National Health Protection Mission Council would be established. The union minister for health and family welfare would serve as the head of this organisation.

Aim of the ABY Scheme:

With a focus on promotion, prevention, and ambulatory care at the secondary, primary, and tertiary levels, the program seeks to apply ground-breaking strategies to treat health holistically. This includes continuing to execute programs supported by the government at the federal level, such as the Rashtriya Swasthya Bima Yojana (RSBY) & Senior Citizen Health Insurance Scheme (SCHIS).

Principal Advantages of Ayushman Bharat Yojana

Ayushman Bharat Yojana intends to provide coverage for 40% of India’s most vulnerable and impoverished citizens. This would be accomplished by providing the following main advantages:

  • During the hospitalisation procedure, all out-of-pocket costs will be reimbursed.
  • The insurance offered would be in a cashless style regardless of whether the hospital is a public or empaneled private facility.
  • The beneficiary would get a transportation stipend, which would pay for travel expenses both before and after the hospitalisation.
  • Facilities for nursery therapy would be made available as part of the insurance plan.
  • Any pre-existing conditions of the recipient would be treated without charge, except for a few conditions listed as an exclusion.
  • There have also been provisions established for follow-up benefits to check on the patient’s level of recovery.

What Expenses Are Covered Under the PMJAY Programme?

PMJAY will pay for the following therapy-related expenses:

  • Pre-hospitalization Costs are covered by the PMJAY policy.
  • Post-hospitalization Costs are paid for a period of 15 days.
  • Hospital housing expenses are also covered under the plan, along with reimbursement for the cost of prescription medications and medical equipment.
  • ICU and non-intensive services
  • The diagnostic services accompanying costs also come under PMJAY Program.
  • Services for medical implantation are offered as necessary.
  • The price of remedying issues that develop throughout therapy.
  • Food shipping

Why this Scheme is so important?

  • India’s economy is one of the world’s fastest expanding, however, the World Bank still categorizes it as a Lower Middle-Income Country (LMIC). The socioeconomic and health sectors’ inconsistencies are mostly to blame for this.
  • Health care providers, especially public sector hospitals, are overloaded with problems such as a lack of funding, a scarcity of pharmaceuticals and medical supplies, and a lack of qualified healthcare professionals.

 

  • Furthermore, during the past 20 years, the numbers show that only 1.2% of India’s GDP was allocated to the health sector. 21% of it comes from government funding, with the remaining 79% coming from personal spending. According to economists, one of the main reasons for poverty in India is the country’s rising healthcare demands and high out-of-pocket costs.

 

  • The majority of the policies and initiatives put forth by the federal and state governments fell short of addressing primary healthcare.

To handle all the above problems, the Indian government has released the Ayushman Bharat Program.

Eligibility Conditions for the Ayushman Bharat Scheme

The program has specified a list of precise qualifying requirements that will aid in properly identifying and serving the recipients. These standards are mostly based on information gathered during the 2011 Socioeconomic Caste Census. Although they make an effort to cover all low-income households, there are certain differences between recipients who live in rural and urban regions. These are the categories for urban and rural areas, respectively.

PMJAY Scheme: Rural Eligibility Requirements

  • Household without any adults or male earners between the ages of 16 and 59 Living quarters for families with Kuccha walls and roofs
  • Families between the ages of 16 and 59 without any members
  • Household with one person with a disability and no adults in good health
  • Families that scavenge manually
  • Landless families that rely heavily on physical labour for their family’s income

11 specific job categories are used to identify eligible households in metropolitan regions. These consist of:

  • Rag collectors and beggars
  • employees in the home
  • Cobblers, Street hawkers, and merchants
  • Building tradespeople, such as masons, plumbers, painters, security personnel, and welders Coolies
  • Sweepers, Gardeners, and sanitation personnel
  • Independent contractors, artists, tailors, and artisans
  • Transportation professionals such as conductors, drivers, and cart pullers.
  • Retail employees, helpers, peons, delivery personnel, waitstaff, and attendants
  • Workers in repair, assembly, and mechanics
  • Washermen & Watchmen

Required Documents

  • Age and identity proof (Aadhaar card or PAN card)
  • Contact information (email or cell phone)
  • A proof of address
  • Caste Certificate
  • Income Tax Certificate
  • Documentation that Supports the Family’s Joint or Nuclear Status
  • The Aadhaar Card

How Do I Online Register for The PMJAY Scheme?

The PMJAY registration process is straightforward. All beneficiaries included on the SECC 2011 list and those who are enrolled in the RSBY program must comply with it. On the other hand, you can adhere to the instructions below to register for PMJAY online:

  • Check out the PMJAY scheme’s authorised webpage.
  • Simply click the tab labelled “Am I Eligible” when you locate it.
  • Enter your mobile number, solve the Captcha Code, and press the Generate OTP button.
  • Enter your State, ration card number, name, residence number, or cell phone number at this time.
  • Your name will appear in the outcome if your family is eligible for the PMJAY.

Generation of PMJAY Patient Cards

Once you have determined whether you are eligible for the Ayushman Bharat Yojana plan, you can apply for an e-card. However, to receive this e-card, you must go through an identity check at a PMJAY kiosk using your identification credentials, such as an Aadhaar card or ration card. A government-certified list of members or even your family identity, including the RSBY automobiles, may be provided.  You can take out a hard copy of your Ayushman Bharat ID & patient e-card once you are done with the validation process.

Exclusions

  • Those who possess a motorised fishing boat or a two-, three-, or four-wheeler.
  • Farmers with automated farming machinery.
  • People having Kisan cards and credit limits of at least Rs 50,000.
  • People working in the government sector.
  • People who work for non-agricultural businesses that are run by the government.
  • People with monthly incomes over Rs 10,000.
  •  Homeowners of nice, well-built homes.
  • People with agricultural land holdings of at least 5 acres.

What Happens During Hospitalisation?

The recipients wouldn’t have to worry about any financial costs throughout their hospital stay. Instead, an ‘Ayushman Mitra’ would be appointed to each impanelled hospital, whose main duty would be to help the qualified families. The Ayushman Mitras would manage the help desk, check the patient’s paperwork, and start the enrolment process.

The recipients would get letters with QR codes after this was finished. They would be able to receive the full range of pre-and post-hospitalization benefits thanks to these letters, which would act as a kind of demographic authentication. The program, along with all of its benefits, is transferable across the nation. This guarantees that the recipient won’t experience hospitalisation difficulties due to a shift in location.

FAQs Section

Will there be any fees for recipients to participate in this program?

No. Both recognised private and public hospitals can provide approved beneficiaries with complimentary secondary and tertiary hospital care for certain PM-JAY packages. Beneficiaries will be able to get medical treatments under PM-JAY without cash or documentation.

Can this scheme’s advantages be obtained without an Aadhar Card?

Yes. The Aadhar card is not required to use the services offered by this program.

Are people with diabetes included in the PM Ayushman Bharat Yojana Scheme?

Since the plan covers pre-existing conditions, you will be covered by it starting on Day 1 even if you have diabetes, but only for inpatient hospitalisation. However, OPD costs will not be reimbursed.

Does the Ayushman Bharat Yojana Program cover cancer?

Yes, the Ayushman Bharat Yojana covers cancer treatment; however, the type of cancer and its length varies depending on the type. To determine optimal patient management, the treatment for this condition must go through a treatment plan and various approvals, such as a “tumour board concept.”

Does the Ayushman Bharat program include orthopedic care?

The program covers orthopaedic procedures up to a predetermined amount.

How long may claim submission requests be approved in advance?

After all supporting evidence has been submitted to SHA for final approval and payment processing, the claim must be authorised within 15 days. SHA will pay claims that have been backed up by its staff within 15 days.

Will the recipient receive a card?

A special PM-JAY family identification number will be provided to each eligible household. The patient will also get an electronic card while they are in the hospital.

What is the procedure for submitting a claim?

When a patient leaves the EHCP, the claim submission procedure is started by submitting a request online along with the patient’s discharge summary and any other pertinent clinical notes and investigative findings. Within 24 hours following the patient’s release, EHCP must file claims.

How can data be updated in PMJAY?

All program participants may update their information by contacting their designated hotline (1800-111-565 or 14555), going online, or visiting the CSC (Common Service Centre) personally.

Who pays for Ayushman Bharat’s expenses?

As a Central Sector Programme, Ayushman Bharat is funded entirely by the Central Government of India.