The government believes that only a healthy India can succeed in global competition. In order to ensure affordable healthcare services to all classes of people, a number of government-sponsored health schemes have been introduced in recent years. Alongside, the government has also come up with the Pradhan Mantri Ayushman Bharat health insurance scheme.

  1. What is Ayushman Bharat health insurance?
  2. Features and benefits of the scheme
  3. Eligibility criteria for rural families
  4. Eligibility criteria for urban families
  5. Eligibility criteria for hospitals

1. What is Ayushman Bharat health insurance?

Ayushman Bharat is a health protection scheme to provide health insurance to citizens. It provides insurance coverage of up to Rs.5 lakh on a family floater basis to beneficiaries every year in order to receive primary, secondary, and tertiary healthcare services. The scheme is mostly referred to as AB-NHPS as it is an initiative under the existing National Health Protection Scheme (NHPS).

The government plans to distribute the AB-NHPS scheme through national insurance companies. The scheme subsumes the existing senior citizen health insurance scheme as well as the Rashtriya Swasthya Bima Yojana.

2. Features and benefits of the scheme

  • A cover of up to Rs.5 lakh is available for the beneficiary family every year.

  • The scheme can be utilised to get primary, secondary, and tertiary healthcare services.

  • The benefits of the scheme can be availed at any government hospital or empanelled private hospital.

  • The eligibility of beneficiaries targeted towards the poor, deprived rural families and identified occupational category of urban workers’ families based on the Socio-Economic Caste Census (SECC) 2011 data.

  • Package model will be followed to make payments. The package will be defined by the government-in-charge in terms of total costs, specific services, and procedures.

  • An Ayushman Bharat National Health Protection Mission Council will be established for effective coordination between the Central and the state governments.

  • The Union Minister for Health and Family Welfare handles the affairs of the council.

  • The scheme covers about 40% of the country‚Äôs population who are poor and vulnerable.

  • All expenses incurred by the beneficiary from his pocket during the hospitalisation will also be covered.

  • The cost incurred for travel during the pre- and post-hospitalisation period will be covered.

  • The insurance provides cashless hospitalisation facility.

  • Daycare treatment expenses are covered by the scheme.

  • Though there are a few exceptions, the insurance scheme covers most pre-existing health conditions.
    Follow-up medical examinations are also covered to ensure that the patients have recovered completely.

  • 3. Eligibility criteria for rural families

    There are six deprivation criteria to identify the rural families that are eligible for the benefits of the scheme. They are:

  • Families that do not have an earning adult member aged between 16 and 59 years.

  • Households headed by female members having no adult male members aged between 16 and 59 years.

  • Households with a single room having makeshift walls and roof.

  • Households belonging to the Scheduled Castes and Scheduled Tribes categories.

  • Households that have disabled members with no able members offering support.

  • Landless households with manual labour as their basic source of income.

  • In addition, the following households are automatically eligible:

  • Destitute families who rely on alms.

  • Families of manual scavengers.

  • Households without proper shelter.

  • Families of bonded labour.

  • Primitive and particularly vulnerable tribal groups.

  • 4. Eligibility criteria for rural families

    An urban family must belong to one of the listed occupational categories to be eligible for the scheme:

  • Street vendors, cobblers, and hawkers.

  • Domestic workers.

  • Rag pickers and beggars.

  • Construction site workers, plumbers, masons, painters, welders, and security guards.

  • Coolies.

  • Sweepers, sanitation workers, and gardeners.

  • Transport workers such as conductors, drivers, cart pullers, and others.

  • Artisans, home-based workers, handicraft workers, and tailors.

  • Washermen and watchmen.

  • Electricians, mechanics, repair workers, and assemblers.

  • Peons, helpers, shop workers, delivery assistants, attendants, and waiters.

  • All families that are eligible under the Annapurna and Antyodaya Anna schemes are also eligible for AB-NHPS.

    5. Eligibility criteria for hospitals

    Similar to setting eligibility criteria for beneficiaries, the government has framed eligibility criteria for a hospital to be empanelled. The criteria are:

  • The hospital must be registered with state health agencies.

  • Qualified medical and nursing staff must be available 24/7.

  • The hospital must have a minimum of 10 in-patient beds.

  • The medical facility must have an accessible washroom.

  • An interoperable IT system should be in place to manage data.

  • A complete record of Ayushman Bharat patients must be maintained and shared with the government as per the requirement.

  • Ambulance and other emergency services must be available.

  • A dedicated medical officer should be appointed to take care of AB-NHPS operations.

  • There should be a blood bank and testing laboratory in the vicinity.

  • The medical facility must have all the equipment and technical necessities.

  • The hospital must have facilities such as regulated water, electricity, and bio-medical waste disposal.