Ayushman Bharat Yojana, also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY), is a scheme that aims to help economically vulnerable Indians who are in need of healthcare facilities.
The Ayushman Bharat Yojana – National Health Protection Scheme, which has now been renamed as Pradhan Mantri Jan Arogya Yojana, plans to make secondary and tertiary healthcare completely cashless. The PM Jan Arogya Yojana beneficiaries get an e-card that can be used to avail services at an empanelled hospital, public or private, anywhere in the country. With it, you can walk into a hospital and obtain cashless treatment.
The coverage includes 3 days of pre-hospitalisation and 15 days of post-hospitalisation expenses. Moreover, around 1,400 procedures with all related costs like OT expenses are taken care of. All in all, PMJAY and the e-card provide a coverage of Rs. 5 lakh per family, per year, thus helping the economically disadvantaged obtain easy access to healthcare services.
PMJAY Health Cover Categories: Eligibility Criteria for Rural & Urban People
The PMJAY scheme aims to provide healthcare to 10 crore families, who are mostly poor and have lower middle income, through a health insurance scheme providing a cover of Rs. 5 lakh per family. The 10 crore families comprise 8 crore families in rural areas and 2.33 crore families in urban areas. Broken into smaller units, this means the scheme will aim to cater to 50 crore individual beneficiaries.
However, the scheme has certain pre-conditions by which it picks who can avail of the health cover benefit. While in the rural areas the list is mostly categorized on lack of housing, meagre income and other deprivations, the urban list of PMJAY beneficiaries is drawn up on the basis of occupation.
The 71st round of the National Sample Survey Organisation reveals that a staggering 85.9% of rural households do not have access to any healthcare insurance or assurance. Additionally, 24% of rural families access healthcare facilities by borrowing money. PMJAY’s aim is to help this sector avoid debt traps and avail services by providing yearly assistance of up to Rs. 5 lakh per family. The scheme will come to the aid of economically disadvantaged families as per data in the Socio-Economic Caste Census 2011. Here too, households enrolled under the Rashtriya Swasthya Bima Yojana (RSBY) will come under the ambit of the PM Jan Arogya Yojana.
In the rural areas, the PMJAY health cover is available to:
1) Those living in scheduled caste and scheduled tribe households
2) Families with no male member aged 16 to 59 years
3) Beggars and those surviving on alms
4) Families with no individuals aged between 16 and 59 years
5) Families having at least one physically challenged member and no able-bodied adult member
6) Landless households who make a living by working as casual manual labourers
7) Primitive tribal communities
8) Legally released bonded labourers
9) Families living in one-room makeshift houses with no proper walls or roof
10) Manual scavenger families
According to the National Sample Survey Organisation (71st round), 82% of urban households do not have access to healthcare insurance or assurance. Further, 18% of Indians in urban areas have addressed healthcare expenses by borrowing money in one form or the other. Pradhan Mantri Jan Arogya Yojana helps these households avail healthcare services by providing funding of up to Rs. 5 lakh per family, per year. PMJAY will benefit urban workers’ families in the occupational category present as per the Socio-Economic Caste Census 2011. Further, any family enrolled under the Rashtriya Swasthaya Bima Yojana will benefit from the PM Jan Arogya Yojana as well.
In the urban areas, those who can avail of the government-sponsored scheme consist mainly of:
1. Washerman / chowkidars
2. Rag pickers
3. Mechanics, electricians, repair workers
4. Domestic help
5. Sanitation workers, gardeners, sweepers
6. Home-based artisans or handicraft workers, tailors
7. Cobblers, hawkers and others providing services by working on streets or pavements
8. Plumbers, masons, construction workers, porters, welders, painters and security guards
9. Transport workers like drivers, conductors, helpers, cart or rickshaw pullers
10. Assistants, peons in small establishments, delivery boys, shopkeepers and waiters
People not entitled for the Health Cover under Pradhan Mantri Jan Arogya Yojana:
1. Those who own a two, three or four-wheeler or a motorised fishing boat
2. Those who own mechanised farming equipment
3. Those who have Kisan cards with a credit limit of Rs.50000
4. Those employed by the government
5. Those who work in government-managed non-agricultural enterprises
6. Those earning a monthly income above Rs.10000
7. Those owning refrigerators and landlines
8. Those with decent, solidly built houses
9. Those owning 5 acres or more of agricultural land
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Medical Packages and Hospitalization Process in Ayushman Bharat Scheme (PMJAY)
The Rs. 5 lakh insurance cover provided by the Pradhan Mantri Jan Arogya scheme can be utilized not just by individuals in particular, but also by families in general. This lumpsum is enough to cover both the medical and surgical treatments in 25 specialities among which are cardiology, neurosurgery, oncology, paediatrics, orthopaedics, etc. However, medical and surgical expenses cannot be reimbursed simultaneously.
If multiple surgeries are necessary, the highest package cost is paid for in the first instance followed by a 50% waiver for the second and a 25% discount for the third. Unlike other health insurance schemes, there is no waiting period for pre-existing diseases under PMJAY scheme, which comes under the larger umbrella scheme of Ayushman Bharat Yojana. Should any beneficiary or anyone in their family require hospitalization, they need not pay anything, provided they are admitted in any empanelled government or private hospital.
The cashless treatment and hospitalization is made possible due to a 60:40 cost sharing agreement between the Centre and states. Once identified as a genuine beneficiary, you or your family member will be issued a health card by specially trained Ayushman Mitras, who man kiosks in hospitals for those unaware of the PMJAY scheme.
With these details in hand, you can benefit from the features of the Pradhan Mantri Jan Awas Yojana or help someone else get the healthcare cover benefit.
PMJAY Illness Coverage: List of Critical Diseases covered under PM Jan Arogya Yojana
PMJAY helps households access secondary and tertiary care via funding of up to Rs. 5 lakh per family, per year. This assistance is valid for day care procedures and even applies to pre-existing conditions. PMJAY extends coverage for over 1,350 medical packages at empanelled public and private hospitals.
Some of the Critical illnesses that are covered are as follows.
Coronary artery bypass grafting
Double valve replacement
Carotid angioplasty with stent
Pulmonary valve replacement
Skull base surgery
Laryngopharyngectomy with gastric pull-up
Anterior spine fixation
Tissue expander for disfigurement following burns
PMJAY has a minimal list of exclusions. They are as follows.
- Drug rehabilitation programme
- Cosmetic related procedures
- Fertility related procedures
- Organ transplants
- Individual diagnostics (for evaluation)
Advantages of Health Insurance in India
The main advantage of having a health insurance policy is that you can avail medical treatment without suffering any strain on your finances. Moreover, as a significant number of Indians end up borrowing money informally to pay medical bills, utilising the features of PMJAY helps avoid the risk of a debt trap. You can get upto Rs. 5 lakh treatment under PMJAY but you can also buy health insurance from Bajaj Finserv to avail more coverage & benefits for yourself and your family.
Alternately, you can explore other health policies too like Pocket Insurance by Bajaj Finserv which offers affordable policies to take care of your specific needs. What’s more, you can apply for these policies easily online. For instance, Dengue Cover helps you pay for diagnostic tests in case you contract malaria or dengue, while Hospital Cash Cover gives you daily cash assistance of up to Rs.1,000 per day that you can use for a range of expenses. You can also purchase plans such as Adventure Cover if you get injured or Kidney Stones Cover in case you suffer from this condition. Regardless of the policy you choose, you can get substantial coverage at a nominal premium and protect every aspect of your health in an instant.
Additional Read: How To Choose The Right Health Insurance Policy For Yourself
- Ayushman Bharat Registration: How to Apply for Ayushman Bharat Yojana (Application Process)
There is no special Ayushman Bharat registration procedure pertaining to PMJAY. This is because PMJAY applies to all beneficiaries as identified by the SECC 2011 and those who are already part of the RSBY scheme. However, here’s how you can check if you are eligible to be a beneficiary of PMJAY.
- Enter your mobile number and the CAPTCHA code and click on ‘Generate OTP’
- Then select your state and search by name/ HHD number/ ration card number/ mobile number
- Based on the search results you can verify if your family is covered under PMJAY
Alternatively, to know if you are eligible for PMJAY you can approach any Empanelled Health Care Provider (EHCP) or dial the Ayushman Bharat Yojana call centre number: 14555 or 1800-111-565
Ayushman Bharat Yojana: PMJAY Patient Card Generation
Once you are eligible for the PMJAY benefits, you can work towards getting an e-card. Before this card is issued, your identity is verified at a PMJAY kiosk with the help of a document like your Aadhaar card or ration card. Family identification proofs that can be produced include a government certified list of members, PM letter and an RSBY card. Once the verification is completed, the e-card is printed along with the unique AB-PMJAY ID. You can use this as proof at any point in the future.