AB-PM-JAN AAROGYA YOJNA

1. Pradhan Mantri Jan Arogya Yojana (PM-JAY)
Under
Ayushman Bharat Programme (Yojana)

2. 1.Introduction/About the programme:- 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)
Ayushman Bharat Yojana announced in February 2018 in the
Union budget of India. AB PM-JAY was launched on 23
September 2018 at Ranchi, Jharkhand by the Hon’ble Prime
Minister of India, Shri Narendra Modi.
Ayushman Bharat is an attempt to deliver a comprehensive
need-based health care service at the primary, secondary
and tertiary level. Ayushman Bharat adopts a continuum of
care approach, comprising of two inter-related components,
which are -
 Health and Wellness Centres (HWCs)
 Pradhan Mantri Jan Arogya Yojana (PM-JAY)
Health and Wellness Centers (HWCs)
 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 centers 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.

3. 2. Public Health Importance: - Health is wealth. Healthy
population can lead a socially and economically productive life
thus increasing their income as well as national income. Govt must
provide a safety net for those on the brink, needy, poor who can’t afford
the cost of modern healthcare. 71st
round of national sample survey
organization (NSSO) has found 85.9% of rural households and
82% of urban households have no access to healthcare
insurance/assurance. *More than 17% of Indian population
spends at least 10% of household budget for health services &
even the expenses put families in debt.
India is still classified as a Lower Middle-Income Country (LMIC)
according to World Bank classification of countries based on per
capita GDP, mostly due to its inconsistent socio-economic and
health indicators. Statistics show that more than 20 per cent of
India’s population still lives under $1.9 per day (2011 PPP).
According to a World Bank projection, by 2021 more than
34% of India’s population will be in the age group of 15-35
years. This rich demographic dividend enables India to be highly
optimistic about a sustained economic growth for few more
decades before a higher dependency ratio sets in. However, the
perceived benefits of the higher demographic dividend are
threatened by the epidemiological transition in India which is
currently facing the unique situation of a “triple burden of
disease.” As the mission of eradication of major communicable
diseases remains unfinished, the population is also bearing the
high burden of non-communicable diseases (NCDs) and injuries.
The second component under Ayushman Bharat is the Pradhan
Mantri Jan Arogya Yojna or PM-JAY as it is popularly known. PM-
JAY was earlier known as the National Health Protection Scheme

4. (NHPS) before being rechristened. It subsumed the then existing
Rashtriya Swasthya Bima Yojana (RSBY) which had been
launched in 2008. The coverage mentioned under PM-JAY,
therefore, also includes families that were covered in RSBY but
are not present in the SECC 2011 database. PM-JAY is fully
funded by the Government and cost of implementation is shared
between the Central and State Governments. PM-JAY has been
rolled out for the bottom 40 per cent of poor and vulnerable
population. In absolute numbers, this is close to 10.74 crore
(100.74 million) households. 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.
3. Evolution of the programme over the years

5. . 4. Programme objectives and Strategies of Pradhan
Mantri Jan Arogya Yojana (PM-JAY):-
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.
 PM-JAY provides cashless access to health care services for
the beneficiary at the point of service, that is, the hospital.
 PM-JAY envisions to help mitigate catastrophic 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.
 There is no restriction on the family size, age or gender.
 All pre–existing conditions are covered from day one.
 Benefits of the scheme are portable across the country i.e. a
beneficiary can visit any empanelled public or private
hospital in India to avail 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.

6.  Public hospitals are reimbursed for the healthcare services
at par with the private hospitals.
Benefit Cover under PM-JAY
. The cover under the scheme includes all expenses incurred on
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 implantation services (where necessary)
 Accommodation benefits
 Food services
 Complications arising during treatment
 Post-hospitalization follow-up care up to 15 days
5. Implementation mechanism and current status of implementation
PM-JAY provides the States with the flexibility to choose their
implementation model.
Assurance Model/Trust Model
Insurance Model
Mixed Model

7. Financing of the Scheme
PM-JAY is completely funded by the Government and costs
are shared between Central and State Governments. The
existing sharing pattern is in the ratio of 60:40, for States
(other than North-Eastern States & three Himalayan States)
and Union Territories with legislature. For North-Eastern
States and three Himalayan States (viz. Jammu and
Kashmir, Himachal Pradesh and Uttarakhand), the ratio is
90:10. For Union Territories without legislatures, the Central
Government may provide up to 100% on a case-to-case
basis
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, and 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

8. 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
 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
*EXCLUSION CRITERIA AS PER SECC2011
Households having motorized two, three or four wheeler, fishing
boat, mechanized three or four wheeler agricultural equipment,
Kisan Credit Card with a credit limit of above Rs 50,000 and in
which a member is a government employee and households with
non-agricultural enterprises registered with the government are
automatically excluded

9. Those having a member earning more than Rs 10,000 per month,
paying income tax, professional tax, three or more rooms with
pucca walls and roof, a refrigerator, and a landline phone are also
excluded.
Households owning more than 2.5 acres of irrigated land with one
irrigation equipment, owning five acres or more of irrigated land
for two or more crop season, owning at least 7.5 acres of land or
more with at least one irrigation equipment are also excluded
Exclusion Policy-Ayushman Bharat PM-JAY-April
2020
Ayushman Bharat PM-JAY shall not be liable to make any payment under this policy in respect
of any expenses whatsoever incurred by any Insured Person in connection with or in respect of: •
Condition that does not require hospitalization and can be treated under Out Patient Care •
Except those expenses covered under pre and post hospitalization expenses, further expenses
incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes only during
the hospitalized period and expenses on vitamins and tonics etc unless forming part of treatment
for injury or disease as certified by the attending physician. • Any dental treatment or surgery
which is corrective, prosthetic, cosmetic procedure, filling of tooth cavity, root canal including
wear and tear of teeth, periodontal diseases, dental implants etc. are excluded. Exception to the
above would be treatment needs arising from trauma / injury, neoplasia / tumour / cyst requiring
hospitalization for bone treatment. • Any assisted reproductive techniques, or infertility related
procedures, unless featuring in the National Health Benefit Package list. • Vaccination and
immunization • Surgeries related to ageing face & body, laser procedures for tattoo removals,
augmentation surgeries and other purely cosmetic procedures such as fat grafting, neck lift,
aesthetic rhinoplasty etc. • Circumcision for children less than 2 years of age shall be excluded
(unless necessary for treatment of a disease not excluded hereunder or as may be necessitated
due to any accident) • Persistent Vegetative State: a condition in which a medical patient is
completely unresponsive to psychological and physical stimuli and displays no sign of higher
brain function, being kept alive only by medical intervention.
Capacity Development
Capacity building activities under PM-JAY attempt to address
more than just training and cover all aspects of building and

10. developing sustainable and robust institutions and human
resource. Capacity building in PM-JAY has three components:
 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
The NHA at the Central level is continuously keeping track on
periodic basis on these UHC dimensions (coverage, benefits and
financial protection) through the following functional domains:
 Beneficiary management
 Transaction management
 Provider management
 Support function management
Fraud Prevention, Detection and Control
 National Anti Fraud Unit
 NAFU works closely with State Ant Fraud Units (SAFU) in
order to ensure the effective implementation of the Scheme,
free from any fraudulent/ abusive activity from any entity
involved in PM-JAY implementation such as providers,
beneficiaries, ISAs or payers.

11. Grievance Redressal
A three-tier Grievance Redressal Committee structure has been
set up at National, State and district levels for this purpose. The
CEO of NHA will be the Chairperson at the National level while
the CEO of SHA will chair the State Grievance Redressal
Committee. The District Magistrate or an officer of the rank of
Additional District Magistrate shall be the Chairperson of the
District Grievance Redressal Committee. The aggrieved parties
can submit grievances through offline (letter) or through an online
portal (https://cgrms.pmjay.gov.in) developed by NHA.. The
National Call Centre (14555 / 1800 111 565) is also integrated to
the Grievance Portal for addressing grievances received through
the call-centre.
Awareness and Communication
A letter from Hon’ble Prime Minister was sent to all
beneficiary families to make them aware about their
entitlements under the scheme and also provide them a
family card with unique family ID Standardized design
materials have been prepared by NHA that are being used
by States for making beneficiaries aware about the scheme.

12. IT System under PM-JAY-pictorial representation
Packages and Rates
The package rate includes:
 Registration charges
 Bed charges (General Ward)
 Nursing and Boarding charges
 Surgeons, Anesthetists’, 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)

13.  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
Process of hospital empanelment in PM-JAY-PICTORIAL
REPRESENTATION

14. 6. Discussion and learning from assignment
PROS
 Ayushman Bharat is providing capability to poor people to take treatment in private hospitals.
 It increases access to quality health care and medication.
 As this scheme is in tie up with insurance companies, number of people that comes under
health insurance will increase drastically. Now, with Ayushman Bharat Approx 40% of the
population will be covered under health insurance.
 Ayushman Bharat has a time-bound approval process which reduces delays in taking
treatments.
 Cashless payments in this scheme will erase the burden on poor people. Paying money first
and to reimburse later is not suitable option for poor and vulnerable people.
 Ayushman Bharat is a first step towards achieving affordable healthcare in India.
 This can solve the problem of fake bills.
 If government takes care of the medical expenses, it can help in poverty reduction.
CONS
 Government prices in Ayushman Bharat scheme and the prices of private hospitals
have a huge difference. What government is paying is a very less amount for the
corporate hospitals. If this situation continues, not many hospitals will sign up for this
scheme fearing losses.
 A fixed rate for all kinds of hospitals located in all areas is not a right approach, because
cost of land and human resources and other facilities changes depending on area and
the type of hospital.
 Numbers of hospitals that are signed up for this scheme are very less and not even half
of the expected number.
 Though the scheme is good, there are no proper hospitals in many areas.
 Rashtriya Swasthya Bima Yojana (RSBY) and Senior Citizen Health Insurance Scheme
(SCHIS) are subsumed under Ayushman Bharat. So it’s like new name for old
schemes with some changes. The two schemes are not successful and it may be
replicated in the case of Ayushman Bharat.
 Ayushman Bharat needs a huge budget and it may seem unrealistic and impossible.
 If another government is elected in the coming election, they will not be interested in
making it successful to avoid giving credit to those who started it.
 People may get low-quality treatment because government is paying less than what
hospitals earn in general
 May cause further discouragement in the improvement of government hospitals.
 Uneven Performance of different states. The gove rnme nt needs to ensure that
be ne fits of Ayushman Bharat are distributed equitably between we ll-off and poore r
states that may ne e d it the most.

15. Conclusion:-
Ayushman Bharat is a good step towards affordable healthcare in India. But
whether it will be successful or not depends on its implementation and the better deal
between hospitals and government of India, corruption and many more factors.
DR PIYUSH KUMAR
M.B.B.S., E.M.O.C., PGDPHM (STUDENT). .
BIHAR HEALTH SERVICES,
GOVERNMENT OF BIHAR
.MOBILE-+919955301119/+917677833752 EMAIL drpiyush003@gmail.com