ayushmaan bharat is Govt. of India Scheme

1. AYUSHMAN BHARAT
DR. SAMTA SONI

2. INTRODUCTION
▪ Ayushman Bharat Or “Healthy India” Is A National Initiative
Launched By Prime Minister Narendra Modi As The Part Of National
Health Policy 2017, In Order 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”.
▪ Ayushman Bharat Yojana Is Set To Be The World’s Largest Sponsored
Insurance Scheme For Maximum’ Number Of Beneficiaries Ever. In
Its Present Form, AB-NHPM Will Subsume And Merge All On-going
Government Schemes Such As Rashtriya Swasthya Bima Yojana
(Rsby) And Senior Citizen Health Insurance Scheme (Schis)

3. AYUSHMAN BHARAT SCHEME
▪ Defined Cover of 5 lakh per family per year for
beneficiaries. The existing insurance plans sponsored by
governments focus on primary health concerns such as
maternity and immunization, while the Ayushman Bharat
Scheme aims to cover most of the secondary and tertiary
care procedures, including pre and post- hospitalization
expenses.

4. NEED OF AB PMJAY
▪ Existing schemes were unable to decrease out of pocket
expenditure.
▪ To address the catastrophic health problems.
▪ Insufficient coverage by the previous schemes.
▪ To achieve universal health coverage.

9. TYPE OF CLAIMS
▪ For extending real-time health insurance benefits to the needy, there
are no exclusions for pre-existing health conditions. One can avail
cashless benefits from empanelled hospitals. The cover would also
include the cost of food for hospital-stay, medicines, diagnosis, fees of
the medical professional and transport allowance for hospitalization.
Patient do not need to pay for any of the procedures from his pocket.

10. NO WAITING PERIOD
▪ There is no waiting period prior making the claims. From
the day one of the policy patient can claim the cover from
all government hospitals and empanelled hospitals.

11. . BENEFITS AVAILABLE PAN INDIA
▪ Once one is listed as a beneficiary for Ayushman Bharat Scheme , he
can seek the insurance benefits across the country from empanelled
hospitals. He can avail comprehensive coverage irrespective of the
nature of his job and place of living.

12. AADHAAR CARD IS NOT MANDATORY
▪ Having an Aadhaar Card is not an eligibility criterion to seek benefits
under Ayushman Bharat Scheme. However, people need to provide a
prescribed identity proof (ID) to avail of the treatment at the
empanelled hospital.

13. AYUSHMAN BHARAT SCHEME ELIGIBILITY
▪ AB-NHPM is an entitlement based scheme that will identify the beneficiaries by
deprivation criteria as listed in the SECC database 2011. The insurance beneficiaries
would be recognized as D1, D2, D3, D4, D5, and D7 for rural areas; while for urban
areas the beneficiary’s occupation will be determinable for entitlement. The 80 % of
beneficiaries are based in rural areas, while 20 % are from Urban regions.

14. DEFINED CATEGORIES FOR RURAL AREA
▪ 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

15. OCCUPATIONAL CATEGORIES WHICH IDENTIFIED FOR
AYUSHMAN BHARAT ENTITLEMENT
▪ Beggars
▪ Rag-pickers
▪ Domestic workers
▪ Street vendors like cobblers, hawkers, etc
▪ Construction workers and other head-load workers such as plumbers, masons, daily wage
labourers, painters, welders, security guards, coolies, sweepers, sanitation workers and
gardeners (Malis).
▪ Home-based workers including artisans, handicrafts workers, and tailors
▪ Transport workers like drivers, helpers, and conductors; cart pullers; rickshaw pullers
▪ Shop workers, assistants, peons in small businesses, helpers, delivery assistants,
attendants, waiters
▪ Electricians, mechanics, assemblers, repair workers
▪ Washer-men, chowkidars

16. IMPLEMENTATION MODELS
1.ASSURANCE MODEL/TRUST MODEL
▪ the scheme is directly implemented by the SHA 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
2.Insurance Model
▪ In the insurance model, the 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..

17. 3.MIXED MODEL
▪ 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. This model is usually
employed by brownfield States which had existing schemes covering a larger group
of beneficiaries.

19. AYUSHMANBHARAT
▪ Ayushman Bharat is an attempt to move from sectoral and segmented approach of
health service delivery to a comprehensive need-based health care service.
Ayushman Bharat aims to undertake path breaking interventions to holistically
address health (covering prevention, promotion and ambulatory care), at primary,
secondary and tertiary level.
▪ Ayushman Bharat adopts a continuum of care approach, comprising of two inter-
related components, which are -
▪ Establishment of Health and Wellness Centres
▪ Pradhan Mantri Jan Arogya Yojana (PM-JAY)

20. The Government Announced Two Major Initiatives In Health Sector , As
Part Of Ayushman Bharat Programme On 1st February 2018 To Build A
New India 2022
• Number of centres 1.5 lakhs
• Benefit:Comprehensive primary health care (CPHC),
including NCDs and MCH services and free essential drugs
and diagnostic services
• Budget allocated Rs 1200 crore
▪(i) Health and Wellness
Centre:
• launched on 23rd September 2018.
• Beneficiaries :10 crore poor and vulnerable families listed
in SECC database (approximately 50 crore beneficiaries)
• Benefit:Coverage upto 5 lakh rupees per family per year
for secondary and tertiary care hospitalization
(ii) National Health
Protection Scheme
(NHPS) / Pradhan
Mantri Jan
ArogyaYojana (PM-JAY):

23. HEALTH AND WELLNESS CENTRE
▪ In February 2018, the Government of India announced the creation of 1,50,000
Health and Wellness Centres (HWCs) by transforming existing Sub Centres and
Primary Health Centres. These centres would deliver Comprehensive Primary Health
Care (CPHC) bringing healthcare closer to the homes of people covering both
maternal and child health services and non-communicable diseases, including free
essential drugs and diagnostic services.
▪ Health and Wellness Centers, are envisaged to 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. The emphasis of
health promotion and prevention is designed to bring focus on keeping people
healthy by engaging and empowering individuals and communities to choose healthy
behaviours and make changes that reduce the risk of developing chronic diseases and
morbidities.

24. HEALTH AND WELLNESS CENTRE

26. OVERVIEW OF HEALTH AND WELLNESS CENTER
(HWC)
▪ The sub-centers (SC) are converted as
health and wellness center. 1st HWC-
Jangla, Bijapur, Chhattisgarh on 14th
April 2018.
▪ Proposed infrastructure
▪ • Branding/ color coding of all SCs will
be done and Citizen charter will be
displayed at each SC
▪ • Space for examination room with
adequate privacy
▪ • Diagnostics and medicine dispensing
room
▪ • Wellness room and waiting area
▪ • Labor room at delivery points
▪ Staff pattern
▪ • Mid-Level Health Provider(MLHP)
▪ • MPW female-
▪ 2 • MPW male- 1
▪ • 5 ASHAs as outreach team per HWCs.

27. PM-JAY
▪ The second component under Ayushman Bharat is PM-JAY, which aims at providing
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
(approximately 50 crore beneficiaries). There is no cap on the family size under the
scheme. 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.
▪ PM-JAY has been rolled out for the bottom 40% of poor and vulnerable population.
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 subsumed then existing Rashtriya Swasthya Bima Yojana
(RSBY), launched in 2008. Therefore, the coverage mentioned under PM-JAY also
includes families that were covered in RSBY but were not present in the SECC 2011
database. PM-JAY is completely funded by the Government, and cost of
implementation is shared between Central and State Governments

28. PRIMARY OBJECTIVES FOR LAUNCHING PM-JAY
▪ To ensure comprehensive coverage for catastrophic illnesses,
▪ To reduce catastrophic out-of-pocket expenditure,
▪ To improve access to hospitalisation care,
▪ To reduce unmet needs,
▪ and to converge various health insurance schemes across the States.
▪ PM-JAY will also establish national standards for a health assurance system and is
providing national portability of care.

29. KEY FEATURES PMJAY
▪ PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by
the government.
▪ PM-JAY 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 (approximately 50 crore
beneficiaries) are eligible for these benefits.
▪ PM-JAY provides cashless access to health care services for the beneficiary at the
point of service, that is, the hospital.
▪ PM-JAY will help reduce catastrophic expenditure for hospitalizations, which pushes
6 crore people into poverty each year, and will help mitigate the financial risk arising
out of catastrophic health episodes.
▪ No restrictions on family size, age or gender.

30. KEY FEATURES PMJAY
▪ 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. a beneficiary can visit
any 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.

31. BENEFITS 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 implant services (where necessary)
▪ Accommodation benefits
▪ Food services
▪ Complications arising during treatment
▪ Post-hospitalization follow-up care up to 15 days

32. PROCESS OF HOSPITAL EMPANELMENT IN PM-JAY

33. PMJAY EXCLUSIONS
▪ • Conditions that do not require hospitalization: Unless necessary for treatment of a
disease covered under Medical and Surgical procedures or treatments or day care
procedures
▪ • Dental: Treatment or surgery which is corrective, cosmetic or of aesthetic
procedure, filling of cavity, root canal etc
▪ • Congenital external diseases: Or defects or anomalies, Convalescence, general
debility, “run down” condition or rest cure.
▪ • Fertility related procedures: Hormone replacement therapy for Sex change or
treatment which results from or is in any way related to sex change.
▪ • Drugs and Alchohol Induced illness: Diseases, illness or injury due to or arising
from use, misuse or abuse of drugs or alcohol or use of intoxicating substances, or
such abuse or addiction

34. PMJAY EXCLUSIONS
▪ • Vaccination: Vaccination, inoculation or change of life or cosmetic or of aesthetic
treatment of any description, plastic surgery other than as may be necessitated due to
an accident or as a part of any illness. Circumcision (unless necessary for treatment
of a disease not excluded hereunder or as may be necessitated due to any accident)
▪ • Suicide: Intentional self-injury/suicide
▪ • Persistent Vegetative State

35. THE PACKAGE RATE (IN CASE OF SURGICAL OR DEFINED
DAY-CARE BENEFITS) INCLUDES:
√ Registration charges
▪ Bed charges (General Ward)
▪ Nursing and Boarding charges
▪ Surgeons, Anaesthetists, Medical
Practitioner, Consultants’ fees, etc.
▪ Anaesthesia, Blood Transfusion, Oxygen,
O.T. Charges, Cost of Surgical Appliances,
etc.
▪ Medicines and Drugs
▪ Cost of Prosthetic Devices, implants
(unless payable separately)
▪ Pathology and radiology tests: radiology
to include but not be limited to X-ray,
MRI, CT Scan, etc. (as applicable)
▪ Food to patient
▪ Pre and Post Hospitalisation expenses:
Expenses incurred for consultation,
diagnostic tests and medicines before
the admission of the patient in the same
hospital, and up to 15 days of the
discharge from the hospital for the same
ailment/ surgery
▪ Any other expenses related to the
treatment of the patient in the EHCP

36. TO ALL ACTIVE LISTENERS
THANKING YOU