Eligibility Of Pradhan Mantri Ayushman Bharat Yojana

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.

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 was earlier referred to as AB-NHPS as it is an initiative under the existing National Health Protection Scheme (NHPS). Currently, it is known as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). The government plans to distribute this scheme through national insurance companies. The scheme subsumes the existing senior citizen health insurance scheme as well as the Rashtriya Swasthya Bima Yojana.

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 payment of total costs, specific services, and procedures.
• An Ayushman Bharat National Health Protection Mission will be established for effective coordination between the Central and the state governments.
• The scheme covers about 40% of the country’s 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 during the pre and post-hospitalisation period will be covered.
• The insurance provides cashless hospitalisation facility.
• Daycare treatment expenses are covered by the scheme.
• The insurance scheme covers all pre-existing health conditions. Follow-up of medical examinations upto 15 days are also covered to ensure that the patients have recovered completely.

Ayushman Bharat Yojana 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.

Eligibility criteria for urban 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.
  

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.

How can you start registering for Pradhan Mantri Ayushman Bharat Yojana online?

To commence the registration process, you will have to visit the Pradhan Mantri Ayushman Bharat Yojana website. It is followed by entering your mobile number and the Captcha Code. You must then click on the ‘Generate OTP’ option. 

An OTP number is sent to your mobile number through which you can access the website and complete the verification process. You are taken to the PMJAY login screen. 

Moreover, you must select the state from which you are applying for the Pradhan Mantri Ayushman Bharat Yojana. You then choose how you want to select your eligibility criteria. 

1. Mobile Number
2. Name
3. Ration Card Number
4. RSBY URN number

If you are eligible for the Pradhan Mantri Ayushman Bharat Yojana, your name will reflect on the right-hand side of the page. Moreover, you can check beneficiary details by clicking on the ‘Family Members’ tab. 

How to Claim the Cashless Bills under the Pradhan Mantri Ayushman Bharat Yojana?

If you and your family members are enrolled under the Pradhan Mantri Ayushman Bharat Yojana, an enrollment letter containing a unique QR code and identification number is sent. It helps to identify your family members in case of a hospitalisation claim. 

All hospitals empanelled under the Pradhan Mantri Ayushman Bharat Yojana have an ‘Ayushman Mitra’ to help insured families get cashless medical treatment. 

The Ayushman Mitra checks your eligibility by scanning the QR code contained in the enrollment letter against your data in the scheme’s database. You enjoy cashless medical treatment if you are eligible for the scheme. 

After submitting valid identification proof, you are issued a Golden Card to avail of cashless hospitalisation treatment. Moreover, you can enjoy a cashless treatment at government hospitals as all of them are empanelled under the scheme. 

Frequently Asked Questions

Will a newborn baby be covered under the PMJAY when there are five members in a family who have already availed of PMJAY benefits? 

Yes, there is no limit of family size under the PMJAY. The newborn baby will be provided care under the PMJAY provided the benefit limit is not exhausted. The newborn baby should be added to the PMJAY scheme with at least one PMJAY verified beneficiary.

Does the scheme entitle a beneficiary for admission to only the general ward?

Yes. When a beneficiary wants an upgrade in the room, then all expenses for treatment will not be covered under the PMJAY scheme. However, admission to ICU for specified packages is allowed.

Does a beneficiary need to pay for medicines he/she receives under this scheme?

No, a beneficiary does not have to pay for the medicines he/she receives for the treatment. Under the PMJAY, medicines will be included in the package for the duration of treatment, including up to 15 days after discharge from the hospital.

What is the meaning of post-hospitalisation expenses under the PMJAY?

Post-hospitalisation expenses are the expenses incurred by the patient from the date of discharge up to 15 days for medicines, consultation, diagnostics and post-operative care. Also in the case of surgery, any post-operative complication and re-admission linked to the treatment are to be covered under the earlier package cost.

What is the meaning of pre-hospitalisation expenses under the PMJAY?

Pre-hospitalisation expenses mean the expenditure incurred by the beneficiary of the scheme up to 3 days before getting admitted to the hospital. However, it is applicable only to the expenses made in the same hospital where treatment under the PMJAY is initiated. The expenditure may be related to consultation, diagnostics, medications, etc., and inclusive in the package.

What are the services that are excluded under the PMJAY?

Any outpatient care, cosmetic treatments, drug rehabilitation, fertility treatment and organ transplants are not covered under the PMJAY.