Ayushman bharath is a government healthcare initiative in INDIA

1. AYUSHMAN
BHARATH
Presented by
Dr. Gagana sindhu HB

2. CONTENT
 Introduction
 Aim and Objective
 Components of Ayushman Bharath
 Ayushman Bharath Digital Mission
 AB-Ark and SAST
 Benefits Under the program
 Financing model
 Utilization rate
 Exclusion under the scheme
 Claim per authorization and settlement process
 Conclusion

3. INTRODUCTION
Presentation title 3
 A flagship scheme of government of India.
 Launched as recommended by National Health Policy 2017.
 Launched on 23 Sep 2018.
 To achieve the vision of Universal Health Coverage ( UHC ).
 This initiative has been designed to make sustainable development
goals(SDG’s).
 Its underlining commitment ‘ LEAVE NO ONE BEHIND’ .

4. AIMS AND
OBJECTIVES
AIM – Ayushman Bharath aims to undertake
path breaking interventions to holistically
address health ( Covering, Preventing,
Promotion and Ambulatory care) at primary,
secondary and tertiary.
OBJECTIVES – Provide Universal Health
Coverage to the poor and vulnerable sections
of society by ensuring access to quality
healthcare services ,agnostic of economic

5. COMPONENTS OF AYUSHMAN
BHARATH
1. Pradhan Mantri Jan Arogya Yojana (PM-JAY) – This provides health
insurance coverage to economically vulnerable families. Covering medical
expenses up to a certain limit . Beneficiaries can avail cashless treatment at
empaneled hospitals for a wide range of medical conditions.
2. Health And Wellness centres (HWC’s) – These aim to provide primary
health care services, including preventive and promotive healthcare at the
grassroot level. HWC’s focus on improving overall community health.

6. AYUSHMAN BHARATH DIGITAL
MISSION
 The Ayushman Bharath Digital Mission (ABDM) was launched on
27th Sep 2021
AIM – ABDM aims to develop the backbone necessary to support the integrated
digital health infrastructure of the country. It will bridge the existing gap amongst
different stakeholders of healthcare ecosystem through digital highways.

7. ABDM Components –
1. ABHA Number – Ayushman Bharath Health Account is a hassle free method of
accessing and sharing health records digitally . It enables your interaction with
participating health care providers, and allows you to receive digital lab reports,
prescriptions and diagnosis seamlessly from verified healthcare professionals
and health service providers.
2. Health Facility Registry – Is a comprehensive repository of all the health
facilities of the country across different systems of medicine. It includes both
public and private health facilities including hospitals, clinics, diagnostic
laboratories and imaging centers, pharmacies, etc.
3. ABHA App – A personal health record is an electronic application through
patients can maintain and manage their health information(and that of others for
whom they are authorized) in a private, secure and confidential environment.

8. AB-ARK AND SAST
Ayushman Bharath – Arogya Karnataka scheme was introduced by Gov of Karnataka
on 2nd march 2018 with a goal of providing universal health coverage to all state
residents
The Gov of India later introduced ABY scheme since both the same goals, scope and
similar modalities both schemes were integrated under a scheme were integrated
under a co-branded name Ayushman Bharath – Arogya Karnataka and is being
implemented in an assurance mode from oct 30 2018.
Eligibility –
• Basic sum assured is Rs 5 lakh per family per annum for ‘Eligible household
(BPL)’ and RSBY enrolled beneficiaries.
• For those who that do not come under ‘Eligible household (BPL)’ as defined under
NFSA 2013 or not enrolled RSBY beneficiaries, the sum assured is 30% of the

9. Benefits packages – The integrated scheme covers simple secondary, complex
secondary, tertiary and emergency procedures. Primary treatments and simple
secondary procedures will be limited to PHIs only. Complex secondary procedures,
Tertiary procedures and emergency procedures will be performed in PHIs and
empaneled private hospitals. Complex secondary procedures and tertiary procedures
require referral from PHIs.
AB-Ark Card – Under the Ayushman Bharath Ark scheme the enrolled card AB-Ark is
provided to the patient at the PHIs on payment of a fee Rs 10

10. SUVARNA AROGYA SURAKSHA
TRUST
 Separate unit of health and family welfare department under the Indian Trust Act
1882.
 For speedy and effective implementation of any new scheme/initiative of the
government.
 Operating the scheme through an independent, autonomous body will be efficacious
as well as economical.
 In charge of overseeing the developments and establishment of the online
enrollment portal.
 Managing the portal and monitoring its operation.
 Create a user ID and password on the enrollment portal for the head of hospital for
each PHI and private empaneled hospital.

11. BENEFITS UNDER THE PROGRAM
1. Health coverage - PM-JAY provides health insurances coverage up to Rs.5
lakh per family per year for secondary and tertiary hospitalization expenses.
2. Financial Protection – The program aims to provide financial protection to
vulnerable families by covering medical expenses for serious illnesses and
surgeries
3. Cashless Treatment – Beneficiaries can avail cashless treatment at
empaneled hospitals reducing the financial burden at the time of treatment.
4. Wide Network of Hospitals – PM-JAY has a vast network of public and
private hospitals across India, ensuring access to healthcare services
5. Paperless and Cashless – PM-JAY promotes paper and cashless
transactions, reducing the hassles associated with medical hassles
associated with medical reimbursements.
6. Maternal and Child Health – PM-JAY priorities maternal and child health by
covering expenses related to childbirth, including both normal and caesarean
deliveries. It also addresses neonatal and pediatric care.

12. BENEFITS OF ABHA
Presentation title 12
Provides health
insurance
coverage to
economically
weaker
sections
Offers access
to quality
healthcare
services at
affordable
prices
Helps in
improving the
overall health
and well being
of society
Provides
cashless
treatment for
beneficiaries
Reduces finical
burden on
beneficiaries

13. PACKAGE BENEFITS
• Medical examination , treatment and consultation
• Pre hospitalization
• Medicine and medical consumables
• Non intensive and intensive care services
• Diagnostic and laboratory investigations
• Medical implantation services
• Accommodation benefits
• Food services
• Complications arising during treatment
• Post hospitalization follow up care upto 15 days

14. WHAT IS NOT
COVERED UNDER
THE SCHEME
 Out patient department
expenses
 Drug rehabilitation
 Cosmetic surgeries
 Fertility treatments
 Individual diagnostics
 Organ transplant

15. BENEFICIARIES
1. Socio-Economic status – Families listed in the socio economic and caste
census database, which categorizes households based on their economic and
social status, are eligible for the scheme. Typically, this includes individuals and
families below poverty line(BPL) and those identified as economically vulnerable.
2. Urban and Rural Areas – Eligibility applied to both urban and rural populations.
3. Identification – Beneficiaries were identified and provided with a golden card or
unique identifier to avail of healthcare services under AB-PMJAY.

16. FINANCING MODEL
1. Central and State government contribution - PM-JAY is completely funded by
the government and costs are shared between central and state government. The
actual premium decided by Gov of India for implementation of PM-JAY which ever
is less, would be shared between central government and states/UT’s with
legislature in the ratio as per the extant directives issued by Ministry of finance.
Ratio of 60:40, for the states( other than North-Eastern states and three
Himalayan states) and UT.
 For North Eastern states and 3 Himalayan states (JnK, HP, UK) ratio is 90:10
 UT without legislature Central Gov may provide up to 100%

17. 2.Public-Private Partnership (PPP) – In some cases, the program may also engage
with private healthcare providers through PPP models. Private hospitals that meet
certain criteria are empaneled, and they are reimbursed for the treatment provided to
eligible beneficiaries. This creates a network of hospitals and clinics where
beneficiaries can receive treatment
3.Insurance companies – Implemented through a network of insurance agencies or
third party administrators (TPAs) rather than insurance companies. These agencies
are responsible for various administrative tasks related to the scheme, such as
enrollments of beneficiaries, processing claims, and managing the day by day
operations.
Some of the prominent TPAs involved in Ayushman Bharat PM-JAY included:
 Medi Assist India TPA Private Limited
 Vidal Health TPA Private Limited
 MD India Healthcare Services (TPA) Private Limited
 Paramount Health Services and Insurance TPA Private Limited

18. CLAIM PER AUTHORIZATION AND
SETTLEMENT PROCESS OF ABY
1. Hospitalization – When a beneficiary requires hospitalization for a covered
medical condition, they should seek treatment at an empaneled hospital under a
AB-PMJAY scheme .
2. Verification of eligibility – The hospital will verify the beneficiaries eligibility for
the scheme using the scheme using the beneficiaries Aadhar card or any other
approved ID. The hospital will also check if the medical condition is covered
under the scheme.
3. Pre – authorization - In many cases the hospital needs to see pre authorization
from the insurance agencies to confirm coverage for the specific medical
procedure . The hospital provides details of the patients condition and treatment
plan to the insurance agencies for approval

19. 4. Treatment and Hospitalization – Once pre authorization is granted the hospital
proceeds with the necessary medical treatment and hospitalization.
5. Bill submission – After the treatment the hospital submits the bill and relevant
document to the insurance agency for reimbursement.
6. Claims processing – The insurance agency reviews the submitted bills and
documents to ensure they align with the approved treatment plan and coverage.
This may involve verifying the authenticity of the treatment and cost.
7. Settlement – Once the claims are verified the insurance agency settles the claim
amount with the hospital. The payment is made directly to the hospital, and the
beneficiary is not required to pay for the covered treatment.

20. UTILIZATION RATE 20

21. UTILIZATION RATE 21

22. CONCLUSION
Presentation title 22
It is a major step by government of India to fulfil
the goal of universal health coverage hence if
implemented properly it could be beneficiary for
economically unstable people .

23. THANK YOU