Ayushman Bharat Yojana PMJAY | Free Treatment up to 5 Lakhs

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.

Summery of Ayushman Bharat Yojana

Public spending on healthcare in India is amongst the lowest in the world at just over 1% of gross domestic product (GDP), and the Indian health system is characterised by substantial shortcomings relating to workforce, infrastructure, and the quality and availability of services.

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), approved by the Indian government in March 2018, is an ambitious reform to the Indian health system that seeks to provide financial health protection for 500 million of the most vulnerable Indians and halt the slide of the 50–60 million Indians who fall into poverty annually as a result of medical-related expenditure.

There is a need for wide reforms across public and private providers of care if India is to meet its stated aims of providing universal health coverage (UHC) for its population. The success of the program will rely on a reformed and adequately resourced public sector to lead implementation, delivery, and monitoring of the scheme.

While there are significant challenges facing the program, by providing the impetus for system-wide reform, AB-PMJAY presents the nation with a chance to tackle long-term and embedded shortcomings in governance, quality control, and stewardship and to accelerate India’s progress towards the stated goal of UHC provision.

Implementation and ongoing operation of the program need to be carefully monitored to ensure that it is meeting its aims in a sustainable manner and that negative unintended consequences are avoided.

Ayushman Bharat Yojana in alliance with the States:

The scheme architecture and formulation has undergone a truly federal process, with stakeholder inputs taken from all States and UTs through the national conclaves, sectoral working groups, intensive field exercises and piloting of key modules.

The Scheme is principle based rather than rule based, allowing States enough flexibility in terms of packages, procedures, scheme design, entitlements as well as other guidelines while ensuring that key benefits of portability and fraud detection are ensured at a national level.

States have the option to use an existing Trust/Society or set up a new Trust/Society to implement the Scheme as State Health Agency and will be free to choose the modalities for implementation.

States can implement the Scheme through an insurance company or directly through the Trust/Society/Implementation Support Agency or a mixed approach.

Ayushman Bharat Yojana – Testimonial from Rutba Hassan

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:

• Those living in scheduled caste and scheduled tribe households
• Families with no male member aged 16 to 59 years
• Beggars and those surviving on alms
• Families with no individuals aged between 16 and 59 years
• Families having at least one physically challenged member and no able-bodied adult member
• Landless households who make a living by working as casual manual labourers
• Primitive tribal communities
• Legally released bonded labourers
• Families living in one-room makeshift houses with no proper walls or roof
• 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 Swasthaya 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:

• Washerman/ chowkidars
• Ragpickers
• Mechanics, electricians, repair workers
• Domestic help
• Sanitation workers, gardeners, sweepers
• Home-based artisans or handicraft workers, tailors
• Cobblers, hawkers and other services provided on streets or pavements
• Plumbers, masons, construction workers, porters, welders, painters and security guards
• Transport workers like drivers, conductors, helpers, cart or rickshaw pullers
• Assistants, peons in small establishments, delivery boys, shopkeepers and waiters

People not entitled to the health cover under Pradhan Mantri Jan Arogya Yojana:

• Those who own a two, three or four-wheeler or a motorised fishing boat
• Those who own mechanised farming equipment
• Those who have Kisan cards with a credit limit of Rs. 50000
• Those employed by the government
• Those who work in government-managed non-agricultural enterprises
• Those earning a monthly income above Rs. 10000
• Those owning refrigerators and landlines
• Those with decent, solidly built houses
• Those owning 5 acres or more of agricultural land

Pradhan Mantri Aarogya Mitra (PMAM):

The scheme is creating a cadre of certified frontline health service professionals called Pradhan Mantri Aarogya Mitras (PMAMs) who will be primary point of facilitation for the beneficiaries to avail treatment at the hospital and thus, act as a support system to streamline health service delivery.

MoU was signed between National Health Agency and Ministry of Skills Development & Entrepreneurship (MSDE) on 27th August 2018 in New Delhi.

AarogyaMitras training is being conducted in collaboration with National Skill Development Corporation (NSDC) and Ministry of Skill Development to strengthen implementation and operational preparedness.

Training has already been conducted in across 20 states and around 3519 AarogyaMitras have been trained so far. Training programs for State, District and PMAMs have been conducted in 27 states.

A total of around 3936 personnel have been trained at state, district and PMAM levels.

MoU has been signed with Common Service Centre (CSC) for Beneficiary Identification and will utilize the over 3 lakh village level entrepreneurs for identifying beneficiaries.

Personalized Letters with unique family code are in the process of being sent to the identified families in the Additional Data Collection Data (ADCD) drive. This will drive awareness among the beneficiaries and further ease the identification process when they visit points of care or CSC centres.

Ayushman Bharat Yojana – Pradhan Mantri Jan AarogyaYojana (AB-PMJAY) is a paradigm shift from sectorial, segmented and fragmented approach of service delivery through various national and State schemes to a bigger, more comprehensive and better converged and need based service delivery of secondary and tertiary care.

Features of Ayushman Bharat Yojana

Below are some Ayushman Bharat Yojana details and key features of the PMJAY scheme:

• It is one of the world’s largest health insurance schemes financed by the government of India.
• 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 1,393 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.

Benefits of Ayushman Bharat Yojana

• The scheme is targeted at the vulnerable and underprivileged sections of the society. To cater to them, below are the benefits of the PMJAY:
• It covers all hospitalisation expenses with cashless transactions to beneficiaries.
• Accommodation during hospitalisation.
• Pre and post-hospitalisation costs.
• Any complications arising during the treatment.
• Can be used by all family members.
• No cap on family size, age or gender.
• Pre-existing conditions are included from day one.

List of Critical Diseases or Illnesses Covered Under Ayushman Bharat Yojana

The medical care scheme extended coverage for more than 1300 medical packages at empanelled public and private hospitals in the country. Below are some of the critical illnesses covered under the Ayushman Bharat Yojana:

• 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.

This is a package medical insurance scheme to cover hospitalization for Medical and Surgical procedures through cashless treatment in respect of the following 34 identified specialties. MJPJAY beneficiary gets benefit of 996 Medical and Surgical procedures with 121 follow up procedures and PMJAY beneficiary gets benefit of 1209 Medical and Surgical procedures (Additional 213 Medical and Surgical procedures) with 183 follow up procedures. There are 131 government reserved procedures out of 996 MJPJAY procedures and additional 37 government reserved procedures for PMJAY 1209 procedures.

1209 packages include bed charges in General ward, Nursing and boarding charges, Surgeons and Anesthetists charges, Medical Practitioner and Consultants fees, Oxygen, O.T. & ICU Charges, Cost of Surgical Appliances, Cost of Drugs, disposables, consumables, implants, Cost of Prosthetic Devices, Cost of Blood Transfusion (Blood to be provided as per policy of State Government), X-Ray and Diagnostic Tests, food to inpatient, one time transport cost by State Transport or second class rail fare (from Hospital to residence of patient only).

The package covers the entire cost of treatment of patient from date of reporting to his discharge from hospital including complications if any, making the transaction truly cashless to the patient. In instance of death, the carriage of dead body from network hospital to the village/ township would also be part of package.

Here are some of the exclusions under PMJAY:

• OPD
• Drug rehabilitation programme
• Cosmetic related procedures
• Fertility related procedures
• Organ transplants
• Individual diagnostics (for evaluation)

How to apply for Ayushman Bharat Yojana

There is no particular Ayushman Bharat Yojana 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
5. 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.

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 PMJAU 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.

Documents Required to Apply For Ayushman Bharat Yojana

1. Below is the list of documents required to apply for PMJAY scheme:
2. Identity and Age Proof (Aadhaar Card/PAN Card)
3. Details of your mobile number, email address and residential address.
4. Caste certificate
5. Income certificate
6. Documents stating your current family status.

How To Download Ayushman Bharat Yojana Card Online?

To ensure cashless, paperless and portable transactions through the PNJAY scheme, the Ayushman Bharat Yojana Golden Card will be issued to beneficiaries. The PMJAY e-card contains all required information of the patient. It is mandatory to present this card at the time of availing the treatment at the empanelled hospital.

To get this PMJAY Golden Card, follow the process below:

• Step 1: Visit the PMJAY website (https://bis.pmjay.gov.in/BIS/selfprintCard) and log in with your registered mobile number.
• Step 2: Enter the ‘Captcha Code’ to generate the OTP.
• Step 3: Opt for the HHD code.
• Step 4: Provide the HHD code to the Common Service Centre (CSC), where they would check the HHD code and other details.
• Step 5: The CSC representatives who are known as Ayushman Mitra will complete the rest of the process.
• Step 6: You will have to pay Rs.30 to get the Ayushman Bharat Yojana card.

How To Check The Name in the PMJAY List ?

• To check if your name is in the PMJAY list, you can check it through different methods. They are:
• Common Service Centre (CSC): Visit the nearest CSCs or you can visit any of the empanelled hospitals to check if you are eligible for the healthcare scheme.
• Helpline Numbers: PMJAY helpline numbers are available to get information about your eligibility for the scheme. You can contact 14555 or 1800-111-565.
• Online: Visit the official website of the scheme (https://www.pmjay.gov.in/) and check if you are eligible for the scheme.

Hospitalisation Process in Ayushman Bharat Yojana (PMJAY):

Any of your family members or you require hospitalisation, you need not pay anything under the PMJAY scheme subject to being admitted in any of the empanelled public or private hospitals. The entire process of hospitalisation and treatment is cashless since there is a 60:40 cost-sharing between the centre and the state, respectively.

As a beneficiary, you will receive the Ayushman health card which will enable you to avail cashless treatment and hospitalisation. With the golden card, you can avail the benefits of the scheme at any of the empanelled public and private hospitals.

Process flow of the beneficiary treatment in the Network Hospital:

• Step 1
  ➢ Beneficiaries shall approach nearby Empanelled Network Hospital. Arogyamitras placed in the above hospitals shall facilitate the beneficiary.
  ➢ The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the vicinity and can get the referral letter based on the diagnosis.
• Step 2
  ➢ The Arogyamitra at the network hospitals examines valid ration cards and Photo ID and enrolls the patient along with registration.
  ➢ The information like admission notes, test done will be captured in the dedicated database by the Medical Coordinator of the Network Hospital as per the requirement of the scheme.
• Step 3
  ➢ If the procedure falls in 996 procedures for MJPJAY beneficiary and 1209 procedures for PMJAY beneficiary, e-preauthorization request is raised by Hospital by attaching mandatory documents.
• Step 4
  ➢ Medical Specialists of the Insurer shall examine the preauthorization request and approve preauthorization if all the conditions are satisfied.
  ➢ If preauthorization is rejected, it is referred to technical committee consisting of CMO of TPA and CMC of SHAS as second step. If there is difference of opinion between the CMO of TPA and CMC of SHAS, the case is referred to ADHS- SHAS as third step. The decision of ADHS for approval or rejection of preauthorization is final.
  ➢ After preauthorization is approved, procedure shall be performed within 30 days by Private Hospital and within 60 days by Public Hospital. After that the preauthorization gets auto cancelled. SHAS shall have right to re-open auto-cancelled preauthorizations of Government Hospitals.
  ➢ Turn-around time for decision on preauthorization is 12 hours. In case of emergencies, the medical / surgical preauthorization approval has to be taken by MCO over telephone – Emergency Telephonic Intimation (ETI) which has a voice recording facility.
• Step 5
  The Network Hospital extends cashless Medical or Surgical treatment to the beneficiary. The Post-operative / daily treatment notes of the Network Hospitals will be updated daily on the portal by the medical coordinator of the Network Hospital.
• Step 6
  ➢ Network Hospital after performing Medical or surgical procedure uploads diagnostics reports, Discharge Summary duly signed by the officials appointed by the Hospital, along with acknowledgement of payments of transportation cost and other documents as per operational guidelines.
  ➢ If the procedure falls in the category of follow up procedures, follow-up details will be informed to patient at the time of discharge by Hospital. It will also be the responsibility of Aarogymitra to educate the patient about follow-up procedures (if eligible) and related details.
• Step 7
  The Network Hospital shall provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge.
• Step 8
  ➢ The Insurer scrutinizes the bills in light of the operational guidelines and mandatory investigations pays claims as per agreed package rates and grade of Hospital. The Insurance Company shall settle the claims of the hospitals online within 15 working days on receipt of complete claim document from the Network Hospital.
  ➢ The claim settlement module along with electronic clearance and payment gateway will be part of the workflow in State Health Assurance Society (SHAS) portal and will be operated by the Insurer.
  ➢ The reports will be available for scrutiny on the State Health Assurance Society (SHAS) login.

PMJAY Hospital List:

To find out the Ayushman Bharat Yojana hospital list, follow the below steps to find out the PMJAY hospital list:

• Step 1: Visit the official website of the PMJAY – Hospitals list section
  Step 2: Select your state and the district.
• Step 3: Now, choose the type of hospital (public/private-for-profit/private and not for profit)
• Step 4: Choose the medical speciality you are looking for.
• Step 5: Enter the “Captcha Code” and click on search.

You will be redirected to the list of Ayushman Bharat Yojana hospitals along with address, website and contact information. You can also check the ‘Suspended Hospital List’ on the same link provided above.

You also read :

• Ayushman Card Hospital List in Lucknow, Uttar Pradesh
• Ayushman Card Hospital List in Dehradun, Uttarakhand
• Ayushman Bharat Hospital List in Jalandhar, Punjab
• Ayushman Bharat Hospital List in Patna, Bihar
• Ayushman Bharat Hospital List in Pune, Maharashtra
• Ayushman Bharat Hospital List in Nagpur
• Ayushman Card Hospital List in Bhopal
• Ayushman Card Hospital List in Indore
• PMJAY Hospital List Rajkot
• Ayushman Bharat PMJAY Hospital List Vadodara
• PMJAY Hospital List Ahmedabad
• PMJAY Hospital List Surat

State wise Empanelled Hospital (as on 15/02/2023)

PMJAY Toll-free Number and Address:

Below is the toll-free number and address of the Ayushman Bharat Yojana :

Toll-Free Number: 14555/1800-111-565

Address:

National Health Authority of India, 3rd, 7th and 9th Floor, Tower-L, Jeevan Bharati Building, Connaught Place, New Delhi – 110001

Grievance Portal:In case of grievances, you can visit PMJAY Grievance section and register your grievance. You can also check the status of your grievance on the same portal.

Regular Health Insurance Plans vs Ayushman Bharat Yojana

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