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

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 or 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 under PMJAY Scheme

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 Yojana Scheme

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.

How to Check AB-PMJAY Hospital List

Since September 2018, a significant number of hospitals across the country have been empanelled under the PMJAY scheme. At present, over 15,000 hospitals form a part of this government-funded healthcare program, among which 50% of the hospitals are private hospitals.

You can find the list of these empanelled hospitals by following the steps given below:

• Visit the link provided below:

https://hospitals.pmjay.gov.in/Search/empnlWorkFlow.htm?actionFlag=ViewRegisteredHosptlsNew

• Select your state and district area

• Choose the type of hospital you are looking for (public, private and for profit, or private and not for profit)

• Choose the kind of medical guidance you need

• Enter the captcha code

• Click on search

The system will provide the list of the PMJAY empanelled hospitals with respective addresses, contact details, and official website. You can also click on Ayushman Bharat Hospital List to know more about the de-empanelled hospitals under the PMJAY scheme.

Steps to Check Your Name in the AB-PMJAY list for 2020

Checking your name in the AB-PMJAY list 2020 is quite easy. There are three different methods to so.

• Visit the Common Service Centre (CSC): You can visit the nearest located CSC or any empanelled hospital to check whether you are eligible for the PMJAY scheme or not.

• Contact the Helpline Number: The PMJAY scheme allows you to check your eligibility by simply contacting the helpline number 14555 or 1800-111-565.

• Visit PMJAY website: By visiting the official PMJAY website (www.pmjay.gov.in), you can check your eligibility for the scheme.

About Ayushman Bharat Yojana Card

The PMJAY beneficiaries can avail cashless healthcare services at any of the empanelled hospitals by simply using the Ayushman Bharat Yojana card. The beneficiaries are issued a card at the time of registration. This card contains all your necessary information and is mandatory to provide it when availing the treatments under the scheme.

To get the Ayushman Bharat Yojana Card, follow the below steps:

1. Visit the official PMJAY website

2. Login with your registered contact number

3. Enter the captcha code and generate the OTP (One-Time-Password)

4. Opt for the HHD code

5. Provide the correct HHD code to the Common Service Centre (CSC)

6. They will check and verify the details provided

7. The CSC representative (also known as Ayushman Mitra) will complete the remaining process

8. You will have to pay INR 30 to get the Ayushman Bharat Yojana Card

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 Enrollment Process

Eligibility Criteria for Ayushman Bharat Yojana Enrollment

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 to Apply for the Ayushman Bharat Yojana Scheme

• 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.

How to lodge a complaint or grievance on the PMJAY portal

You can lodge a complaint or grievance online on the CGRMS portal of the PMJAY scheme - www.cgrms.pmjay.gov.in

In case you want to lodge a complaint offline, you can do so by –

• Contacting the PMJAY helpline centre operated by your State/NHA

• Sending a letter, email, or fax to the official addresses of the SHA/NHA

• Directly meeting with the District Grievance Nodal Officer (DGNO) of your district where the complaints are formally processed. The DGNO will enter the contents of grievances received via the offline mode in the portal

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.

Contact Information regarding Ayushman Bharat Yojana

The PMJAY scheme contact and mailing information is as follows –

Contact Number –

14555 or 1800-111-565 (both toll-free).

Mailing Address –

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

You also get easy access to the information related to PMJAY with the Ayushman Bharat (PMJAY) app. It is available on the Google Play Store for Android users only as of now. The app also offers the facility to check your eligibility for the scheme and search the empanelled hospitals around you.

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.

Latest News around the AB-PMJAY Scheme

• Empanelled private and government hospitals under PMJAY to get star ratings

There are over 23,000 hospitals empanelled under the scheme across the country. Both the private and government hospitals empanelled under the PMJAY scheme will get star ratings based on six quality domains – effective, timely, safe, patient-centred, efficient, and equitable healthcare. For any hospital to get a five-star rating, it needs to score above or equal to 90 per cent. To get a four-star rating the hospital needs to score 75 to 90 per cent; for a three-star rating, it has to score 50 to 75 per cent; for two-star rating, it needs to score 25 to 50 per cent; whereas to get a one-star rating it has to score less than 25 per cent. Moreover, these ratings will be reviewed every month based on the quality domains.

- August 30, 2020

• The Governing Board of NHA approves the integration of existing health schemes of Central Ministries with PMJAY scheme.

Recently, the Governing Board of the National Health Authority (NHA) sat and reviewed the implementation of health facilities under the PMJAY scheme. The meeting concluded with approval from the authorities to integrate the existing health facilities of Central Ministries with PMJAY for employees (government as well as contractual employees). Other beneficiary groups, such as building and construction workers, manual scavengers, road accident victims, and Central Armed Police Force (CAPF) personnel, can also access these facilities.

- August 13, 2020

• A new cashless scheme for road accident victims is introduced in PMJAY.

According to the Union Road Transport Ministry, the government is planning to offer cashless treatments for the road accident victims by creating a special road accident fund under the PMJAY scheme.

- June 30, 2020

• A piece of good news for PMJAY beneficiaries!

The National Health Authority (NHA) has started to empanel dialysis centres and laboratories to extend the benefits of the PMJAY scheme that helps the low-income families across India.

- June 15, 2020

• The PMJAY scheme crossed a new milestone!

The AB-PMJAY scheme has marked one crore treatments worth INR 13,412 crore approx. in under 20 months of its launch. The authorities have planned to launch a new WhatsApp Chatbot and special ecards to exhibit the milestone.

- May 20, 2020

• Beware! A fake PMJAY website has been circulating via WhatsApp lately.

It has come to notice by the PMJAY authorities that a fake website has been circulating among the citizens recently. The Ayushman-Yojana.Org is not the official website for the government-funded scheme – AB-PMJAY. The official website is www.pmjay.gov.in

- May 12, 2020

• More 1000 hospitals to be added under the PMJAY scheme.

To increase the availability of medical facilities under the PMJAY scheme, the government has empanelled 1000 hospitals since April 01. This takes the total number of empanelled hospitals under the PMJAY scheme to 21,541 across the country.

- May 12, 2020