PMJAY: Ayushman Bharat Yojana Scheme, Benefits, Eligibility Criteria and Application Process

Health Insurance has been there for decades in India, but it has been limited to a small well-to-do section of the population. A majority of the underprivileged population, including a maximum of the rural population was not covered by health insurance, resulting in great financial burden on these people during illnesses and other health crises. This led to huge debt traps for the vulnerable people.

To protect the poor families from high expenditure due to hospitalizations and other health issues, a primary health insurance scheme along with primary medical care was the need of the hour and a solution to the problem. Therefore, The Government of India, Prime Minister Narendra Modi started the Ayushman Bharat Yojana – National Health Protection Scheme, now known as the Pradhan Mantri Jan Arogya Yojana, to cater to the poor and rural families.

What Is Ayushman Bharat Yojana (PMJAY)?

Ayushman Bharat Yojana (PMJAY) is one of the largest healthcare schemes sponsored by the government of India and aims to cover more than 50 crore Indian citizens and more than 10 crore poor families. Under this scheme beneficiaries can avail healthcare services and specified medical procedures at empaneled hospitals throughout the country by using an e-card.

The scheme was launched in September 2018, providing health insurance coverage of a maximum sum insured amount of Rupees 5 lakhs. PMJAY subsumes the Senior Citizen Health Insurance Scheme (SCHIS) and Rashtriya Swasthya Bima Yojana (RSBY). It covers most of the Diagnostic and treatment cost of medicine. In addition to this, the scheme offers cashless hospitalization expenses through the Ayushman Bharat Yojana e-card in any of the empaneled hospitals across the country. It covers medical and hospitalization expenses of nearly all secondary and tertiary care procedures. The scheme has defined several medical packages covering surgery, medical and day care treatments including medicines and transport.

The PMJAY e- card can be used for cashless treatment at any private or Public empaneled Hospital across the country. 3 days of pre- hospitalization and 15 days of post-hospitalization expenses, around 1400 procedures including OT charges are covered under this scheme. By providing a health insurance coverage of 5 lakh rupees per family per year, the scheme envisages to provide healthcare to the economically disadvantaged people of the country.

Salient Features of Ayushman Bharat Yojana Scheme (PMJAY)

Health cover up to 5 lakhs per family per year
More than 10 crores poor and vulnerable families are covered across the country
Households listed in the SECC database as per defined criteria are covered
No limit to family size and age of members
Free treatment can be availed at all public and empaneled private hospitals
Covers the cost of secondary and tertiary care hospitalization.
1350 medical packages included covering surgery, medical and day care treatments, cost of medicines and diagnostics.
All pre-existing diseases are covered
Cashless and paperless quality health care services.

Benefits of Ayushman Bharat Yojana (PMJAY) Scheme

The vulnerable and underprivileged section of people get the following benefits from the Ayushman Bharat Yojana scheme:

Cashless hospitalization facility
Pre and post hospitalization expenses covered
Can be availed by all family members
No cap on age, gender or family size
Pre-Existing conditions are included from day one
Accommodation expenses during hospitalization can be availed

Critical Illnesses Covered under the Bharat Yojana (PMJAY) Scheme

Prostate cancer
Double valve replacement
Coronary artery bypass graft
COVID-19
Pulmonary valve replacement
Skull base surgery
Anterior spine fixation
Laryngopharyngectomy with gastric pull-up
Tissue expander for disfigurement following burns
Carotid angioplasty with stent

Eligibility Criteria for Rural and Urban Populations

The Pradhan Mantri Jan Arogya Yojana was designed to provide healthcare to the poor and underprivileged people of the country, covering 10 crore families comprising 8 crore families in the rural and 2.33 crore families of the urban population. Altogether 50 crore beneficiaries were to be covered under the scheme. However, certain pre-conditions were specified for being eligible for the scheme, so that only the deprived section of the country were benefitted.

PMJAY Rural

Members of the Schedule Caste Schedule Tribe Households
Families with no male members aged between 16 to 59
Beggars and those surviving on alms
Families with no individual age between 16 and 59
Families with at least one physically challenged individual or with no able-bodied individuals
Primitive Tribal Communities
Legally released bonded laborers
Families living in one room makeshift houses with no proper walls or roof
Manual Scavenger families

PMJAY Urban

According to the national sample survey organization, more than three fourths of the urban households do not have health insurance. Many of them borrow money and fall into debt traps to address their medical expenses. To help these households the PMJAY urban scheme has been introduced with certain pre-existing conditions. The beneficiaries of the Rashtriya Swasthya Bima Yojana can also avail the benefits under this scheme. The following are eligible to avail this scheme:

Washerman, Chaukidar
Ragpickers
Mechanics electricians, and repair workers
Domestic help
Sanitation workers, gardeners, sweepers
Home based artisans or handicraft workers
Cobblers, hawkers and other Street vendors
Plumbers, masons and other construction workers
Porters, welders, painters and security guards
Transport Workers like drivers, conductors, helpers, cart or rickshaw pullers
Peons in small establishments, assistants, helper, attendants, delivery assistants, waiters

Persons Not Entitled to Avail the Ayushman Bharat Yojana Scheme

People who own a two, three, four-wheeler or a mechanic boat
People who own a mechanized farming a equipment
People who have kisan card credit limit of 50000
Persons employed by the government
Those working IN government managed non-agricultural Enterprises
Those earning a monthly income of above rupees 10,000
Those owning refrigerators and landlines
Those with decent solidly built houses
Those warning 5 acres or more of agricultural land

To check eligibility, beneficiaries can contact the helpline (14555/1800111565), or visit the nearest Common Service Centers (CSC) or log on to mera.pmjdy.gov.in. This can also be checked at empaneled hospitals.

How to apply for Ayushman Bharat Yojana Scheme

The scheme does not require any form of registration as it is meant for the poor and vulnerable people. All the families identified as poor and vulnerable by the Socio-economic caste census, 2011 become automatically eligible for the scheme. The eligibility can be checked by visiting the official site of Ayushman Bharat Yojana. The introduction of Ayushman Bharat will change the entire healthcare system in India.

Application Process

The Pradhan Mantri Jan Arogya Yojana was launched to provide for the healthcare needs of the underprivileged section of the population. There is no registration procedure as such. Eligible persons who are identified by the Socio-Economic Caste Census (SECC) 2011 and those already under the RSBY scheme are eligible. To check online whether a person is eligible for the PMJAY scheme, the following steps need to be followed:

Step 1: Visit the PMJAY portal and click on ‘Am I eligible’

Step 2: Enter mobile number and CAPTCHA code and click on ‘Generate OTP’

Step 3: Select your state and search by name/HHD number/ration card number/mobile number

Step 4: The search results show whether you are eligible for the PMJAY scheme.

You can also contact the Ayushman Bharat Yojana customer care at 1800-111-565 or 14555 or you can reach out to any of the Empaneled Health Care Providers (EHCPs).

Documents Required to Apply for Ayushman Bharat Yojana Scheme

The following is the list of documents required to apply for the PMJAY scheme:

Identity and age proof (Aadhaar Card/PAN Card)
Details of applicant’s mobile number email address and residential address
Caste certificate
Income certificate
Documents mentioning your current family status

Also Read: Uses of e-RUPI for Providing Diagnostic Services

Steps to Download Ayushman Bharat Yojana Card online

The Bharat Ayushman Yojana golden card is issued to the beneficiaries to ensure cashless, paperless, portable transactions in the PMJAY scheme. The card contains all the relevant information of the patient. This card has to be compulsorily submitted at the time of treatment or admission at the empaneled hospital. The steps to download the card online are as follows:

Step 1: Visit the PMJAY website (https://mera.pmjay.gov.in/search/login) and log in with your registered mobile number.

Step 2: Enter the ‘Captcha Code’ and click on ‘generate OTP’.

Step 3: Opt for the HHD code.

Step 4: Provide the HHD code to the Common Service Center (CSC), which checks the HHD code and other details.

Step 5: The CSC representatives who are called Ayushman Mitra will complete the rest of the process.

Step 6: A payment of Rs.30 has to be made to get the Ayushman Bharat card.

Steps to Download the PMJAY Hospital List

Step 1: Visit the official website of PMJAY
Step 2: Select your state and district

Step 3: Choose the type of hospital (public, private-for-profit, private-for-nonprofit)

Step 4: Choose the medical facility that is required

Step 5: Enter the Captcha Code and click on search

The list of Ayushman Bharat Yojana hospitals along with address, website, and contact information will be shown.

Grievance Portal: Grievances can be registered in the Grievance section of the PMJAY portal. The status of the grievances can also be checked in the same portal.

FAQs

1.What are Ayushman Bharat Arogya Mitras?

Answer: Ayushman Bharat Arogya Mitras are facilitators in empaneled hospitals who ensure the smooth functioning of the insurance scheme. Every empaneled hospital will have at least one Arogya Mitra to help with the beneficiary verification, grievance redressal, authentication, query management, and handling of emergency cases. They are well trained in software usage, patient registration and interaction.

2. What is the hospitalization process in the scheme?

Answer: The Ayushman Mitra will help the eligible families by verifying the patient’s documents, and initiating their admission. Once the registration is completed, the patients are provided with letters having QR codes. These letters serve as a demographic authentication that enables them to avail the whole set of pre and post hospitalization benefits. The scheme with all its associated benefits is portable across the country. This ensures that a change of location does not pose a problem during hospitalization of the beneficiary.

3. How to claim under the Ayushman Bharat Yojana?

Answer: The Arogya Mitras in the empaneled hospitals will assist the patients and coordinate with beneficiaries and the hospital. They will operate a help desk and will look into the documents to verify their eligibility. The patients will be provided with letters containing QR codes, which will be scanned. A demographic authentication is also conducted for identification and verification of the patient’s eligibility to avail the benefits of the scheme. For medical packages, the pre and post hospitalization investigation details need to be handed over or uploaded.

4. What is the cost incurred for a person to avail the PMJAY scheme?

Answer: The scheme is completely cashless. That is there is no cost to the beneficiary. All the expenses are borne by the state and central governments.

Conclusion

The Ayushman Bharat Health Insurance Scheme, envisaged to help the poor and vulnerable families is an example of the government’s commitment to improve the healthcare system in the country. The poor people, especially the rural poor of the country who have been struggling with health risks due to lack of finances will now be able to access proper treatment and medication. This will not only lead to the development of a healthy population but also ensure better labor resources for the country’s development. The initial response to the scheme has been very encouraging. It has brought hope to the underprivileged section of the nation and is a positive step in the right direction.