Ayushman Bharat - Ayushman Bharat Yojana

The full potential of a nation can only be realised if its citizens are strong and healthy. However, in a country where about 276 million people are living below the poverty line, ensuring adequate healthcare access across various sectors is indeed a tough job. A number of government sponsored schemes have been introduced in the past, but most of them were ridden with numerous flaws. This posed consistent and significant challenges. It was primarily in order to counter these difficulties and provide an efficient healthcare system that the Ayushman Bharat health insurance scheme was recently launched.

What is Ayushman Bharat Health Insurance?

As the name itself suggests, Ayushman Bharat is essentially a health protection scheme which aims to provide health insurance to nearly 10 crore beneficiaries. A coverage of up to Rs. 5 lakh will be offered to vulnerable families every year for availing any form of primary, secondary, and tertiary healthcare services. It is meant to be an umbrella scheme which will subsume the existing Senior citizen health insurance scheme and the Rashtriya Swasthya Bima Yojana.

Ayushman Bharat scheme will be implemented via national insurance companies. The expenditure incurred on the payment of premiums will be proportionally shared between the central and the state governments. Being a National Health Protection scheme, Ayushman Bharat is often abbreviated as AB-NHPS.

Basic Information About Ayushman Bharat Yojana

Name Of The SchemeAyushman Bharat Yojana
Launched InIndia
Launched ByNarendra Modi
Implemented And Supervised ByMinistry Of Health And Family Welfare
Date Of Announcement February 2018
Date Of LaunchSeptember 2018
Target BeneficiariesPoor People Of The Country
Total Numbers Of Beneficiary Families10 Crore Households
Total Health Coverage AmountRs. 5 Lakhs
Offical Websitewww.pmjay.gov.in
Toll free Helpline Number14555

Key Features Of Ayushman Bharat Health Insurance Scheme

In order to understand the scheme better, it would be wise to know what it truly entails. Here is a list of features which constitute the core of Ayushman Bharat Health Insurance:

  • A well-defined cover of Rs. 5 lakh will be provided to every eligible family, every year.

  • The beneficiaries will be permitted to avail primary, secondary, and tertiary healthcare services from any of the empanelled public or empanelled private hospitals.

  • The benefits will be entirely cashless and portable. This means that neither would the beneficiary have to wait for reimbursements, nor would their location impact their ability to access healthcare.

  • The beneficiaries would be identified on the basis of the same deprivation criteria which were used while conducting the socio-economic caste census. This would help determine their entitlement.

  • The principle of cooperative federalism would be strictly followed by giving adequate flexibility to the states in terms of expenditure incurred.

  • The payments would be made on a package basis. The total costs, specific services and procedures which can be included in the package would be defined by the government in charge.

  • An Ayushman Bharat National Health Protection Mission Council would be set up to facilitate coordination between the central and state governments. This apex body would be chaired by the Union minister for health and family welfare. To know more about Ayushman Bharat Yojana (आयुष्मान भारत योजना), please refer to official website: https://www.pmjay.gov.in/

  • Each state would be asked to create a health agency in order to seamlessly implement the scheme.

  • An inter-operable and robust IT platform would be designed under the leadership of NITI Aayog, to make sure that all transactions under the plan, remain paperless and scalable.

Key Benefits Of Ayushman Bharat Yojana

The Ayushman Bharat Yojana aims to cover approximately 40% of India's poorest and the most vulnerable population. This would be done by delivering the following key benefits:

  • All out-of-pocket expenses incurred during the hospitalisation process would be covered.

  • Irrespective of whether the hospital is public or empanelled private, the insurance provided would be in a completely cashless format.

  • A transport allowance would be paid to the beneficiary, which will cover the cost of travel during the pre and post hospitalisation period.

  • Daycare treatment facilities would be made available within the insurance package.

  • Except a few ailments cited as an exclusion, any pre-existing conditions of the beneficiary would be treated free of charge.

  • Provisions for follow-up benefits to ascertain if the patients have fully recovered, have also been made.

Eligibility Criteria Of Ayushman Bharat Yojana (Modicare)

The scheme has delineated a set of specific eligibility criteria which would help identify and serve the beneficiaries in an appropriate manner. These criteria are primarily based on the data collected under Socio-economic caste census, 2011. Although, they try to include all the poor families across the spectrum, there are certain distinctions between the beneficiaries belonging to rural and urban areas. These are: Rural Area Categories and Urban Area Categories.

What Are Rural Area Categories of Ayushman Bharat yojana?

Six deprivation criteria have been outlined to identify eligible rural families. These include the following:

  • Households which only have a single room with makeshift walls and roof.
  • Families which do not have an adult, earning member aged between 16 and 59.
  • Households which are headed by females and have no adult males aged between 16 and 59 years.
  • Households consisting of disabled members with no able-bodied member offering support.
  • Households belonging to the Scheduled caste & Scheduled Tribe categories.
  • Landless households whose basic source of income is manual labour.

Apart from the aforementioned, a few categories of households are automatically included in the beneficiary list. These are:

  • Households without any appropriate shelter.
  • Destitute families who are living on alms.
  • Families of manual scavengers.
  • Primitive and particularly vulnerable tribal groups (PVTG)
  • Families of bonded laborers.

What Are Urban Area Categories of Ayushman Bharat yojana?

The eligible families in urban areas are identified on the basis of 11 detailed occupational categories. These include:

  • Rag pickers & Beggars
  • Domestic workers
  • Street vendors, cobblers & hawkers
  • Construction workers, plumbers, masons, painters, welders & security guards
  • Coolies
  • Sweepers, gardeners & sanitation workers
  • Artisans, home-based workers, handicrafts workers & tailors
  • Transport workers including drivers, conductors, cart pullers etc.
  • Shop workers, peons, helpers, delivery assistants, attendants & waiters
  • Electricians, mechanics, assemblers & repair workers
  • Washer-men & watch-men

Moreover, all families, whether rural or urban, who are eligible under the Annapurna and Antyodaya Anna schemes are included in the beneficiary list.

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

Ayushman Bharat Health Insurance Plan Hospital Eligibility

Just like the beneficiaries, the Ayushman Bharat health insurance scheme also specifies the essential eligibility criteria to determine which hospitals would be empanelled. These are:

  • The medical facility must have at least 10 beds to handle in-patients.
  • Support staff must be available round-the-clock which comprises of qualified medical and nursing staff (doctors & nurses).
  • An accessible washroom facility should be available.
  • The hospital must have an inter-operable IT system to maintain data.
  • Ambulance and other emergency services should be at their disposal.
  • A dedicated medical officer should be hired to coordinate AB-NHPS.
  • All technical necessities and equipments should be purchased.
  • Availability of a blood bank & a testing laboratory in the vicinity.
  • The hospitals must be registered with state health agencies.
  • Regulated handling of power, water supply, bio-medical waste etc. The hospitals are also required to maintain a full-fledged record of Ayushman Bharat patients and share them with the government, as and when needed.

Ayushman Bharat Yojana's - Ayushman Bharat Arogya Mitra

Ayushman Bharat Arogya Mitras are facilitators in empanelled hospitals who look to ensure the smooth functioning of the public health insurance scheme. Every empanelled public and private hospital will have at least one Arogya Mitra, who will help with beneficiary verification, grievance redressal, authentication, query management and handling emergency cases. They have been adequately trained in software use, patient registration and interaction.

What Is The Hospitalisation Process?

Throughout the period of hospitalisation, the beneficiaries would not have to deal with any monetary expenses. Instead, each empanelled hospital would appoint an 'Ayushman Mitra', whose primary job would be to assist the eligible families. The Ayushman Mitras would run a help desk, verify the patient's documents and initiate their enrollment. Once this is complete, the beneficiaries would be provided letters with QR codes. These letters would serve as a form of demographic authentication, which would enable them to avail the whole set of pre and post hospitalisation benefits. The scheme and all its associated advantages are portable across the country. This ensures that a change of location does not pose a hospitalisation hindrance to the beneficiary.

How Can I Apply For Ayushman Bharat Scheme?

Being entitlement based, the scheme does not require any form of registration. Therefore, the question of applying for it does not arise. If you have been identified as a vulnerable family under the Socio-economic caste census, 2011, you will automatically become eligible for the scheme. You can visit the Ayushman Bharat Health Insurance official website, click on the 'check eligibility' link and find out if your name features in the list of beneficiaries.

With Ayushman Bharat, the entire healthcare landscape in India is set to change. People, who have been struggling with health risks owing to a lack of finances, would now be able to access appropriate treatment and medication. Not only would this lead to the development of a more healthy population, but it would also make sure that the demographic dividend of the country can be truly harnessed.

Documents & Claim Process Of Ayushman Bharat Yojana

Documents Required for Ayushman Bharat Yojana

The Documents Required For Enrolling in the Ayushman Bharat Scheme Are:

  • Special Category Certificate
  • Age Proof Documents
  • Scanned Copy of Aadhar
  • Income Certificate
  • Caste Certificate
  • Family Structure
  • Identification Details
  • Contact Information

Documents Required for Claiming Ayushman Bharat Yojana

Every empanelled hospital will have an 'Ayushman Mitras' who will assist the patients and coordinate with beneficiaries as well as the hospital. They will operate a help desk and look into the documents to verify the eligibility. All of the beneficiaries will be provided letters containing QR codes, which will be scanned.

A demographic authentication shall also be conducted for the purpose of identification and to verify the patient’s eligibility to avail the benefits of the scheme. For medical packages, it is necessary to hand over or upload details of pre and post-op investigations for pre-authorization/claims' settlement.

FAQ's on Ayushman Bharat Yojana?

How will Ayushman Bharat be implemented?

At the top level, an Ayushman Bharat National health protection mission council would be set up. This will be headed by the Union health & family welfare minister. The council will have a governing board which will take key policy decisions regarding the scheme. Furthermore, each state will have to set up a state health agency to coordinate with this council and maintain a database of empanelled hospitals. However, on the ground, the actual implementation will take place via development officers who will inform beneficiaries about the services they can avail, thus facilitating their inclusion under the scheme.

How can I avail the Ayushman Bharat Scheme?

In order to avail the scheme, all you need to have is an identity proof in place. This will help establish whether you are eligible for the plan under SECC, 2011.

Who is eligible to apply for the Ayushman Bharat health insurance?

The eligibility criteria will vary depending on whether you are located in a rural or an urban area. In rural areas, the 6 deprivation criteria identified under SECC are used to determine eligibility, while in the urban areas, 11 specific occupational categories are deemed eligible.

What has been the experience with Ayushman Bharat health insurance schemes?

Such schemes have been launched in various forms previously, but they have not been able to achieve their aims. This was primarily owing to implementation flaws, identity duplication and the fact that they were enrollment-based. Ayushman Bharat resolves to correct these issues by using entitlement as a basis, providing for dedicated implementation agencies and making identification procedures seamless.

How much will it cost to buy Ayushman Bharat Health insurance?

Despite the size of a family, the scheme would be completely cashless. In other words, it wouldn't cost anything to the beneficiaries. All expenses incurred would be borne by the central and state governments.

What are the inclusions of Ayushman Bharat Health Insurance?

The AB-NHPS would cover most primary, secondary and tertiary care procedures. Moreover, pre-existing conditions, travelling costs and in-patient/ out-patient hospitalisation expenses would also be covered.

When Was Ayushman Bharat Launched?

The Ayushman Bharat scheme was launched across the country, on September 25, 2018.

What is Ayushman Card?

Ayushman card will contain the names of all those who are eligible for the Ayushman Bharat Yojana scheme. It will be attached to a personalised letter that informs every beneficiary about the scheme’s salient features.

Who is the CEO of Ayushman Bharat?

Dr. Indu Bhushan is the CEO of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana.

What is National Health Protection Mission?

Ayushman Bharat -National Health Protection Scheme is a health insurance scheme that provides coverage of up to Rs. 5 lakhs for poor and vulnerable families on an annual basis for secondary and tertiary care hospitalization.

Why Was Ayushman Bharat Launched?

The Ayushman Bharat scheme was launched to make health insurance accessible to the poor, deprived rural families. The plan has a defined benefit cover of Rs. 5 lakh per family annually for secondary and tertiary care hospitalisation.

How to get application form and register for the scheme?

There is no application form for availing the Ayushman Bharat scheme.

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