AYUSHMAN BHARAT

Ref: (National Health Authority, Govt. of India)

Presenter: Dr. Md. Abu Khan

1st year PGT, Department of Community Medicine.

Moderator: Prof. (Dr.) Bishnu Ram Das

Head of the Department, Community Medicine.
Contents:
1. Introduction about Ayushman Bharat.
2. key features and benefits of PMJAY.
3. Coverage under PM-JAY.
4. Implementation.
5. Financing of the Scheme.
6. Hospital Empanelment.
7. Packages.
8. IT System.
9. Awareness and Communication.
10. convergence.
 Ayushman Bharat:

• Ayushman Bharat, a flagship scheme of Government of India, was launched as

recommended by the National Health Policy 2017, to achieve the vision of
Universal Health Coverage (UHC).

• Ayushman Bharat comprising of two inter-related components, which are –

a) Health and Wellness Centres (HWCs).

b) Pradhan Mantri Jan Arogya Yojana (PM-JAY).
 Pradhan Mantri Jan Arogya Yojana (PM-JAY):

• The second component under Ayushman Bharat is the Pradhan Mantri Jan Arogya
Yojana or PM-JAY .

• This scheme was launched on 23rd September, 2018 in Ranchi, Jharkhand by the
Hon’ble Prime Minister of India.

• Ayushman Bharat PM-JAY is the largest health assurance scheme in the world.
• PM-JAY is fully funded by the Government and cost of implementation is shared

between the Central and State Governments.

• which aims at providing a health cover of Rs. 5 lakhs per family per year for

secondary and tertiary care hospitalization to over 12 crores poor and vulnerable

families (approx. - 55 crore beneficiaries) that form the bottom 40% of the Indian

population.
 Key Features of PM-JAY

• PM-JAY provides cashless access to health care services for the beneficiary at the
point of service, that is, the hospital.

• It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization

expenses such as diagnostics and medicines.

• There is no restriction on the family size, age or gender.

• All pre–existing conditions are covered from day one.

• Benefits of the scheme are portable across the country i.e. a beneficiary can visit
any empaneled public or private hospital in India to avail cashless treatment.

• Services include approximately 1,929 procedures covering all the costs related to
treatment.

• Including drugs, supplies, diagnostic services, physician's fees, room charges,

surgeon charges, OT and ICU charges etc.
 Benefit Cover Under PM-JAY:

• Medical examination, treatment and consultation.

• Pre-hospitalization for 3 days.

• Medicine and medical consumables.

• Non-intensive and intensive care services.

• Diagnostic and laboratory investigations.

• Medical implantation services (where necessary)

• Accommodation benefits

• Food services.

• Complications arising during treatment

• Post-hospitalization follow-up care up to 15 days

 Why PM-JAY: (Background)

• India as it’s economy making remarkable progress in several sectors, India is still
classified as a Lower Middle-Income Country (LMIC) according to World Bank
classification of countries based on per capita GDP.

• The public sector hospitals in India are overburdened and have to work under
challenging circumstancing arising from the lack of sufficient funds.

• Shortage of health workers and often deficient supply of drugs and equipment which
adversely impacts their functioning.
• Over the last two decades, the Government of India’s overall expenditure on health
has remained stagnant at about 1.2% of its GDP.

• The increasing health care needs, pushes nearly 6 crore Indians back into poverty
each year.

• To address these challenges, the Government of India launch the Pradhan Mantri-Jan
Arogya Yojana (PM-JAY) which aims to create a system of demand-led health care
reforms that meet the immediate hospitalization needs of the eligible beneficiary
family in a cashless manner.

• PM-JAY has subsumed the existing various State Government funded health
insurance/ assurance schemes.
 Coverage under PM-JAY

Rural Beneficiaries:

PM-JAY covered all such families who fall into at least one of the following six
deprivation criteria (D1 to D5 and D7) and automatic inclusion(Destitute/ living on alms,
manual scavenger households, primitive tribal group, legally released bonded labour)
criteria:

• D1- Only one room with Kucha walls and Kucha roof
• D2- No adult member between ages 16 to 59
• D3- Households with no adult male member between ages 16 to 59
• D4- Disabled member and no able-bodied adult member
• D5- SC/ST households
• D7- Landless households deriving a major part of their income from manual casual labour
 Urban Beneficiaries:

The following occupational categories of workers are eligible for the scheme:

• Ragpicker
• Beggar
• Domestic worker
• Street vendor/ Cobbler/hawker / other service provider working on streets
• Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard.
• Coolie and other head-load worker.
• Sweeper/ Sanitation worker/ Mali
• Home-based worker/ Artisan/ Handicrafts worker/ Tailor
• Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart
puller/Rickshaw puller
• Shop worker/ Assistant/ Peon in small establishment/ Helper.
• Delivery assistant / Attendant/ Waiter
• Electrician/ Mechanic/ Assembler/ Repair worker
• Washer-man/ Chowkidar.
 Implementation Model:

Various States are using different models for implementing their own health insurance/
assurance schemes. Some of them are using the services of insurance companies while
others are directly implementing the schemes in their States.

A. Assurance Model/Trust Model

• This is the most common implementation model adopted by most of the States.

• Under this model, the scheme is directly implemented by the SHA without the
intermediation of the insurance company. The financial risk of implementing the
scheme is borne by the Government in this model.
B. Insurance Model

• In the insurance model, the SHA selects an insurance company through a

tendering process to manage PM-JAY in the State.

• Based on market determined premium, SHA pays premium to the insurance

company per eligible family for the policy period and insurance company.

• The claims settlement and payments to the service provider. The financial risk for
implementing the scheme is also borne by the insurance company in this model.
C. Mixed Model

• Under this, the SHA engages both the assurance/ trust and insurance models
mentioned above in various capacities with the aim of being more economic,
efficient, providing flexibility and allowing convergence with the State scheme.

• This model is usually employed by the States which had existing schemes
covering a larger group of beneficiaries
 Financing of the Scheme:
• PM-JAY is completely funded by the Government and costs are shared between
Central and State Governments.

• The existing sharing pattern is in the ratio of 60:40, for States (other than North-
Eastern States & three Himalayan States) and Union Territories with legislature.

• North-Eastern States and three Himalayan States (viz. Jammu and Kashmir,
Himachal Pradesh and Uttarakhand), the ratio is 90:10. For Union Territories, the
Central Government may provide up to 100% on a case-to-case basis
 States have been provided the flexibility in terms of the following
parameters:

• Mode of implementation – States can choose the implementation model and can
implement the scheme through Trust, Insurance company or Mixed model.

• Usage of beneficiary data – PM-JAY uses SECC data for targeting the beneficiaries.

• Co-branding – States can co-brand their existing health insurance/assurance

schemes with PM-JAY as per co-branding guidelines of the scheme.
•Expansion of cover to more people – States can cover more number of families those
defined as per SECC data. For these additional families, full cost will need to be borne
by the States.

•Increasing benefit cover to higher value – If the State want they can even expand the
benefit cover beyond `5 lakh per family per year. However, in this case cost of additional
cover will need to be completely borne by the State.

•Revision in package numbers and pricing – PM-JAY provides cover of more than
1300 packages and their prices have been fixed by NHA. However, flexibility has been
provided to the States to expand the number of packages and also to revise the package
prices.
•Reservation of packages for public hospitals – To ensure that such services
that can be provided well by Government health facilities are not misused by
private providers.

•IT Systems – Before the launch of PM-JAY some of the States were
implementing their own health insurance schemes and were using their own IT
systems. PM-JAY provides flexibility that State can continue using their own IT
system and share data with NHA on a real time basis in specified format.

•Payment to public hospitals – States have also been provided flexibility to

deduct a certain percentage of claims amount that is paid to public hospitals.
 Hospital Empanelment:

• The supply of health care services under PM-JAY must be ensured through pre-
selected, well equipped and well-prepared hospitals to deliver the benefits. Also, the
hospitals must be distributed widely enough over the geography so as to ensure
accessibility to the eligible families.

• Empanelment Criteria:

• General criteria – For hospitals that provide non-specialized general medical and
surgical care with or without ICU and emergency services.

• Special Criteria (for clinical specialties) – For each specialty, a specific set of criteria
has been identified. Under PM-JAY, a hospital is not allowed to select the risk, must
agree to offer all specialties to PM-JAY beneficiaries.
 Process of hospital empanelment in PM-JAY

• At the State level, a State Empanelment Committee (SEC) has been set up under the
State Health Agency. At the district level, a District Empanelment Committee (DEC)
has been set up.

• Each empanelled hospital needs to set up a dedicated help desk for the beneficiaries.
These help desk staff are called Pradhan Mantri Arogya Mitra's (PMAMs) and their
role is to facilitate treatment of beneficiaries at the hospitals

• Hospitals are required to apply online which is free of cost. The progress of the
application can also be tracked online.

• The online applications are scrutinised by the DEC and physical verification of the
hospitals is carried out.

• Following this verification, the DEC submits a recommendation to approve or reject

the hospital to the SEC. The final decision regarding empanelment rests with the SEC
 Packages includes:

• Registration charges

• Bed charges (General Ward)

• Nursing and Boarding charges

• Surgeons, Anesthetists, Medical Practitioner, Consultants’ fees, etc.

• Anesthesia, Blood Transfusion, Oxygen, O.T. Charges, Cost of Surgical

Appliances, etc.

• Medicines and Drugs

• Cost of Prosthetic Devices, implants (unless payable separately)

• Pathology and radiology tests: radiology to include but not be limited to X-ray,
MRI, CT Scan, etc. (as applicable)

• Food to patient.

• Pre and Post Hospitalization expenses: Expenses for consultation, diagnostic

tests and medicines before the admission of the patient in the same hospital, and
up to 15 days of the discharge from the hospital for the same ailment/ surgery
 IT System under PM-JAY:

• PMJAY Dashboard : It is used for real-time reporting of transactions, evaluating

performance and understanding utilization trends.

• Hospital Empanelment System : Allows for registration and approval of hospitals

for empanelment. Features for Hospital Quality Assurance are also being made
available in this system.

• Beneficiary Identification System (BIS) : Allows for searching beneficiaries

through SECC or additional data sets through APIs and supports Aadhaar eKYC
(electronic Know Your Customer) and non-Aadhaar based KYC for Authentication.
• Transaction Management System (TMS) : Allows for capturing of in-patient data
on admission, treatment and discharge, and onwards to hospital claims and financial
settlement. It is integrated with other State based and external systems through
Application Program Interface (APIs).

• Citizen Portal (mera.pmjay.gov.in) : Allows for citizens to search the beneficiary

database to ascertain the eligibility under the scheme. The popular self-help tool has
allowed for mass scale searches right at the field level being mobile responsive.

• Citizen Call Centre (14555) : National Toll-Free number backed with a 400+ multi-
lingual, multi-location call centre services which allows beneficiaries to find out their
eligibility, nearest hospital, nearest Common Service Centre etc. Service offerings
through the call centre have been enlarged to allow for beneficiary feedback and
grievance redressal.
• National Portability : Unique to the scheme, IT system has allowed portability of
benefits for the beneficiary regardless of the location. This has been possible only by
designing systems which allow for a real-time integration and data-exchange across the
IT landscape

• Anti-Fraud Measures : As part of the IT landscape, a ‘Man-Machine’ model has been

envisaged to counter fraudulent transactions and entities. The model shall generate
triggers for suspicious transactions and entities, and will also allow for closure of
investigations of such transactions. National Anti-Fraud Unit and State Anti-Fraud Unit
have been institutionalized to support investigations at the State level.

• Citizen Mobile App : Allows for registered beneficiaries to find out their existing
‘wallet balance’ in the scheme, search for the nearest hospitals and provide feedback on
the services being provided by the hospitals. As a simple personal tool shall empower
the beneficiaries to know their utilization of the entitled benefits.
Awareness and Communication:

• 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 need to be 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 communication strategy across the
target audience.

• NHA is also working on the overall co-operation & capacity-building with the States
for implementation and development of communication strategy required for
increasing awareness at the State level.
 Convergence between National Health Authority (NHA) and Employee’s State
Insurance Corporation (ESIC):

• The National Health Authority (NHA) has entered into a partnership with the
Employee’s State Insurance Corporation (ESIC).

• Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) and
Employees State Insurance Scheme (ESIS) will create an ecosystem wherein ESIC
beneficiaries will be able to access services at ABPM-JAY empanelled hospitals.

• The convergence between PM-JAY and ESIC is a landmark initiative for the
development of health systems in the country.
•Key Benefits of AB PM-JAY and ESIS convergence:

• ESIC beneficiaries will get access to healthcare providers under AB PM-JAY

• AB PM-JAY beneficiaries will be able to avail services in ESIC empanelled hospitals.

• Beneficiaries of ESIC can use their ESIS card to access free treatment at AB PM-JAY
empanelled hospitals.

• Similarly, beneficiaries of AB PM-JAY can use their PM-JAY card to access free
treatment at ESIC empanelled hospitals.

• For more information beneficiaries can call ESIC tollfree number: 1800 112 526/ 1800
113 839