Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY)
is a flagship health insurance scheme launched by the Government of India on
September 23, 2018. It is part of the Ayushman Bharat initiative, which aims to
provide accessible, affordable, and quality healthcare to vulnerable populations
in India. PMJAY is a health insurance program started by the Indian government.
It helps families who don’t have a lot of money to pay for medical treatments
when they get sick or hurt.
Below is a detailed breakdown of PMJAY:
1. Objectives of PMJAY
- Health Coverage: The main goal is to provide health
coverage of up to ₹5 lakh per family per year for secondary and tertiary
hospitalization. PMJAY gives money for medical treatments, covering up to ₹5
lakh (500,000 rupees) for each family every year.
- Financial Protection: Reduce the financial burden on poor
and vulnerable families due to catastrophic health expenses. It helps protect
families from spending too much money on health issues.
- Universal Health Coverage (UHC): Promote access to
essential health services for all citizens. The goal is to make sure that all
citizens have access to good health services.
2. Target Beneficiaries
- PMJAY targets economically disadvantaged families
identified using the Socio-Economic Caste Census (SECC) data.
- Approximately 10.74 crore families (over 50 crore
individuals) are eligible for benefits under the scheme. - The scheme is for
poor families. The government uses a special survey to find families who
qualify for help.
3. Key Features
- Cashless Treatment: Beneficiaries can avail of cashless
treatment for covered healthcare services at public and empaneled private
hospitals across India. When a family member goes to a hospital that is part of
the scheme, they don’t have to pay upfront money. The hospital gets paid
directly by the government.
- Wide Coverage: The scheme covers various medical
procedures, including surgeries, treatments, and diagnostics for a
comprehensive list of diseases (around 1,500 treatment packages). PMJAY covers
a lot of different medical treatments, like surgeries and tests for many
serious illnesses.
- No Cap on Family Size: There is no restriction on family
size and age, allowing families of any size to benefit from the scheme. It
doesn’t matter how many people are in a family; all can benefit from the
scheme.
- Portability: Beneficiaries can avail themselves of medical
services in any empaneled hospital across the country. Families can get
treatment at hospitals anywhere in India that are part of the program.
4. Implementation Mechanism
- State Health Agencies: PMJAY is implemented by state
governments through State Health Agencies (SHAs) which are responsible for
planning, implementing, and monitoring the scheme. Each state has a special
group that takes care of the program and makes sure it runs smoothly.
- Empanelment of Hospitals: Both public and private
hospitals are empaneled to provide services under PMJAY. Hospitals must meet
the procedural and quality standards set by the scheme. Hospitals can sign up
to provide services under PMJAY, which means they have to meet certain quality
standards.
- Digital Platform: The scheme uses a digital platform for
the verification of beneficiaries, claim processing, and management of records.
5. Services Covered
- Inpatient treatments including major surgeries, maternity
care, and more.
- Pre and post-hospitalization expenses for diagnostic
tests, medications, and follow-ups.
- The program pays for hospital stays, surgeries, and tests
that are needed.
- It also covers some follow-up care and medicines given
after treatment.
- A number of high-cost treatments such as cardiac
surgeries, cancer treatments, etc.
6. Exclusions
While PMJAY provides comprehensive coverage, certain
services are excluded:
- Outpatient services.
- Dental treatments (unless surgical).
- Treatments for conditions like infertility.
- Non-therapeutic cosmetic procedures.
- PMJAY doesn’t pay for outpatient services (when you visit
a doctor and don’t stay overnight).
- It also doesn’t cover things like dental work (unless it’s
surgery directly related to health) or cosmetic surgeries.
7. Enrollment Process
- Beneficiaries can check their eligibility through the
PMJAY website/mobile app or at Common Service Centers (CSCs).
- Beneficiaries can also enroll for the scheme through
hospitals providing services.
- Families can check if they are eligible for PMJAY online
or at special centers in their communities.
- Once they know they can join, they can get a card that
lets them use the benefits.
For more information related to enrolment you can check the
official website here https://ump.pmjay.gov.in/signup
8. Financing
- The scheme is primarily funded by the central and state
governments, with 60% of the cost borne by the central government and 40% by
the respective state governments.
- Financial support is given for treatments availed up to ₹5
lakh per family annually.
- The government pays for most of the costs of the program,
sharing the expenses between the central and state governments.
9. Achievements and Highlights
- PMJAY is one of the largest government-funded health
insurance initiatives in the world.
- By 2023, millions of hospital admissions have been
covered, significantly lowering out-of-pocket expenditures for low-income
families.
- The scheme has also encouraged an increase in the quality
of healthcare services in private hospitals due to competition.
- PMJAY has helped millions of people get medical treatment
without worrying about huge bills.
- It has encouraged hospitals to provide better services as
they serve more patients.
10. Challenges
- Awareness: A significant challenge remains in creating
awareness about the scheme among eligible populations. Not everyone knows about
PMJAY, and sometimes families don’t know how to use it.
- Infrastructure: Ensuring adequate healthcare
infrastructure and capacity in hospitals to meet the increased demand. Hospitals
need to be ready to handle more patients because of the program.
- Fraud Prevention: Adopting measures to prevent fraudulent
claims and misuse of the scheme. The government has to be careful to prevent
people from trying to cheat the system.
Conclusion
Ayushman Bharat - PMJAY is a transformative health
initiative aimed at improving healthcare access and affordability for millions
of Indians. It aligns with the broader goals of achieving Universal Health
Coverage and improving the overall health and well-being of the population. PMJAY
is a big health program in India that helps families get the medical care they
need without spending a lot of money. It aims to make sure everyone can visit a
doctor or a hospital when they are sick or hurt.
For the most current updates and details, you can refer to
the official PMJAY website or government publications related to the scheme
here https://ump.pmjay.gov.in/signup
