Know everything about Ayushman Bharat Yojana, from eligibility criteria and application process

Ayushman Bharat Yojana (PMJAY): Introduction

Ayushman Bharat Yojana, also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY), is a scheme that aims to help the economically weaker section of the society who need healthcare facilities.

Rolled out by the Prime Minister on 23 September 2018, this health insurance scheme covers about 50 crore citizens in India and already has several success stories to its credit. As of September 2019, around 18,059 hospitals were empanelled, over 4,406,461 beneficiaries were admitted, and over ten crore e-cards were issued under the scheme.

The Ayushman Bharat Yojana - National Health Protection Scheme has now been renamed Pradhan Mantri Jan Arogya Yojana. This plans to make secondary and tertiary healthcare completely cashless for the underprivileged section of society. The PM Jan Arogya Yojana beneficiaries get an e-card that can be used to avail of services at an empanelled hospital, public or private, anywhere in the country. With it, you can walk into a hospital and obtain cashless treatment.

The coverage includes three days of pre-hospitalisation and 15 days of post-hospitalisation expenses. Moreover, around 1,400 procedures with all related costs like OT expenses are taken care of. PMJAY provides Rs. 5 lakh coverage to every family per year, thus helping the economically disadvantaged access healthcare services easily.

PMJAY health cover categories: eligibility criteria for rural and urban people

The PMJAY scheme aims to provide healthcare to 10 crore families, mostly poor and have lower middle income, through a health insurance scheme covering Rs. 5 lakh per family. The ten crore families comprise eight crore families in rural areas and 2.33 crore families in urban areas. Broken into smaller units, this means the scheme will aim to cater to 50 crore individual beneficiaries.

However, the scheme has certain pre-conditions by which it picks who can avail of the health cover benefit. While in the rural areas, the list is mostly categorised on lack of housing, meagre income and other deprivations, the urban list of PMJAY beneficiaries is drawn up based on occupation.

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 aims 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 aid 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 health insurance. 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 of 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 in the Socio-Economic Caste Census 2011. Further, any family enrolled under the Rashtriya Swasthya Bima Yojana will benefit from the PM Jan Arogya Yojana.

In the urban areas, those who can avail of the government-sponsored scheme consist mainly of:

1. Washerman/ chowkidars
2. Ragpickers
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 other services provided 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 to 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

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Medical packages and hospitalisation process in Ayushman Bharat Scheme (PMJAY)

Individuals in specific and families, in general, can benefit from the Rs. 5 lakh insurance cover provided by the Pradhan Mantri Jan Arogya Scheme. This lump sum is enough to cover the medical and surgical treatments in 25 specialities: cardiology, neurosurgery, oncology, paediatrics, orthopaedics, etc. However, medical and surgical expenses cannot be reimbursed simultaneously.

If multiple surgeries are necessary, the highest package cost is paid for in the first instance, followed by a 50% waiver for the second and a 25% discount for the third. Unlike other health insurance schemes, there is no waiting period for pre-existing diseases under the PMJAY scheme, which comes under the larger umbrella scheme of Ayushman Bharat Yojana. Should any beneficiary or anyone in their family require hospitalisation, they need not pay anything, provided they are admitted in any empanelled government or private hospital.

The cashless treatment and hospitalisation are possible due to a 60:40 cost-sharing agreement between the centre and states. Once identified as a genuine beneficiary, you or your family member will be issued a health card by specially trained Ayushman Mitras. They manage kiosks in hospitals for those unaware of the PMJAY scheme.

With these details in hand, you can benefit from the features of the Pradhan Mantri Jan Awas Yojana or help someone else get the healthcare cover benefit.

PMJAY illness coverage: List of critical diseases covered under PM Jan Arogya Yojana

PMJAY helps households access secondary and tertiary care by funding up to Rs. 5 lakh per family per year. This assistance is valid for daycare procedures and even applies to pre-existing conditions. PMJAY extends coverage for over 1,350 medical packages at empanelled public and private hospitals.

Some of the critical illnesses that are covered are as follows:

1. Prostate cancer
2. Coronary artery bypass grafting
3. Double valve replacement
4. Carotid angioplasty with stent
5. Pulmonary valve replacement
6. Skull base surgery
7. Laryngopharyngectomy with gastric pull-up
8. Anterior spine fixation
9. Tissue expander for disfigurement following burns

Here are some of the exclusions under PMJAY:

1. OPD
2. Drug rehabilitation programme
3. Cosmetic related procedures
4. Fertility related procedures
5. Organ transplants
6. Individual diagnostics (for evaluation)

Advantages of health insurance in India

The main advantage of having a health insurance policy is that you can avail of medical treatment without suffering any strain on your finances. Moreover, as many Indians end up borrowing money informally to pay medical bills, utilising the features of PMJAY helps avoid the risk of a debt trap. You can get up to Rs. 5 lakh treatment under PMJAY. You can also buy a health insurance plan from reputed insurance companies like Bajaj Finserv that offer more coverages and benefits for you and your family.

You may choose to buy a family health insurance plan to secure your entire family under one umbrella or go for an individual health insurance plan. For senior citizens, it is advised to have a separate health insurance plan to cover their medical expenses. Several health insurance plans for senior citizens provide adequate financial coverage.

Alternatively, you can also explore small-ticket health policies like Pocket Insurance by Bajaj Finserv, which offers affordable policies catering to specific needs. What’s more, you can apply for these policies easily online. For instance, Dengue Cover helps you pay for diagnostic tests if you contract malaria or dengue, while Hospital Cash Cover gives you daily cash assistance of up to Rs. 1,000 per day that you can use for a range of expenses. You can also purchase plans such as Adventure Cover if you get injured or Kidney Stones Cover if you suffer from this condition. Regardless of the policy you choose, you can get substantial coverage at a nominal premium and instantly protect every aspect of your health.

Ayushman Bharat registration: How to apply for Ayushman Bharat Yojana (application process)

There is no particular Ayushman Bharat registration procedure of PMJAY. PMJAY applies to all beneficiaries identified by the SECC 2011 and those already part of the RSBY scheme. However, here’s how you can check if you are eligible to be a beneficiary of PMJAY.

1. Visit the PMJAY portal and click on 'Am I Eligible'
   
2. Enter your mobile number and the CAPTCHA code and click on ‘Generate OTP’
3. Then select your state and search by name/ HHD number/ ration card number/ mobile number
4. Based on the search results, you can verify if your family is covered under PMJAY

Alternatively, to know if you are eligible for PMJAY, you can approach any Empanelled Health Care Provider (EHCP) or dial the Ayushman Bharat Yojana call centre number: 14555 or 1800-111-565.

Ayushman Bharat Yojana: PMJAY patient card generation

Once you are eligible for the PMJAY benefits, you can work towards getting an e-card. Your Aadhaar card or ration card will be verified at the PMJAY kiosk before issuing a card. Family identification proofs that can be produced include a government certified list of members, a PM letter and an RSBY card. Once the verification is completed, the e-card is printed along with the unique AB-PMJAY ID. You can use this as proof at any point in the future.