PMJAY Scheme – About Ayushman Bharat Yojana Features, Eligibility & Coverage

PMJAY Scheme – Ayushman Bharat Yojana Features & Coverage

The uncertainties in life have led to the growth of the healthcare sector in India. There has been a subsequent rise in the demand for health insurance plans over the past three decades.

The government of India is keen on providing its citizens with better healthcare services to battle medical contingencies. In fact, the authority is planning to increase the public health expenditure to 2.5 percent of the country’s GDP by the year 2025.

Due to this very reason, the Government of India has introduced Pradhan Mantri Jan Arogya Yojana (PMJAY) and Prime Minister Modi announced it from the ramparts of the Red Fort.

This scheme subsumes Ayushman Bharat Yojana, which was the flagship programme launched by the government, offering financial protection to the poor in case of unannounced medical exigency. Hence it is also known as AB-PMJAY scheme among the masses. Finserv MARKETS brings to you all the PMJAY scheme details you need.

What is The Ayushman Bharat Yojana (PMJAY) Scheme?

The primary aim of PMJAY scheme is to provide health coverage to approximately 50 crore citizens of India. Moreover, it offers beneficiaries with an average coverage amount of Rs. 5 Lakh. This covers a majority of diagnostics, medicines, pre-hospitalization costs, and medical treatment expenses. In addition to this, the cashless, as well as paperless services, work in the favour of the nominees at any given point of time in their lives.

PMJAY Scheme makes quality healthcare accessible to the poorest of poor families in India. Hence, the benefits offered by this health plan are massive. Take a look at these PMJAY benefits provided to every needy family:

The Benefits of PMJAY Scheme

• It handles all the uncovered hospital expenses with ease.

• It provides a cashless facility to its beneficiaries.

• It covers the transport allowances of the beneficiary during the pre-hospitalization and post-hospitalization period.

• It covers the day-care expenses within the insurance package.

• It also covers the pre-existing ailments of the beneficiary, which are included under the PMJAY plan.

• It makes provisions for the follow-up treatments to ensure the complete recovery of the patient.

PMJAY has specific criteria requirements. The criteria depend on the data collected under the Socio-economic caste census conducted in the year 2011. Under the Pradhan Mantri Jan Arogya Yojana, the eligibility criteria are divided between the rural and the urban sectors of India. Take a look below:

Eligibility Criteria for Rural and Urban People

Like we know, over 10 crore families across the country will be provided basic health care under the PMJAY scheme. This facility is mainly for the poor and the families with lower middle income. The health coverage provided is of INR 5 lakh per family.

Among the 10 crore families, almost 8 crore families belong to the rural areas while the remaining are from the urban areas. If we break the statistics even further, the scheme will be beneficial to over 50 crore individuals.

Now, just like any other health plan, PMJAY scheme too has certain pre-conditions. Depending on these pre-conditions, it picks who can avail the health coverage benefits. When it comes to rural areas, the eligibility criteria mainly depends on the individuals’ living conditions, income, and other deprivations. Whereas for the urban areas, it is based on each individual’s occupation.

PMJAY Rural

According to the 71st round of the National Sample Survey Organisation, over 85.9% of people in rural areas do not have access to basic healthcare plans. Moreover, 24% of the rural population seeks healthcare facilities by borrowing money.

This is where PMJAY scheme comes in handy. It helps these people avoid getting into a debt trap and avail health facilities. This scheme is economically beneficial to underprivileged households. Also, the families enrolled under the Rashtriya Swasthya Bima Yojana (RSBY) will be covered under the PMJAY scheme.

In the rural areas, the PMJAY health facility is available to –

• People belonging to scheduled caste and scheduled tribe families

• Households with no male member between the age of 16 years and 59 years

• Beggars and those surviving on alms

• Families with no individual between the age of 16 years and 59 years

• Households with at least one physically challenged member and no healthy adult individual

• Landless families who make a living by working as casual manual labourers

• Primitive tribal communities

• Legally released bonded labourers

• People living in one-room makeshift houses with no proper walls or roof

• Manual scavenger families

PMJAY Urban

Much like the rural areas and as per the 71st round of the National Sample Survey Organisation, over 82% of urban families do not have access to adequate healthcare insurance. Furthermore, over 18% of the urban population avails health facilities by borrowing money in one form or another.

With the PMJAY scheme, these people can avail healthcare services, as the funding provided is of INR 5 lakh per family. According to the Socio-Economic Caste Census 2011, PMJAY in the urban areas is beneficial to workers’ families. Also, the families enrolled under the Rashtriya Swasthya Bima Yojana (RSBY) will be covered under the PMJAY scheme.

In the urban areas, PMJAY scheme can be availed mainly by –

• Washerman/ Chowkidars

• Rag Pickers

• Mechanics, electricians, and repair workers

• Domestic help

• Sanitation workers, gardeners, and sweepers

• Home-based artisans and handicraft workers

• Tailors

• Cobblers, hawkers, and people providing services by working on streets or pavements

• Plumbers, masons, construction workers, porters, welders, painters, and security guards

• Transport workers such as drivers, conductors, helpers, cart, or rickshaw pullers

• Assistants, peons of a small organization, delivery men, shopkeepers and waiters

People Who are Not Entitled for Health Coverage under PMJAY Scheme

People who are not eligible for availing PMJAY health services include the ones –

• Owning a two, three, or four-wheeler or a motorized fishing boat

• Have a mechanized farming equipment

• Have a Kisan card with a credit limit of INR 50,000

• Employed by the government

• Working in government-managed non-agricultural enterprises

• Earning a monthly income above INR 10,000

• Owning refrigerators and landlines

• With decently build houses

• Owning 5 acres or more of agricultural land

Medical Packages and Hospitalization Process in Ayushman Bharat Scheme (PMJAY)

Individuals, as well as families, can utilize the health coverage of INR 5 lakh provided under the Pradhan Mantri Arogya Scheme. This amount is enough to cover medical expenses and surgical treatments in almost 25 specialities that include cardiology, neurology, oncology, paediatrics, and orthopaedics. However, you cannot reimburse medical and surgical expenses simultaneously.

In case of multiple surgeries, the surgery with the highest cost is paid in the first instance; then a 50% waiver is offered for the second surgery and a 25% discount on the third.

 Additionally, unlike other health insurance plans, PMJAY has no waiting period for pre-existing illnesses. This service comes under a larger umbrella scheme of Ayushman Bharat Yojana. So, in case you or any of your loved ones need immediate medical assistance, you do not have to worry about the expenses incurred. However, make sure that the individual seeking treatment is admitted in a network government or private hospital.

Moreover, this scheme also provides cashless treatment and hospitalization, primarily because of the 60:40 cost-sharing agreement between the Centre and States. Once you are recognized under the plan, you and your family members will be issued a health card by professionals identified as Ayushman Mitras. With the health card handy, you can avail the benefits of Pradhan Mantri Jan Arogya Yojana at any of the network hospitals.

PMJAY Illness Coverage

PMJAY scheme provides funding of INR 5 lakhs per family annually. The benefit can be utilized for daycare procedures and can even be availed for pre-existing illnesses. Some of the critical ailments covered under the plan are as follows –

• Prostate cancer

• Coronary artery bypass grafting

• Double valve replacement

• Carotid angioplasty with stent

• Pulmonary valve replacement

• Skull base surgery

• Laryngopharyngectomy with gastric pull-up

• Anterior spine fixation

• Tissue expander for disfigurement following burns

Similar to any other health insurance plan, PMJAY has a minimal list of exclusions as follows –

• OPD

• Drug rehabilitation programme

• Cosmetic related procedures

• Fertility related procedures

• Organ transplant

• Individual diagnostics (for evaluation purposes)

PMJAY Scheme - COVID-19 Coverage

In the light of the coronavirus (COVID-19) situation across the country, the Insurance Regulatory and Development Authority of India (IRDAI) has issued a memorandum to all the health insurance providers in India to cover COVID-19 hospitalisation and treatment expenses.

Even the government-funded healthcare facility, the PMJAY scheme offers coverage to the COVID-19 patients.

Dr. Indu Bhushan, CEO of the National Health Authority (NHA), confirmed the same via twitter: “Treatment of symptoms of #COVID19 #Corona like Pneumonia, Fever, Respiratory Failure etc. is available, thru diff. Packages, under #AyushmanBharat #PMJAY free of cost for eligible people in empanelled hospitals & other designated hospitals.”

In fact, the NHA has also advised people to seek medical guidance in case of any COVID-19 symptoms. The empanelled hospitals under the PMJAY scheme are well-equipped for the treatment, testing, and quarantine facilities.

So, the poor and vulnerable families in India can avail the PMJAY benefits for coronavirus treatment and hospitalisation. However, check your eligibility and provide the necessary documents. The information regarding the same is explained below.

PMJAY Enrollment Process

Eligibility Criteria

There is no specific process for PMJAY registration. It applies to all beneficiaries as identified by the SECC 2011 and those who are already a part of the RSBY plan. In case you want to check whether you are eligible to be a beneficiary of PMJAY, follow the steps below –

1. Visit the PMJAY government website (https://www.pmjay.gov.in/) and click on 'Am I Eligible.'

2. Enter your contact information and click on 'Generate OTP.'

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

4. Based on the results, you can verify whether your family is covered under the PMJAY scheme.

Alternatively, to know about Ayushman Bharat Yojana eligibility, you can contact any Empanelled Health Care Provider (EHCP) or Ayushman Bharat Yojana call centre at 14555 or 1800-111-565.

Documents Required

• A certified document confirming your age and identification.

• Existing contact details of the buyer

• Income certificate

• Caste certificate

• A document stating the current family status.

For additional PMJAY technical support, you can head to https://mera.pmjay.gov.in/search/login

To sum up, the exorbitant medical expenses have made having comprehensive health insurance the need of the hour. However, certain people cannot afford the premiums of health insurance plans. The PMJAY programme is a measure to help the underprivileged families to tackle medical emergencies. In the end, health is an essential aspect of our lives. Hence, it should not be ignored, at any cost. Ayushman Bharat registration can be done in order to get access to quality healthcare under this programme. Thus eventually, every citizen of our country will be able to lead a worry-free healthy life.

Pradhan Mantri Jan Arogya Yojana (PMJAY), is one of the world’s largest national health insurance schemes. Under this umbrella medical insurance scheme, the Government has launched several healthcare initiatives like National Health Protection Scheme (NHPS), Rashtriya Swasthya Bima Yojana (RSBY), Senior Citizen Health Insurance Scheme (SCHIS) and Employees’ State Insurance Scheme (ESIS). Get exclusive insights and details related to all healthcare programs under the PMJAY scheme at Finserv MARKETS.

Also, since the PMJAY scheme has been launched recently, a majority of people are unaware of this government initiative. Hence, you can go through these top frequently asked questions (FAQs) about the Ayushman Bharat Yojana Scheme mentioned below.