PMJAY - About Ayushman Bharat Yojana, Benefits, Eligibility, Hospitalization, Claim Process

The onus of providing adequate welfare to the citizens of a nation rests on the shoulders of the Government. The basic needs of a citizen include having access to healthcare. The Government of India launches many schemes from time to time for the betterment of society, regardless of the economic standing of the citizens. The Ayushman Bharat Yojana is one such program launched by the Government to make healthcare accessible for the economically backward sections of the country.

Ayushman Bharat Yojana, also known as PMJAY (Pradhan Mantri Jan Arogya Yojana scheme), was launched in 2018. It is one of the biggest healthcare schemes in the world. Around 50 crore Indians are expected to benefit from the Ayushman Bharat Yojana scheme. The Government launched this scheme as quite a large section of its citizens are economically backward and cannot afford substantial medical expenses. Besides this majority of the citizens of India reside in small towns and villages, tier 2 and tier 3 cities. The rural population of our country can benefit immensely from this scheme. However, this scheme is more comprehensive and caters more to the rural population. It is also beneficial for needy and poor households in urban areas. Upon enrolling for health insurance , the maximum sum assured is Rs. 5 lakhs.The areas covered under the PMJAY scheme are medicines, medical treatment, pre-hospitalization expenses, and expenses incurred in diagnosis. The hospitalization expenses are covered under this scheme. After undergoing treatment, post-hospitalization expenses also need to be met. Under this Government health insurance scheme, an Ayushman Bharat Yojana e-card has been issued. With the help of this card, an individual can avail of cashless hospitalisation healthcare services. Such healthcare facilities can be availed only if the treatment is done in one of the hospitals that are listed under this scheme. The beneficiaries of the cardholder can also avail of any treatment related to health as specified by showing the Ayushman Bharat Yojana e-card.Also Read: How Will Ayushman Bharat Yojana Impact Health Insurance Sector In India

Some of the crucial features of PMJAY(Pradhan Mantri Jan Arogya Yojana scheme) are:1. It is a family floater scheme with the maximum sum assured of Rs. 5 lakh. This amount is for the entire family of those enrolled under the Ayushman Bharat Yojana scheme.2. The Ayushman Bharat Yojana e-card holder can avail of cashless treatment in any public hospital and some listed private hospitals.3. Pre-hospitalization expenses (up to 3 days) like diagnosis and medical bills are covered under this scheme.4. Post-hospitalization expenses (up to 15 days) like diagnosis and medical bills are covered under this scheme.5. The Ayushman Bharat Yojana scheme is designed in such a way that people who are below the poverty line can get proper healthcare facilities.6. Such individuals cannot buy health insurance schemes online as they do not have any access to the Internet.7. The transportation cost incurred during the pre and post-hospitalization period is also reimbursed under this scheme. This facility is extended to the Ayushman Bharat Yojana e-card holders and their family members.8. The Ayushman Bharat Yojana covers some of the pre-existing diseases from the very first day of its issue.9. This life-saving scheme package covers not only medical expenses but also expenses incurred during the daycare treatment.10. The Government of India has opened many health and wellness centres to make the Ayushman Bharat Yojana scheme available to its citizens.11. The packages of this health insurance scheme are pre-determined by the Government. The payment of the medical expenses depends upon the package taken by the individual.12. There is no discrimination based on gender, age or family size. The Ayushman Yojana cardholder can get treatment anywhere in India.13. One thousand three hundred ninety-three medical procedures are included in the Ayushman Bharat Yojana scheme.

PMJAY (Pradhan Mantri Jan Arogya Yojana scheme) has proved to be a lifesaver for many socio-economically backward people. Some salient features covered under this Government health insurance plan are:1. Eligibility: Ayushman Bharat Yojana is available only to lower-income groups. It cannot be availed by people not falling in this bracket.2. Premium: It depends upon the plan taken. It is usually Rs. One hundred per month, or it can also be paid entirely by the Government.3. Sum insured: The maximum sum under this scheme is up to Rs. 5 lakhs.4. Public hospital rooms - depending upon availability. However, most of the time, it is available.5. Private hospital rooms : Depends upon the availability of the room at that time. Only a few private hospitals are associated with this scheme.6. Ambulance charges: It is covered under a few plans taken by the insurance policyholder.7. Maternity benefits: It is available only for a single child (in some cases depending upon the plan chosen). This facility cannot be availed every time.8. Online renewal: Can or cannot be renewed online, but in most cases, internet accessibility is unavailable.9. Health check-up facility: Is not covered under this plan.

The Ayushman Bharat Yojana scheme caters to the underprivileged section of our society. Some of the benefits of this scheme that they can avail of are as follows:1. Treatment of the healthcare policyholder is extended to the beneficiary (policyholder) and their family members.2. Treatment is free of cost and can be availed anywhere in India.3. Pre-hospitalisation and post-hospitalisation expenses are covered under the Ayushman Bharat Yojana scheme.4. Around 25 specialties with one thousand three hundred ninety-three medical packages are included in the Ayushman Bharat Yojana scheme.5. The cost of multiple surgeries is covered if the health insurer buys the highest package available under this scheme. However, for the second surgery, 50% and 3rd surgery, 25 % is covered.6. This scheme covers all treatments requiring cardio surgery, neurosurgery, etc.7. The cost of the treatment of oncology, which requires chemotherapy for treating cancer patients, is also covered under this scheme. The only condition is that surgical and medical packages cannot be clubbed together.8. Any complications arising during surgery are also covered under the Ayushman Bharat Yojana scheme.

This is a list of treatments that are covered under the Ayushman Bharat Yojana scheme:1. It covers a medical examination of the patient, consultation fees of the doctor, and the cost of the treatment.2. Pre-hospital expenses of 3 days are covered.3. Post-hospitalization treatment for 15 days is covered.4. Accommodation in the hospital during treatment is covered under this scheme.5. Cashless treatment that covers all hospital expenses is extended to all the beneficiaries.6. Intensive care units and non-intensive services are included in this package.7. The cost of everything additional that is required during surgery, like medical durables, anesthesia, cost of medicines and injections etc., are covered under the Ayushman Bharat Yojana scheme.8. It also covers diagnostic expenses and medical implantation expenses.9. The cost of the catering services (the food given to the patient during hospitalization) is included in this package.10. In case of any complication during the treatment, this scheme also covers the expenses incurred for further treatment.11. Covid-19 treatment of lower income groups of people is also covered.

Specific categories of people are not covered under this scheme. People falling under this category are as follows:1. Any citizen of India owning a two-wheeler or a three-wheeler or car.2. A person whose monthly income is more than Rs. 10,000.3. A person who is a Government employee.4. A person who lives in a constructed house which is built correctly.5. A person who has a Kisan card.6. A person working with machinery, farming and any type of equipment.7. A person who owns and has an income from a motorised fishing boat.8. A person who owns agricultural land of 5 acres or more.9. A person who has a landline and a refrigerator in their house.10. A person employed by the Government to run a non-agricultural enterprise.11. Fertility treatment and organ transplant surgeries are not covered under the Ayushman Bharat Yojana scheme.12. The drug rehabilitation facility is also not provided to the policyholder under this scheme.13. This scheme also does not take care of individual diagnostics and cosmetic surgery.

The treatment of critical illnesses can be done in any public hospital or listed private hospital. The acute diseases or illnesses covered under this scheme are:1. Skull base surgery2. Coronary artery bypass surgery3. Prostate cancer4. Carotid Angioplasty with stent5. Pulmonary valve surgery6. Double valve replacement surgery7. Anterior spine fixation8. Covid-199. Tissue expander following disfigurement, which is caused due to burns.

Through the Ayushman Bharat Yojana scheme, the Government intends to cover at least 40% of the rural and economically backward urban populations. These figures have been reached by collecting data from the socio-economic caste Consensus 2011.

Eligibility criteria for rural people under this scheme

1. Families who do not have any adult/ earning member /male in the age group of 16 to 59 years of age.2. Family living in 1 room with no concrete structure (kaccha wall).3. A family that doesn't have any healthy members with one disabled member.4. A manual scavenger family (member of a family involved in sanitation work like sweepers, garbage collectors and sewage cleaners etc.)5. A family who doesn't have a house earns a living on daily wages.

Eligibility criteria for urban people under this scheme

1. Domestic helper2. Ragpicker3. Beggar4. Construction worker, plumber, labourer, painter and mason.5. Security guard, coolie, painter and washerman.6. Electrician, repair worker, mechanic and assembler.7. Cart puller, a rickshaw puller, a transport worker and a conductor.8. Peon, waiter, delivery assistant and shop worker.9. Cobbler, hawker and street vendor.

The Ayushman Bharat Yojana scheme offers health insurance facilities to vulnerable and lower-class people who find it hard to meet medical expenses when hospitalized. The entire treatment cost is borne by the Government (60:40 cost sharing by the centre and the state). The inpatient charges during hospitalization, along with the medical expenditure, are free of cost under the Ayushman Bharat Yojana scheme. It also covers pre-hospitalization and post-hospitalization treatment.All the beneficiaries enrolled in the PMJAY(Pradhan Mantri Jan Arogya Yojana scheme) program are entitled to an Ayushman Bharat Yojana e-card. Treatment and benefits can be availed if this card is shown in the empanelled private and public hospitals.Ayushman Mitra's appointed in the empanelled private and public hospitals under the PMJAY scheme. They will be available near the help desk. Their main work is to check and verify eligibility criteria and all the documents needed for hospitalization. They also help the beneficiary with the enrollment process. After all this is done, they provide a letter to the beneficiary. This letter contains a QR code which has to be scanned and verified. It helps in checking the eligibility to avail of the benefits of this scheme.

The Ayushman Bharat Yojana scheme covers 25 specialties. Some of them are:1. Cardiology2. Neurology3. Pediatrics4. Oncology5. Covid-196. Orthopedics

Like the beneficiaries' eligibility for this scheme, hospitals must also fulfil the eligibility criteria to be listed under the Ayushman Bharat Yojana scheme . Some of these criteria are:1. Should have at least 10 beds to handle in-patients.2. Hospital staff should be available around the clock.3. The Washroom accessibility facility should be available.4. Hospitals should have the technology to save data.5. Emergency services and ambulances should be provided to the patients.6. The medical officer hired should coordinate with AB-NHPS.7. All the necessary types of equipment should be available.8. Testing laboratories and blood banks should be near this hospital.9. The hospital should be registered with state health agencies.10. Power, bio-medical waste, water supply, etc., should be handled regularly.The hospitals that treat the Ayushman Bharat Yojana cardholders should maintain a complete record and keep updating it. They are supposed to share this data with the Government as and when required.

A few steps need to be followed to check which hospitals in India provide treatment under this scheme (empanelled private and public hospitals).These steps are as follows:Step 1: Visit the official website of PMJAY and click on the hospital's list section.Step 2: Select the residing state and the district.Step 3: Here one needs to choose the type of hospital, which has 3 categories:a. Publicb. Private for-profitc. Private and not-for-profit.Step 4: Choose from the list which medical speciality is needed.Step 5: After choosing the medical speciality, enter the 'CAPTCHA code'.Step 6: Finally, click on search.Some hospitals had earlier treated patients with the Ayushman Bharat Yojana e-card but are now suspended. Such hospitals can also be viewed on this site by following the same procedure. Immediately upon clicking search, the list of hospitals, addresses, contact numbers, and website details will be displayed on the screen.

The IRDAI (Insurance Regulatory and Development Authority) issued guidelines to all insurance companies to cover the expenses incurred during the treatment of Coronavirus. The Ayushman Bharat Yojana scheme also covers all the charges related to this deadly virus. These include providing medical test facilities in all the empanelled private and public hospitals. Along with this, arrangements for isolation in hospitals and quarantine expenses are also covered under this scheme. This initiative by the Government has helped the socio-economically backward people.

The beneficiaries enrolled under this scheme were selected from those who participated in the RSBY(Rashtriya Swasthya Bhima Yojana) plan. They were selected based on the SECC (Socio-Economic Caste Consensus) 2011.To apply and check for enrollment, follow these steps:Step 1: Visit the official Government website https://pmjay.gov.in .Step 2: Once the webpage is opened, the next step is to click on the icon 'Am I eligible icon'.Step 3: Enter the contact details. An OTP will be generated on the mobile number entered.Step 4: Choose the residing state.Step 5: Now search by either mobile number, ration card number or name.Step 6: After clicking this, the search site will inform whether the person who entered the details is eligible for this scheme.Alternatively, an individual can contact the Ayushman Bharat Yojana customer care number, which is 1800-111-565 or 14555. Empanelled Health Care Providers (EHCP) also have information regarding the eligible people for this scheme.

The documents needed to apply for Ayushman Bharat Yojana Scheme are as follows:1. Personal details like name, contact number, residential address, and email address.2. Age proof and identity proof (Aadhaar card, ration card, voter ID)3. Income certificate4. Caste certificate5. The document states the family status.6. Special category certificate7. Identification details8. Family structure

The Ayushman Bharat Yojana Card contains all the information related to the beneficiary. It has to be shown in the empanelled hospital to get treatment.To download this card, follow these steps:Step 1: Open the PMJAY website, which is https://mera.pmjay.gov.in/search/login. Step 2: 'Captcha code' will appear. Enter it, and an OTP will be generated.Step 3: Opt for HDD number. This number is the household ID number.Step 4: Provide this number to CSC(Common Service Center).Step 5: The details and the HDD number will be checked and verified here.Step 6: From here onwards, Ayushman Mitra, the CSC(Common Service Center) representative, will complete the remaining process.Step 7: Once all the formalities are done and the Ayushman Bharat card is ready, the beneficiary must pay Rs. 30 to obtain it.

The Government is trying to uplift the weaker sections of society. They provide many health care packages for the citizens of India. By introducing the Ayushman Bharat Yojana, they have tried to provide a good healthcare package to the socio-economically weaker class. The citizens covered under this scheme should utilise the health benefits provided by the Government.