Ayushman Bharat: Pradhan Mantri Jan Arogya Yojana

About

India, which has emerged as one of the leading of the world's fastest growing major economies, can still not claim to be free of large socio-economic and health problems. Most of their population struggle to exist below the poverty level, while the disease burden comprises communicable diseases, non-communicable diseases (NCD), and injuries.

Added to this are issues arising from a poorly funded public health sector struggling to attend to the health needs of a burgeoning and increasing diverse population. In this context, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) or Modicare is one of India’s largest experiments in effort towards enhancing health care accessibility, decreasing the financial distress and attaining UHC for its population.

PM-JAY is another significant measure taken by the Government of India in September, 2018 to bring health protection to the economically vulnerable population in terms of incidence of catastrophic health expenditure. Goal of the programme is to enhance the effectiveness of health systems and thereby it supports the implementation of the National Health Policy 2017 and also bears a strong relationship with United Nations Sustainable Development Goals (SDGs) related to health(1^✔ ✔Trusted Source
About Pradhan Mantri Jan Arogya Yojana (PM-JAY)

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Ayushman Bharat: The Foundation of Universal Health Coverage

Ayushman Bharat is a comprehensive health program that comprises two primary components:

Health and Wellness Centres (HWCs): These centres are designed to respond to common health needs, with a major focus on the health promotion, prevention and early diagnosis components. They are set up in the rural areas to help fill the health care needs of rural populations, and for every citizen need equal access to some level of basic health care regardless of where they live in the country.

Pradhan Mantri Jan Arogya Yojana (PM-JAY): This is the second largest part of Ayushman Bharat and is a revolution in the healthcare system of the country. PM-JAY is a health insurance plan for the economically disadvantaged families to enable them to meet the cost of hospitalization for secondary and tertiary care. PM-JAY is expected to help the government to lessen the contribution of the households in bearing for health care costs and provide universal health coverage.

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Pradhan Mantri Jan Arogya Yojana (PM-JAY): World's Largest Health Assurance Scheme

A flagship program for Ayushman Bharat, PM-JAY was launched on 23rd September, 2018, and is currently considered the largest state-funded health insurance program across the world. The program delivers inpatient care of secondary and tertiary care for economically low-income families.

Key Features of PM-JAY:

Health Coverage: PM-JAY provides a financial resource for healthcare in the amount of INR 50000 per family per year where the empanelled categories of hospitalized expenses are included in public and also in private standards of the hospital in every part of India.

Beneficiary Coverage: About 12 crore families i.e., approximately 55 crore population are covered under this scheme. These target the poor directly and beneficiaries are selected according to the socio-economic norms of the SECC 2011.

Cashless Healthcare: PM-JAY has trimester composite covering private and public hospitals and other healthcare providers where care is-free-at the point of use. Hospital services are available free of charge which means that beneficiaries do not contribute to the costs in any way.

No Family Size or Age Limits: Uniquely unlike many other health insurance schemes, there are no restrictions as to the size or the age of the family for inclusion in PM-JAY.

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Pre-existing Conditions Covered: All the previous ailments are taken care of from the start, so healthy coverage for families is provided.

Portability: The advantages possessed by PM-JAY are all easily transferable enabling beneficiaries to avail cashless treatment in any empanelling hospital of their choice in the country.

Benefit Structure of PM-JAY

Comprehensive Financial Protection: Gives to INR 5 lakh per annum cashless for medical bills for treatment, such that eligible families can be financially less of a burden.

Access to a Wide Range of Treatments: Contains information on more than 1,932 medical treatments such as surgical operations, diagnostics, and critical care.

Pre-Hospitalization and Post-Hospitalization Coverage: Covers from the day before admission up to 15 days after discharge and relevant treatments and medications or follow-up appointments that are needed.

Surgical and Non-Surgical Coverage: They ensure that both operations and non-operations, as well as Intensive Care Services are covered in the scheme.

Diagnostic and Laboratory Services: Includes all the investigations mandatory for diagnosis and management of the case.

Accommodation and Food Services: It also concerns hospital accommodation and food during the treatment, which may also be helpful in cutting the costs for hospital stay.

Post-Hospitalization Follow-Up Care: Offers 15 days of follow up after being discharged from the hospital to avoid hospitalization again, and cater for the continued healing process.

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Family Floater Basis:

PM-JAY health coverage is in a family floater mode, that is, the total amount of allocated Rs. 5 lakh limit is for all the members of the family. Instead of a fixed number of family members, as in previous PM-Health Insurance schemes there is no upper ceiling on the number of persons in the family, which makes the coverage flexible to needs of different families.

PM-JAY Hospital Empanelment Criteria and Process

More so, the success of any PM-JAY is pegged on the hospital empanelled for the purpose to provide quality health care services that are accredited to the requirements of the programme. Hospitals are empanelled under PM-JAY based on a set of criteria, which are divided into two categories:

• General Criteria: General medical and surgical hospitals with or without Intensive Care Units and emergency services fall under the broad category.
• Special Criteria (for Clinical Specialties): Hospitals that perform outpatient services need to have other structures and human resource capacity standards to achieve. They are expected to offer all the specialties in the package to beneficiaries of the PM-JAY.

Empanelment Process

The process of empanelment in PM-JAY especially hospital empanelment is online, has clear specifications, free of cost and highly efficient. It follows a two-tier structure:

• State-Level Empanelment: The State Empanelment Committee (SEC) under the state health agency (SHA) has the authority to approve the list.
• District-Level Empanelment: A District Empanelment Committee (DEC) scrutinises the applications, undertake physical verification and forward the list to SEC for final approval.

Hospitals are required to submit applications online and the status of the applications can be seen through a web based system. Once approved, the DEC approves or rejects the hospital by advising the SEC who has the final say.

They also receive a unique ID and have to set up a separate help desk of Pradhan Mantri Arogya Mitras (PMAMs) for enrolment of each beneficiary respectively.

Incentives for Continuous Quality Improvement

PM-JAY incentivizes empanelled hospitals to maintain high standards of care through various rewards:

• Higher Package Rates: Facilities with basic NABH certification get 10% more for the package, while fully accredited NABH hospitals get 15% more for the package.
• Special Incentives for Underserved Areas: Districts having a higher level of vulnerability or being the ones preferred by the public are given a 10% bonus on the package rate to ensure all hospitals in the vulnerable districts offer health services at low rates.

Ayushman Mitras: Frontline Heroes of Ayushman Bharat PM-JAY

Pradhan Mantri Arogya Mitras (PMAMs) are called Ayushman Mitras, frontline workers employed under Ayushman Bharat PM-JAY. They help the beneficiary in availing healthcare service for treatment at empanelled hospital(2^✔ ✔Trusted Source
Be An Ayushman Mitra

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Ayushman Mitras help beneficiaries by:

• Verifying eligibility using the PM-JAY database.
• Assisting with documentation and admission processes.
• Guiding patients on available treatment packages.
• Ensuring cashless transactions and coordinating with hospital administration.
• Addressing beneficiary queries and grievances.

Individuals who wish to be recruited as an Ayushman Mitras can do so through their respective State Health Agency. Ayushman Mitras are reimbursed through stipends or incentives which depend on the state and hospital they work for. Successful candidates may also be offered extra bonuses that are based on performance of the candidate and the level of input s/he is willing to offer.

Ayushman Mitras work as intermediaries between the beneficiaries and the institutions of the health sector. In this regard, while ensuring that Prime Minister’s Jan Arogya Yojana (PM-JAY) successfully addresses cases of poor health and maximizes the availability of access to quality and affordable care, they so provide easy links to access to cashless treatment so that the spirit of the programme serves its right course.

PM-JAY is a worthy flagship programme for the government of India and a new paradigm of financial risk protection for millions of Indian families. It is one of the largest universal healthcare plans in the world because it includes nearly everyone, covers cashless treatment and targets several sensitive demographics.