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Pradhan Mantri Jan-Arogya Yojana (Ayushman Bharat)

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The presentation aim to explain Pradhan Mantri Jan-Arogya Yojana (Ayushman Bharat) to everyone. In terms of how what where, so that public can get benefit of it.

The presentation aim to explain Pradhan Mantri Jan-Arogya Yojana (Ayushman Bharat) to everyone. In terms of how what where, so that public can get benefit of it.


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Pradhan Mantri Jan-Arogya Yojana (Ayushman Bharat)

  1. 1. “PRADHAN MANTRI-JAN AROGYA YOJANA” (PM-JAY) By Dr Sanket V. Nandekar JR-1, Dept. of Community Medicine IMS-BHU, VARANASI
  2. 2. Outlines of the topic:- Background Introduction Timelines Beneficiary Identification Process Implementation Process Current scenario INDIA, VARANASI, SSH-BHU. Conclusion
  3. 3.  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).  This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to "leave no one behind." Ayushman Bharat:
  4. 4. Background of the scheme: Ayushman Bharat 1. Health and Wellness Centers (HWCs) For Comprehensive Primary Health Care 2. Pradhan Mantri Jan Arogya Yojana (PM-JAY) For Comprehensive Secondary & Tertiary Health care
  5. 5.  In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres.  These centres are to deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people.  They cover both, maternal and child health services and non- communicable diseases, including free essential drugs and diagnostic services. 1. Health and Wellness Centers (HWCs)
  6. 6. 2. Pradhan Mantri Jan Arogya Yojana(PM-JAY):  The second component under Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojna or PM-JAY as it is popularly known.  Ayushman Bharat PM-JAY is the largest health assurance scheme in the world which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries) that form the bottom 40% of the Indian population.
  7. 7. Pradhan Mantri Jan Arogya Yojana Highlights:  Name of the Scheme: Pradhan Mantri Jan Arogya Yojana  Launched By: Shri. Narendra Modi, PM of INDIA  Date of Announcement: 1/02/2018 In Union Budget  Officially Launch Date: 15/08/2018  Officially Implementation Date: 23/09/2018  Target Beneficiaries: Poor People of the Nation  Supervised By: Ministry of Health & Family Welfare  Toll-Free No. : 14555  Launched Place: Ranchi, Jharkhand
  8. 8. Key Features and Benefits of PM-JAY: PM-JAY is the world’s largest health assurance scheme fully financed by the government. It provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empanelled hospitals in India. Over 10.74 crore poor and vulnerable entitled families (approximately 50 crore beneficiaries) are eligible for these benefits.
  9. 9. Key Features and Benefits of PM-JAY: PM-JAY provides cashless access to health care services for the beneficiary at the point of service. PM-JAY envisions to help reduce destructive expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year. It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.
  10. 10. Key Features and Benefits of PM-JAY: All pre–existing conditions are covered from day one. Services include approximately 1,393 procedures covering all the costs related to treatment. There is no restriction on the family size, age or gender. Benefits of the scheme are portable across the country.
  11. 11. PMJAY Milestones:
  12. 12. Beneficiary Inclusion criteria:  The inclusion of households is based on the deprivation and occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas, respectively.  This number also includes families that were covered in the RSBY but were not present in the SECC 2011 database.  The SECC involves ranking of the households based on their socio-economic status.
  13. 13. Rural beneficiary inclusion criteria: I. PM-JAY covered all such families who fall into at least one of the following six deprivation criteria (D1 to D5 and D7). II. Automatic inclusion (Destitute/ living on alms, manual scavenger households, primitive tribal group, legally released bonded labour) criteria:
  14. 14. Rural Beneficiary inclusion 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
  15. 15. Urban Beneficiary inclusion criteria: • Ragpicker • Beggar • Domestic worker • Street vendor/ other service provider working on streets • Construction worker/ Plumber/ Painter/ Welder/ Security guard • Sweeper/ Sanitation worker/ Mali • Handicrafts worker/ Tailor/Transport worker/ Cart puller/ Rickshaw puller • Shop worker/ Peon in small establishment / Delivery assistant / Waiter • Electrician/ Mechanic/ Assembler/ Repair worker • Washer-man/ Chowkidar
  16. 16. Overview of beneficiaries under PMJAY:
  17. 17. Benefit Cover Under PM-JAY: • Medical examination, treatment and consultation • Pre-hospitalization • Medicine and medical consumables • Non-intensive and intensive care services • Diagnostic and laboratory investigations • Medical implantation services (where necessary) • Accommodation benefits • Food services to patient • Complications arising during treatment • Post-hospitalization follow-up care up to 15 days
  18. 18. Modes of Implementation: Assurance/ Trust modes • 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. (ISA- Implementation support agency) Insurance Modes • Insurance company selected through a tendering process by SHA. • SHA pays premium to the insurance company for family. • Insurance company, in turn, does the claims settlement and payments to the service provider. Mix modes • 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. 19. How to get treatment under PM-JAY? Check whether you are listed beneficiary or not? If Yes, Register yourself for Ayushman/Golden/E Card. Card Holders can get free treatment under PMJAY. Ayushman Mitra are suppose to guide Beneficiaries at Hospitals. Claim submission, Claim approval, Transaction management done by Hospitals.
  20. 20. Where to check whether you are listed beneficiary or not?  Toll free number: 14555  PM-JAY android app   At selected Jan-seva-Kendra (CSC- Common cervice centres)  Visit nearest PHC, CHC, District Hospital, CMO office Or any empaneled private Hospital.
  21. 21. How to get a Golden Card? All registered beneficiaries can apply for a Golden card at any of the following:  At selected Jan-seva-Kendra (CSC- Common service centers)  At nearest PHC, CHC, District Hospital, CMO office etc.  At any empaneled private Hospital.  Golden Card approval is by BIS portal (Beneficiary Identification System).
  22. 22. (Any of the following)  Adhar card  Ration card  PM Letter / CM letter (with 24 digit Household ID no. as per SECC 2011). Documents required to register for Golden card:
  23. 23. PM/CM Letter:  PM/CM letter is a part of awareness campaign conducted NHA & SHA collectively.  Purpose is to make all the beneficiaries(as per SECC 2011) of the scheme aware about PMJAY.  Letter has unique HH-id number (Household identification number) as per SECC 2011.
  24. 24. Process of Beneficiary Identification:
  25. 25. Steps to be followed by Empaneled Hospitals: • Hospitalization of the patient. • Beneficiary identification through BIS Portal • Preauthorization request & approval. • Package selection by the Doctor & Documentation. • Treatment & Discharge of Patient. • Claim submission & Approval by TMS portal
  26. 26. Process At Glance :
  27. 27. Stakeholders in PM-JAY:
  28. 28.  The National Health Authority is responsible for ensuring implementation and providing oversight (guidelines) for PM-JAY.  The State Health Agency/State Nodal Agency is the program implementing agency at the state level, ensuring that policies and guidelines set by NHA are carried out in letter and spirit. Responsibilities under PM-JAY:
  29. 29. NHA SHA District Magistrate Chief Medical Officer Nodal officer (Additional CMO) District Program coordinator District Grievance Manager District Information System Manager Ayushman Mitra- at Hospitals Hierarchy of PMJAY:
  30. 30. Vision of PM-JAY: The Vision of PM-JAY for the next five years is:“Achieving SDG 3.8: Ensuring financial protection against catastrophic health expenditure and access to affordable and quality healthcare for all”
  31. 31. Mission of PM-JAY: The Mission of PM-JAY for the next five years is: “Creating the world’s best health assurance programme on an efficient and technologically robust ecosystem”
  32. 32. National data of PM-JAY: 0 1000000 2000000 3000000 4000000 5000000 6000000 5251348 2001081 1427690 1121958 1099765 865054 715518 684369 NO OF PROCEDURES SPECIALITIES No of PROCEDURES DONE IN DIFFERENT SPECIALITIES Medical 49% Surgical 41% Other 10%
  33. 33. 3290155 2534684 1581202 1562153 1245959 877433 876335 782942 0 500000 1000000 1500000 2000000 2500000 3000000 3500000 1 NO OF PROCEDURES STATES Tamil Nadu Kerala Chhatisgarh Karnataka Andhra Pradesh Madhya Pradesh Jharkhand Uttar Pradesh STATE WISE NO OF PROCEDURES DONE Private 54% Public 44% Other 2% SECTOR WISE PATIENT COVERAGE
  34. 34. 2 1.7 1.5 REQUESTED PROCESSED CLAIMED 0 0.5 1 1.5 2 2.5 CASE SETTELEMENT( IN CRORES) 53% 47% GENDER MALE FEMA National data of PM-JAY:
  35. 35. 15.1 7.9 6.4 6.1 5.8 0 2 4 6 8 10 12 14 16 ORTHO NEONATAL UROLOGY MED ONCO RADIATION ONCO Top Tertiary Specialties paid in Millions Ortho Neonatal Urology Med Onco Radiation Onco 23, 13% 150, 87% Hospital Empanelled Public Private VARANASI DISTRICT
  36. 36. Varanasi District PMJAY Stats: 2.8L Ayushman Card Issued. 56308 No of Claim Submitted. 54055 No of Claims accepted. 572095 No of eligible beneficiaries. 114419 No of eligible Families. 49% Beneficiaries having ayushman cards. June 2021 monthly report PMJAY Varanasi
  37. 37. AADHAR 90% non AADHAR 10% BENEFICIARY VERIFICATION AADHAR non AADHAR Paid 92% Rejected 4% Due 4% CLAIM SCENARIO Paid Rejected Due 44091, 75% 14488, 25% Service Utilization Private Hosp. Gov. Hospi. PM-JAY Varanasi District:-
  38. 38. SSH 2020 PMJAY: 4 2 32 127 47 58 2 13 5 4 1 7 9 9 2 41 25 12 0 20 40 60 80 100 120 140 No of Procedures done in Various Specialties
  39. 39. 2% 79% 19% CLAIM SETTLEMENT Data Not available Paid Pending SSH 2020 PMJAY: 73, 18% 303, 76% 24, 6% TYPE OF PROCEDURE Medical Data not available Surgical
  40. 40. 1. Due to delayed submission of case. 2. Due to delay update, the case is not processed, and discharge summary late updated by medico. 3. No proper Document Provision by Hospital side. Top 3 Reasons for Rejection of Claims done by SSH in 2020:
  41. 41. Conclusion of the Presentation: Pros of PMJAY: • Being a largest free health assurance scheme, PMJAY is a commendable initiative by GOVERNMENT OF INDIA. • The scheme provide services in both government & private hospitals under single umbrella. • A step towards DIGITAL-BHARAT by providing cashless & paperless hospitalization services at a point of contact. • Claim settlement ratio is more than 90% till now.
  42. 42. Cons of PMJAY: • No provision for any financial support to hospitals before claim settlement, till then hospitals have to invest their resources. • Lack of awareness among the public about the scheme & its benefits. • Inadequate No of Ayushman Mitras to handle heavy documentation process by the side of hospitals, that too are underpaid. • Grievance Management System for Migrants or out of state beneficiaries is not adequate as like SACHIs(State agency for comprehensive health insurance & integrated services). • No provision for inclusion of transgender’s. • Inefficient implementation of scheme by the side of Hospitals.
  43. 43. Suggestions: There is need to raise awareness amongst the public regarding benefits of the scheme. Appointment of Ayushman Mitras at private hospitals should be done by government side. Ayushman Mitras should be paid according to a centralized criteria that should not be less than the minimum wages so as to keep them Motivated. There should be a “annual reward system” for Government as well as private hospitals to keep them motivated. There should be a provision for inclusion of Transgender’s in the beneficiary list of PMJAY