PRADHAN MANTRI JAN AROGYA YOJANA – AYUSHMAN BHARAT

3 Sep 2021

Curtain Hug

ABSTRACT:
In 2018, The government of India launched a “Ayushman Bharat Initiative1

” under which the
government has introduced Pradhan Mantri Jan Arogya Yojana (PMJAY). Government of India has
taken a major step towards fulfilling the goal of universal health coverage and if the initiative is
implemented properly, it could be revolutionary and a game changer. The aim of PMJAY is to grant
Rs. 5 lakhs every year to families who are poor and the families who don’t have enough resources
to acquire proper health care facilities so this initiative makes sure that everyone in India have access
to proper healthcare. This scheme offers cashless hospitalization to underprivileged families at
public hospitals and private hospitals as it covers the cost of hospitalization, pre-hospitalization,
medication, and post hospitalization expenses incurred during the treatment, which is applicable to
almost all tertiary and secondary care procedures. Further this article aims to study the PMJAY
Initiative and its importance.
INTRODUCTION:
Prime Minister Shri Narendra Modi announced the launch of (PMJAY) Ayushman Bharat Yojana
is a flagship scheme announced by Prime Minister Shri Narendra Modi on Independence Day in
2008. Ayushman Bharat Yojana scheme caters not only The Scheme not only caters Poor families
but also provides resources to rural families. This scheme was designed to meet Sustainable
Development Goals 2

(SDGs). The scheme is an attempt to deviate from sectoral and segmented
approach to a very comprehensive need-based health care service. The main objective of the scheme
is to address the healthcare system by taking the necessary steps at the primary, secondary and

tertiary level. There are two inter-related components in Ayushman Bharat which are-
1. Health and Wellness Centres (HWCs)3

:

Health and Wellness Centers (HWCs) In February 2018, the Government of India announced the
creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub
Centres and Primary Health Centres. These centres are to deliver Comprehensive Primary Health
Care (CPHC) bringing healthcare closer to the homes of people. They cover both, maternal and

1 https://pmjay.gov.in/about/pmjay
2 https://www.undp.org/sustainable-development-goals
3 https://ab-hwc.nhp.gov.in/home/aboutus

child health services and non-communicable diseases, including free essential drugs and
diagnostic services.

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)4
Pradhan Mantri Jan Arogya Yojana (PM-JAY) The second component under Ayushman Bharat
is the Pradhan Mantri Jan Arogya Yojna or PM-JAY as it is popularly known. Ayushman Bharat
PM-JAY is the largest health assurance scheme in the world which aims at providing a health
cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over
10.74 crores poor and vulnerable families which was approximately 50 crore beneficiaries that
form the bottom 40% of the Indian population. The households included are based on the
deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for
rural and urban areas respectively. PM-JAY was earlier known as the National Health Protection
Scheme (NHPS) before being rechristened. It subsumed the then existing Rastriya Swasthya

Bima Yojana (RSBY) which had been launched in 2008. The coverage mentioned under PM-
JAY, therefore, also includes families that were covered in RSBY but are not present in the SECC

2011 database. PM-JAY is fully funded by the Government and cost of implementation is shared
between the Central and State Governments. States can implement PMJAY either through the
insurance route or the trust route or both. The states implementing the scheme through the
insurance mode select the insurance companies through an open tender process. The states
implementing the scheme through the trust mode may engage Third-Party Administrators (TPAs)
and Implement Support Agencies (ISAs) through an open tender process for implementing the
scheme. The cover under the scheme includes all expenses incurred on the following components
of the treatment. Medical examination, treatment and consultation, Pre-hospitalization, Medicine
and medical consumables, non-intensive and intensive care services, Diagnostic and laboratory
investigations, medical implantation services, Accommodation benefits, Food services,
Complications arising during treatment, Posthospitalization follow-up care up to 15 days Tamil

Nadu has topped the list in the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-
PMJAY) in beneficiary enrolment. As of July 2019, the state enrolled 15.7 million families. This

was followed by Madhya Pradesh that enrolled 12.8 million families. The scheme, which was
launched in September 2018, already reached its target of reaching 500 million in India just
within 10 months. According to Union Health Minister Harsh Vardhan as on July 2019, the
scheme enrolled 16,039 hospitals, including 8,059 private hospitals and 7,980 public hospitals.

4 https://pmjay.gov.in/

Need for Awareness about AB-PMJAY Since PM-JAY is an entitlement-based scheme where
there is no advance enrolment process, making beneficiaries aware of the scheme is the most
critical aspect. Information, Education and Communication activities were carried out to educate
beneficiaries about the scheme. Various modes of communication such as leaflets, booklets,
hoardings, TV, radio spots etc are important elements for creating a comprehensive
communication strategy for disseminating the desired messages across the target audience.

FEATURES OF PMJAY: AYUSHMAN BHARAT YOJANA SCHEME:
3. A sum of Rs. 5 Lakhs are granted per family every year under the Ayushman Bharat Yojana
scheme which is also considered as family floater scheme
4. Design of the Ayushman Bharat Yojana scheme has been made by keeping the objective of
providing best healthcare facilities to people below the poverty line who do have access to
internet or online health plans
5. PMJAY scheme facilitates Cashless healthcare services is facilitated under the AB-PMJAY
scheme in any of the public sector hospitals and private network hospital
6. The transportation expenses incurred during the pre- and post-hospitalization period by the
beneficiary are compensated under Pradhan Mantri Ayushman Bharat Yojana.
7. Day-care expenses are also covered under Ayushman Bharat Yojana along with medical
treatment expenses.
8. Expenses for some of specific pre-existing diseases are also covered under Ayushman
Bharat Yojana scheme .
9. Government pre-determines the package rate and only with reference to it the payment for
medical expenses should be made based .
WHAT ALL IS COVERED UNDER PMJAY?
1. Medical examination, treatment and consultation fee are covered under PM-JAY
2. For 15 days all the pre-hospitalization expenses are covered
3. Cost of medicines and related consumables are covered
4. Accommodation in Hospital is also covered under PM-JAY
5. Diagnostic procedure expenses are covered
6. Necessary medical implantation services are covered
7. When complications arises due to medical treatment, all the expenses are covered under
the policy regarding the same

8. Cost of food are covered
WHAT DISEASES ARE COVERED UNDER PMJAY?
Government is providing assistance to needful under the PMJAY scheme by offering 1,350
medical packages at any private network hospital or public hospital. Some of diseases which
are covered under this scheme are:
1. A person suffering from carotid angioplasty with stent
2. A person suffering from prostate cancer
3. A person suffering from coronary artery bypass grafting
4. A person suffering from injury on skull
5. A person suffering from pulmonary valve surgery
6. A person suffering from double valve replacement surgery
7. A person suffering from anterior spine fixation
8. A person suffering from tissue expander for disfigurement following burns
ADVANTAGES:
1. Focus of government initiatives to comprehensive primary health care rather than
disease specific and reproductive and child health.
2. It makes us realise that economic growth of India depends on better health. Target
beneficiaries have increased significantly with social sector program expanded to
vulnerable and deprived population rather poor only population.
3. Health conditions like mental health, noncommunicable diseases, food and internal
congenital dis-eases not addressed before have been given due emphasis in the scheme
4. Provides both global and national level focus on Universal health coverage.
DRAWBACKS:
1. The focus on broader health system is minimally addressed. Strengthening entire health
system is required than concentrating only on Health and wellness centres.
2. Major part of OOPE constitutes preventive and/or outpatient care however scheme will
provide coverage only for secondary and tertiary care hospitalisation.

3. Inadequate Funds allocated for setting up Health and Wellness Centres
(HWC’s).Budget allocation of 1200 crores for setting up and upgrading 1.5 lakh,
HWC’s centres to cater to medical treatment need appears to be grossly inadequate.
4. By putting no limitation on age of beneficiaries and including pre-existing diseases
from first day onwards hints at a faulty coverage proposed in the scheme putting undue
pressure on insurance companies.
5. Little effort or investment to develop a well-coordinated referral mechanism with
specialists and doctors in the secondary and tertiary hospitals which shall be the
cornerstone of the project.
EFFECTS:
1. Chance of changes in the political leadership poses a major threat to the program.
2. Focus is not proportionate on one of two initiatives in ABP.
3. Lack of human resource for setting up of 150000 HWC’s.
4. Lack of regulatory mechanism to monitor the quality of service being provided by
private hospital, its ethical necessity and whether the patient was made to pay more than
what the scheme covered. 5. Government hospitals lacking infrastructure will also chip
in thus compromising the aim to ensure accessible and affordable healthcare.
5. Too much engagement of private hospitals to provide financial cover will reinforce the
impression that private healthcare is better than government healthcare.
6. Strict monitoring between State Health Insurance Schemes and Ayushman Bharat
required as state would try to reduce their financial burden by pushing patients through
this scheme.
WHO ALL ARE NOT ELGIBLE FOR PMJAY SCHEME:
1. Those people who own a car, two-wheeler or any other kind of vehicle
2. Those people who are working in government offices.
3. Those people who earn more than 10,000 per month
4. Those people who have Kisan Card and own agriculture machinery and equipment’s
5. Those people who own properly build houses
ELGIBILTY CRITERIA:

RURAL AREAS:
1. Families with no breadwinner within the age of 16-59 years
2. Families living in old house or in one room with Kuccha walls and roof
3. Families in which there is no member within the age of 16-59 years
4. Families with no healthy member
5. Families which are earning income through labour
URBAN AREAS:
1. Servant or a domestic worker
2. Beggar or a ragpicker
3. Person who is working as a Home-based Artisans or a Handicrafts worker
4. Person who is working as Sanitation worker or as a Mali
5. Person who is working as Construction worker, Labour, Welder or Security guard
6. Person who is working as working as a Coolie at railway station
7. Person who is working as a Washer-man or Plumber
8. Person who is working as Electrician, Mechanic or Repair worker
9. Person who is working as a Transport worker, Rickshaw puller, Conductor, Cart puller
10. People working on road sides such as Street vendors, hawker ,Cobbler
STEPS TO REGISTER FOR PMJAY SCHEME ONLINE:
1. First Step is to visit official website of PMJAY
2. Second Step is to find out whether you are eligible for the scheme or not by clicking on
“Am I Eligible” Tab
3. Third Step is to enter the necessary details such as mobile number, email, captcha code
and further click on Generate OTP button to get OTP on mobile number
4. Fourth Step is to further enter personal details such as ration number, Aadhar number,
address, state or mobile number
5. If you fulfil the eligibility criteria for the scheme then your name will be displayed on
the results on the official site.
STEPS IN PMJAY:
ELIGIBILITY:

Very first step in the scheme is to check for eligibility. This process is done by Empanelled
health care providers registration desk through ‘Am I Eligible’ app or website or through call
centre number 14555 Patient card: After the eligibility process is over patient will be directed
to PMJAY Kiosk where Pradhan Mantri Arogya Mitra will help in verifying the beneficiary
identity by using Beneficiary Identification System (BIS). If e-card is not available then golden
record will be created. The required documents for Ayushman Bharat include Age proof
document, identification details, contact information, family structure, income certificate, caste
certificate. Aadhar card and PAN card is source of identification under the scheme. Person
belonging to reserved category will get benefits based on prescribed annual income criteria I.e.
maximum income being 5 lakh per year.
EXPENSES:
Pradhan Mantri Arogya Mitra will then inform the beneficiaries about the scheme and expenses
which the beneficiary has to bear in case he/ she is not hospitalised. Beneficiary is then directed
to doctor for treatment of the disease ailment. Beneficiary is either pre-scribed drugs or
hospitalised depending on the severity of the disease. The beneficiary if admitted it is the
responsibility of doctor to provide necessary documents to PMAM and the Arogya Mitra will
up-load the documents with Transaction Management System Portal for Government
verification. Post treatment medications will be provided by the hospital unto 15 days as
applicable.
DOCUMENTS REQUIRED TO APPLY FOR PMJAY:
• Age Proof
• Identity Proof
• Contact Information
• Certificate of Caste
• Certificate of Income
• Family Structure(Joint Family or Nuclear Family)
PAST ACCOMPLISHMENTS IN INDIA IN FIRST 100 DAYS:
The program has been utilised by 6.85 lakh patients and among them 5.1 lakh received the
payment. Many people from weaker sections had avoided treatment in view of unbearable

payment but now 40% of India’s poorest are assured treatment at the cost of public expenditure.
Gujarat is top performer among the states rolling out the scheme with 76000 hospital
admissions and second place goes to Tamil Nadu with 54,273 admissions as per health ministry
data as of February 2019. Railway ministry has shown interest in joining PMJAY and have
empanelled ninety-three hospitals to provide free treatment of PMJAY Beneficiaries and this
will ensure additional 10000 beds and 2000 doctors to provide services. A visit was also
arranged to AIIMS, New Delhi to make hospital staffs to expose themselves in operation of
Arogya Mitra Sahayata Kendra. Ayushman Bharat scheme has led to timely treatments,
improvements in health outcomes, patient satisfaction, improvement in productivity and
efficiency, job creation thus, leading to an improvement in the quality of life
HOW THIS SCHEME WILL BENEFIT THE WHOLE NATION:
1. More chance of strengthening entire health care system in India with novel models and
strategies.
2. Experience gained from RSBY and other such schemes could be utilised for a rapid growth.
3. Implementation will be accelerated since this program has wide public and media attention.
4. Recruitment of additional cadre of health providers on priority basis thus giving
employment opportunities.
5. Generate real time data and analyse it to further strengthen existing schemes.
6. Alignment with NHP 2017 and Niti Ayogs 3-year action agenda 2017-20.
CONCLUSION:
From this article we come to a conclusion that it is very important to promote and create
awareness about the various components of AB-PMJAY. Government’s duty does not end
by implementing health insurance schemes but it increases the responsibilities of government
to regulate health system frequently and government should ensure high amount of
transparency and standardization. I believe this is a great step taken by the government
towards providing healthcare to people who can’t afford it as Elizabeth Edwards5

once said
“Successful health reform must not just make health insurance affordable, affordable health
insurance has to make health care affordable”.