1.
“PRADHAN MANTRI-JAN
AROGYA YOJANA” (PM-JAY)
By
Dr Sanket V. Nandekar
JR-1, Dept. of Community Medicine
IMS-BHU, VARANASI

2.
Outlines of the topic:-
Background
Introduction
Timelines
Beneficiary Identification Process
Implementation Process
Current scenario INDIA, VARANASI, SSH-BHU.
Conclusion

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.
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.
 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.
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.
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.
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.
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.
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.
PMJAY Milestones:

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.
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.
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.
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.
Overview of beneficiaries under PMJAY:

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.
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.
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.
Where to check whether you are listed
beneficiary or not?
 Toll free number: 14555
 PM-JAY android app
 www.mera.pmjay.gov.in
 At selected Jan-seva-Kendra (CSC- Common cervice
centres)
 Visit nearest PHC, CHC, District Hospital, CMO
office Or any empaneled private Hospital.

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.
(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.
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.
Process of Beneficiary Identification:

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.
Process At Glance :

27.
Stakeholders in PM-JAY:

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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