Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

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Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched on 23^rd September 2018. The salient features of AB-PMJAY are:

1. AB-PMJAY is the world’s largest Government funded health assurance scheme.

2. AB-PMJAY provides health assurance of up to Rs.5 Lakh per family per year for secondary and tertiary healthcare hospitalizations.

3. AB-PMJAY is a completely cashless and paperless scheme.

4. The benefits under AB-PMJAY are portable across the country.

5. There is no cap on family size, or age or gender.

6. The beneficiary families under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) have been identified from the Socio Economic Caste Census (SECC) of 2011 on the basis of select deprivation and occupational criteria across rural and urban areas. Details are as below:

Detailed list of criteria for eligibility under AB-PMJAY as per SECC 2011

Automatically included:

• Households without shelter
• Destitute/ living on alms
• Manual scavenger families
• Primitive tribal groups
• Legally released bonded labour

Deprivation criteria in rural area:

D1: Only one room with kucha walls and kucha roof

D2: No adult member between age 16 to 59

D3: Female headed households with no adult male member between age 16 to 59

D4: Disabled member and no able-bodied adult member

D5: SC/ST households

D7: Landless households deriving major part of their income from manual casual labour

Occupational criteria in urban area:

1. Rag picker
2. Beggar
3. Domestic worker
4. Street vendor/ Cobbler/hawker / Other service provider working on streets
5. Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and other head-load worker
6. Sweeper/ Sanitation worker / Mali
7. Home-based worker/ Artisan/ Handicrafts worker / Tailor
8. Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller
9. Shop worker/ Assistant/ Peon in small establishment/ Helper/ Delivery assistant / Attendant/ Waiter
10. Electrician/ Mechanic/ Assembler/ Repair worker/Washer-man/ Chowkidar

7. The number of eligible beneficiaries under SECC 2011 is 10.74 crore (50 crore people). 33 States/UTs implementing AB-PMJAY have further expanded the coverage of the scheme to include 13.44 crore families (65 crore people).

8. AB-PMJAY is being implemented in all States and UTs barring West Bengal, NCT of Delhi and Odisha.

9. The scheme is implemented across the country through a three-tier model. National Health Authority, an attached office of the Ministry of Health and Family Welfare with full functional autonomy, is the apex body implementing AB-PMJAY across the country. For effective implementation of AB-PMJAY at States/UTs level, State Health Agencies (SHAs) have been established. District Implementation Units (DIUs) have been set up for ensuring on-ground coordination between scheme stakeholders and for smooth implementation.

10. AB-PMJAY is completely funded by the Government and costs are shared between Central and State Governments in the ratio as per the extant directives issued by Ministry of Finance.

11. The States/UTs have been provided with the flexibility to implement the scheme in the operational model best suited to the local conditions. Thus, AB-PMJAY is being implemented in Insurance mode, Mixed mode and Trust mode.

As regards procedure involved, AB-PMJAY is an entitlement-based scheme. All the eligible beneficiary families are covered from day one of the implementation of the scheme in the States/UTs. AB-PMJAY does not require enrolment. However, beneficiary verification process is being undertaken to verify the genuineness of the beneficiary. Ayushman cards are issued to all eligible beneficiaries as part of this process to ensure easy availing of health benefits.

Targets are not fixed for AB-PMJAY as the scheme operates on the basis of beneficiary demand for healthcare services. All the eligible beneficiaries of the implementing States/UTs are entitled for free healthcare services under the scheme from the day of launch of the scheme.

A total of 1.96 crore hospital admissions worth Rs. 24,315 crores have been authorized through a network of approximately 23,000 Empanelled Health Care Providers (EHCPs).

State wise details of Ayushman-cards issued, authorized hospitals admissions by count and amount under AB-PMJAY and schemes converged with AB-PMJAY are as follows:

The funds allocated for the scheme for the current financial year 2021-22 are Rs. 6400 crore.

Following the onset of Covid-19, AB-PMJAY provided valuable support to the healthcare ecosystem by ensuring that beneficiary registration process was kept active and empanelled hospitals continued to provide services to the scheme beneficiaries. However, there was a noticeable impact on the uptake of the scheme on account of factors such as restriction of mobility, restrictions on elective surgeries, reluctance from scheme beneficiaries to visit hospitals due to fear of infection and designation of public facilities as dedicated COVID centres. During the period from 01^stMarch 2020 –19^thJuly 2021, a total of approx. 1.05 crore hospital admissions worth approx. Rs. 11,862 crore have been authorized under AB-PMJAY.

As on 20.07.2021, a total of 16.14 crore Ayushman cards have been issued to the scheme beneficiaries.

AB-PMJAY provides services only for inpatient treatment, therefore, only hospitals providing inpatient services are empanelled under this scheme.

Accordingly, NHA has developed guidelines for empanelment of hospitals under the scheme. The empanelment of hospitals under AB-PMJAY is done for general treatment and for treatment under particular speciality. The guidelines for empanelment of hospitals under AB-PMJAY can be accessed on PMJAY website.   (https://pmjay.gov.in/sites/default/files/2020-06/Empanelment-and-De-empanelment-guidelines.pdf )

            Since the empanelment of hospitals under AB-PMJAY is primarily done by the respective State/UT Governments, flexibility has been provided to the State/UT Governments to modify the empanelment criteria based on local requirements including supply and demand.

As on 20^th July 2021, approx. 23,000 hospitals have been empaneled under AB-PMJAY by various State/UT Governments. The State/UT wise details of the empaneled hospitals are at Annexure-III.

Under Ayushman Bharat Health and Wellness centre, Government of India is committed to establish 1,50,000 Health and Wellness Centres (AB-HWCs) by upgrading the Sub Health

Centres (SHCs) and rural and urban Primary Health Centres (PHCs) to bring health care closer to the community.

As on 20^th July 2021, 77,406 AB-HWCs are operational across the country. Details are at Annexure – IV.

Details of financial assistance provided to States/UTs are at Annexure – V.

AB-PMJAY provides treatment corresponding to a total of 1669 procedures under 26 different specialties including chronic diseases like Cancer, Diabetes, Heart Disease and other non-communicable diseases and renal and corneal transplant. The specialty wise breakup of packages is provided under Annexure – VI.

Chemotherapy and Radiotherapy packages, along with surgical oncology are covered as part of cancer treatment under the scheme.

Additionally, there is a category of unspecified packages which can be booked for procedures which are not defined in the Health Benefit Packages (HBPs).

 The following measures have been adopted by NHA to offer state-of-the-art healthcare service delivery under AB-PMJAY

• Public hospitals empanelled under AB-PMJAY are reimbursed for treatment provided under the scheme at par with cost reimbursed to their private sector counterparts. These funds can be leveraged by such institutions to carry out infrastructural development and establish state-of-the-art facilities. NHA has issued necessary guidelines and instructions to the SHAs and public hospitals to encourage the same. Many States have effectively used the funds allotted to public hospitals for infrastructure upgradation and for providing better amenities to beneficiaries.
• A targeted approach is being followed to empanel the top corporate hospitals in the country under AB-PMJAY.
• NHA has partnered with Quality Council of India to develop a quality certification program for empanelled hospitals. AB-PMJAY quality certifications include Bronze, Silver and Gold Quality certifications. Hospitals achieving PMJAY Gold, Silver and Bronze certifications are provided 15%, 10% and 5% higher package rates respectively. As on 19th July, 2021 over 200 empanelled hospitals have been Quality Certified under the scheme.
• Further, if an empanelled hospital attains entry level NABH accreditation, it is incentivized by reimbursing the cost of treatment at a rate which is 10 per cent higher that the standard package rates. Similarly, a PMJAY empanelled hospital attaining full NABH accreditation is paid 15 percent higher rate.

These incentives have been designed to promote state-of-the-art healthcare service delivery under AB-PMJAY.

Beneficiary families under AB-PMJAY have been identified from the SECC-2011 database on the basis of 6 deprivation criteria and 11 occupational criteria across rural and urban areas respectively. Details are at Annexure – I.

Representations have been received regarding the inclusion of families under AB-PMJAY. However, the beneficiary database under the scheme has been frozen with the approval of the Union Cabinet.

At the same time, it may be noted that the 33 States/UTs implementing the scheme have expanded the scope of AB-PMJAY to include other categories of beneficiaries beyond SECC 2011 at their own cost. As on 20^th July, 2021, approximately 13.44 crore beneficiary families are covered under AB-PMJAY.

With respect to Assam, it may be noted that in addition to AB-PMJAY, the Government is implementing a local health insurance scheme known as “Atal Amrut Abhiyan” (AAA).

AAA is an enrolment-based scheme, providing insurance coverage of up to Rs. 2 Lakh per year to every entitled family in the State. Moreover, those families belonging to the APL category with income between Rs. 1.2 Lakh and 5 Lakh per annum can also avail the benefit of AAA by paying a nominal premium of Rs. 100/- per year per member. Thus, eligible beneficiaries can avail services under either of these schemes.

National Health Authority has entered into a collaboration with WHO to carry out research and evaluation studies. In this regard, a study on “Mainstreaming quality in empaneled hospitals under PMJAY” is being conducted in three States viz. Haryana, Gujarat and Uttar Pradesh.

Annexure – III

State/UT list of empanelled hospitals in AB-PMJAY

Annexure – IV

Functional Health and Wellness Centres as on 20^th July 2021

Annexure – V

Central Release (allocation) for the activity Ayushman Bharat – Health & Wellness Centres for the FY 2018-19 to 2020-21 (Rupees in crore)

Annexure – VI

Specialty wise breakup of packages and procedures under AB-PMJAY

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