2. INTRODUCTION
• Ayushman Bharat is a flagship scheme of Government of India
• It was launched as recommended by the National Health Policy 2017, to
achieve the vision of Universal Health Coverage (UHC).
• This initiative has been designed on the lines as to meet SDG and its
underlining commitment, which is "leave no one behind".
• It provides comprehensive need-based health care service to its
beneficiaries.
• Holistic approach- interventions under preventive, promotive and
ambulatory care.
3. KEY FEATURES
• PM-JAY is the world’s largest health insurance/ assurance scheme fully financed
by the government.
• It provides cover of Rs. 5 lakhs per family per year, for secondary and tertiary
care hospitalization across public and private empaneled hospitals in India.
• Over 10.74 crore poor and vulnerable entitled families are eligible for these
benefits.
• It provides cashless access to health care services for the beneficiary at the point
of service, that is, the hospital.
• It will help reduce catastrophic expenditure for hospitalizations, and will help
mitigate the financial risk arising out of catastrophic health episodes.
4. KEY FEATURES
• No restrictions on family size, age or gender.
• All pre–existing conditions are covered from day one.
• Covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses
such as diagnostics and medicines
• Benefits of the scheme are portable across the country i.e. empanelled public or
private hospital for cashless treatment.
• Services include approximately 1,393 procedures covering all the costs related to
treatment, including but not limited to drugs, supplies, diagnostic services,
physician's fees, room charges, surgeon charges, OT and ICU charges etc.
• Public hospitals are reimbursed for the healthcare services at par with the private
hospitals.
5. OBJECTIVES
• To reduce out- of -pocket expenditure.
• To focus on wellness of the poor families.
• To provide medical benefits to poor families.
• To establish Health and Wellness Centers at the nearest distance, to make health
services more accessible to people.
7. HEALTH AND WELLNESS CENTERS
• These are upgraded sub-centers which provide Comprehensive
Primary Health Care(CPHC)
• They deliver an expanded range of services to address the primary
health care needs of the entire population in their area, expanding
access, universality and equity close to the community.
• Emphasis on Health promotion and prevention by engaging and
empowering individuals and communities to choose healthy
behaviours and make changes that reduce the risk of developing
chronic disease and morbidity.
8. PRADHAN MANTRI JAN AROGYA YOJANA
• It provides health insurance cover of Rs. 5 lakhs per family per year
for secondary and tertiary care hospitalization to over 10.74 crores
poor and vulnerable families.
• This scheme was earlier known as National Health Protection
Scheme (NHPS) before it was rechristened to PM-JAY.
• This scheme was launched on 23rd September 2018 by the
Hon’ble Prime Minister Shri Narendra Modi in Ranchi, Jharkhand.
9. PRADHAN MANTRI JAN AROGYA YOJANA
• The households included are based on the deprivation and
occupational criteria of Socio-Economic Caste Census 2011 (SECC
2011) for rural and urban areas respectively.
• The scheme is subsumed with the existing Rashtriya Swasthya
Bima Yojana (RSBY), launched in 2008.
• PM-JAY is completely funded by the Government, and cost of
implementation is shared between Central and State
Governments.
10. BENEFITS COVERED UNDER PM-JAY
• The cover under the scheme includes all the expenses incurred for the following
components of the treatment.
• Medical examination, treatment, and consultation
• Pre-hospitalization
• Medicine and medical consumables
• Non-intensive and intensive care services
• Diagnostic and laboratory investigations
• Medical implant services (where necessary)
• Accommodation benefits
• Food services
11. BENEFITS COVERED UNDER PM-JAY
• Complications arising during treatment
• Post-hospitalization follow-up care up to 15 days
• There is no cap on family size and age of members.
• In addition, pre-existing diseases are covered from the very first day.
• This means that any eligible person suffering from any medical condition before
being covered by PM-JAY will now be able to get treatment for those medical
conditions under the scheme.
12. COVERAGE
• The SECC involves ranking of the households based on their socio-economic
status.
• It uses exclusion and inclusion criteria and accordingly decides on the
automatically included and automatically excluded households.
• Rural households which are included (not excluded) are then ranked based on
their status of seven deprivation criteria (D1 to D7).
• Urban households are categorised based on occupation categories.
13. COVERAGE
• Rural Beneficiaries: Out of the total seven deprivation criteria for rural areas,
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
14. COVERAGE
• Urban Beneficiaries: For urban areas, the following 11 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
15. COVERAGE
• Urban Beneficiaries:
• 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
16. IMPLEMENTATION MODELS
• 1. Assurance Model:
• Under this model, the scheme is directly implemented by the SHA (State Health
Authority) without the intermediation of the insurance company.
• The financial risk of implementing the scheme is borne by the Government in
this model.
• SHA essentially reimburses health care providers directly.
• SHA also carries out specialised tasks such as hospital empanelment, beneficiary
identification, claims management and audits and other related tasks.
17. IMPLEMENTATION MODELS
• 1I. Insurance Model:
• SHA competitively 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, in
turn, does 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.
18. IMPLEMENTATION MODELS
• III. 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.
19. HOSPITAL EMPANELMENT
• Criteria:
• General criteria – For hospitals that provide non-specialised 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, which
means it cannot apply for selected specialties and must agree to offer all specialties
to PM-JAY beneficiaries that are offered by it.
21. HOSPITAL EMPANELMENT: PROCESS
• PM-JAY prescribes a two-tier approach to the empanelment of hospitals which is
online, transparent and efficient and is completely free for all steps of the process.
• States are in the stewardship position of the entire process of hospital empanelment
and they have the final decision-making power in this regard.
• Each empanelled hospital needs to set up a dedicated help desk for the beneficiaries,
which is manned by a dedicated staff appointed by the Empanelled Health Care
Provider (EHCP).
• These help desk staff are called Pradhan Mantri Arogya Mitras (PMAMs) and their role
is to facilitate treatment of beneficiaries at the hospitals.
• Every empanelled hospital receives a unique ID also.
22. NATIONAL HEALTH CARE PROVIDERS
• There are eminent tertiary care hospitals and specialised care hospitals that
operate as autonomous institutes of excellence directly under the Ministry of
Health and Family Welfare (MoHFW) or some other department.
• Most popular examples of such hospitals are AIIMS, Safdarjang Hospital, JIPMER,
PGI Chandigarh, etc.
23. NATIONAL HEALTH CARE PROVIDERS
• To ensure that the hospitals do not overcharge and rates do not vary across
hospitals, empanelled health care providers (EHCP) are paid based on specified
package rates.
• A package consists of all the costs associated with the treatment, including pre
and post hospitalisation expenses.
• The specified surgical packages are paid as bundled care (explained below)
where a single all-inclusive payment is payable to the EHCP by insurer/SHA.
• The medical packages, however, are payable to the EHCP on a per day rate
depending upon the admission unit (general ward, HDU, ICU) with certain pre-
decided add-ons payable separately.
24. SUPPORT SYSTEMS
• Capacity building: Setting up sustainable institutional structures, Building and strengthening
the human resource and institutional capacity, and Sustaining knowledge and skill through
knowledge management and use of appropriate tools.
• Monitoring and evaluation: Beneficiary management, Transaction management, Provider
management and Support function management
• Grievance Redressal: to address grievances of all PM-JAY stakeholders based on the principles
of natural justice while ensuring cashless access to timely and quality care remains
uncompromised. A three-tier Grievance Redressal Committee structure has been set up at
National, State and district levels for this purpose.
• Call Center: National Helpline – 14555 was set up by then National Health Agency on August
24, 2018.
32. AROGYA
MITRA
• He/She is the primary contact for the
beneficiaries at every empanelled hospital
care provider.
• The AM shall be extensively responsible for
operating the Beneficiary Identification
System to identify and verify the beneficiaries
entitled under Ayushman Bharat – Pradhan
Mantri Jan Arogya Yojna (AB-PMJAY);
undertaking Transaction Management such
as submitting requests for Pre-Authorization
and Claims and guiding the Beneficiary
about the overall benefits under AB-PMJAY
and providing information related to prompt
treatment at empaneled health care provider.
33. AROGYA
MITRA
• The role holder needs to work in collaboration with
healthcare providers and interact with patients and
their families in a hospital setting.
• She/he should exhibit good coordination skills, self-
discipline, dedication, persistence, ethical behavior
and deal empathetically with patients.
• Minimum qualification- 12th passed
• Should have Basic computer knowledge and skills
• Should complete Arogya Mitra training course
• Possess fluent communication skills in
English/Hindi/Local language.
• Qualified female candidates and ASHA’s to be
given preferences.
34. AROGYA
MITRA
• Job responsibilities:
• Prepare for help desk preparation
• Provide relevant AB-PMJAY information to
others.
• Check eligibility and verify patients beneficiaries
for AB-PMJAY
• Submit registration, pre-authorization and claim
request and facilitate services.
• Use computers, electronics and related
equipment for carrying out various works
activities.
• Maintain IPR with patients, colleagues and
others.
• Maintain professional personal standards of
grooming and conduct.
• Apply work and safety practices at the
