“I used the Ayushman Bharat card twice, as I had to undergo a procedure to remove water from my lungs. My entire expense was covered by the scheme. It would have been a burden to arrange ₹2 lakh on my own, but thankfully, all expenses were taken care of through this scheme,” says Chikkamaregowda, a resident of Yelahanka. He opines that the Ayushman Bharat Scheme has been beneficial for people who fall below the poverty line.
The Ayushman Bharat (AB) scheme is a key initiative of the Central government, launched with a vision to achieve ‘Universal Health Coverage’ as recommended by the National Health Policy 2017. One of its components is the Pradhan Mantri Jan Arogya Yojana (PM-JAY), which is the largest health assurance scheme in the world and aims to provide a health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalisation.
Here is a comprehensive guide covering eligibility criteria, the services offered under the scheme, and the application process for an AB card.
What is Ayushman Bharat Yojana?
Launched on September 23, 2018, the Ayushman Bharat Yojana is an attempt to move from a sectoral and segmented approach to health service delivery to a comprehensive need-based healthcare service. The aim is to holistically address the primary, secondary (where patients are referred to hospitals from PHCs) and tertiary (specialised medical care with advanced facilities like ICUs and consultations by specialised medical personnel) healthcare systems. The scheme has two components:
- Health and Wellness Centres (HWCs)
- Pradhan Mantri Jan Arogya Yojana (PM-JAY)
The HWCs are supposed to provide a comprehensive range of services spanning preventive, promotive, curative, rehabilitative and palliative care for all ages. AB-HWCs provide free essential medicines and diagnostic services, teleconsultation, and health promotion, including wellness activities like yoga. More than 1.6 lakh HWCs are said to be providing primary healthcare in the country, though the reality of how many remain functioning is yet to be determined.
As per the National Health Mission, 12 crore families are eligible for the AB scheme. This accounts for about 55 crore beneficiaries and 40% of the population. It covers up to three days of pre-hospitalisation and 15 days of post-hospitalisation, including medicines. There is no limitation on family size, age or gender to avail the benefits. Once approved, cashless treatment will be given for the specific medical ailment, and the hospital will directly process the bill.
The coverage under the scheme includes all expenses incurred on the following components of the treatment:
- Medical examination, treatment and consultation
- Pre-hospitalisation
- Medicine and medical consumables
- Non-intensive and intensive care services
- Diagnostic and laboratory investigations
- Medical implantation services (where necessary)
- Accommodation benefits
- Food services
- Complications arising during treatment
- Post-hospitalisation follow-up care up to 15 days
Who is eligible?
Families that are identified as beneficiaries under the Socio-Economic and Caste Census (SECC-2011) are eligible for PM-JAY. Of the total seven deprivation criteria for rural areas, PM-JAY covered all such families who fall into at least one of the following six deprivation criteria (D1 to D5 and D7) and automatic inclusion (Destitute/ living on alms, manual scavenger households, primitive tribal group, legally released bonded labour) criteria:
- D1- Only one room with kucha walls and roof
- D2- No adult member between ages 16 to 59
- D3- Households with no adult male member between ages 16 to 59
- D4- Disabled member and no able-bodied adult member
- D5- SC/ST households
- D7- Landless households deriving a major part of their income from manual casual labor
For urban areas, the following 11 occupational categories of workers are eligible for the scheme:
- Ragpicker
- Beggar
- Domestic worker
- Street vendor/cobbler/hawker/other service provider working on the streets
- Construction worker/plumber/mason/labourer/painter/welder/security guard/coolie and other head-load worker
- Sweeper/sanitation worker/ mali (gardener)
- Home-based worker/artisan/handicrafts worker/tailor
- Transport worker/driver/conductor/helper for drivers and conductors/cart puller/rickshaw puller
- Shop worker/shop assistant/peon in small establishment/helper/delivery assistant/attendant/waiter
- Electrician/mechanic/assembler/repair worker
- Washerman/chowkidar
All senior citizens above the age of 70 years are eligible for the scheme, regardless of their financial or occupational standing.
You can check your eligibility on the official PM-JAY website under the ‘Am I Eligible?’ section.
Who is an Arogya Mitra under Ayushman Bharat?
Pradhan Mantri Arogya Mitras (PMAMs) are scheme-specific experts who guide the beneficiaries about the overall benefits under AB PM-JAY and provide relevant information about receiving prompt treatment at the hospital. They are recruited by the State Health Agency (SHA) or hospitals based on the caseload. PMAMs play the role of a trusted partner for the beneficiaries and the authorities. They search the list of beneficiaries for each district using their name, ration card and other details and look up the Beneficiary Identification System (BIS).
Read more: Newborn screening: Why it is needed and what we must know
How to register for Ayushman Bharat card?
To apply for a PM-JAY e-card personally, individuals must either visit a hospital or a Community Service Centre (CSC) for identification and follow these steps:
- Submission of relevant details: The individual must submit the Prime Minister’s letter (sent to eligible families)/Rashtriya Swasthya Bima Yojna Unique Relationship Number (RSBY URN)/ration card number/mobile number. The Arogya Mitra then searches the available list of beneficiaries. The operator does this by entering details such as name, location, ration card number, mobile number, or RSBY URN of the beneficiary.
- Search in the BIS Application: The operator searches for the potential beneficiary in the entitled SECC, RSBY, State Health Scheme, and additional data collection drive databases.
- Individual identification: The identification process is carried out if the name is found on the list. For this, documents like Aadhaar or any government ID and a ration card or an alternative family ID are required to validate against the details available in the system. Scanned documents are then uploaded.
- Family Identification: The Arogya Mitra then identifies the family records through the ration card and uploads documents. The individual and family records are submitted to the trust/insurance company for approval.
- Application approval or rejection: The health insurance company or trust may then approve or reject the submitted application for the potential beneficiaries. Rejected cases will be finally verified for approval or rejection by the State Health Agency (SHA).
- E-card issuance: On approval by SHA/insurance company/trust, an e-card will be issued to the beneficiary.
In India, each person has a unique 14-digit health identification number called their Ayushman Bharat Health Account (ABHA) number. Its goal is to give each Indian citizen a digital health identification. With the individual’s permission, it makes it easier to save and retrieve medical records digitally. It offers a single platform for medical information with the goal of streamlining healthcare services. It falls under the Ayushman Bharat Digital Mission (ABDM).
Documents required and other details
- Age & Identity Proof (Aadhaar Card / PAN Card).
- Proof of Address.
- Contact details (Mobile, e-mail).
- Caste Certificate.
- Income Certificate.
- Document Proof of the Current Status of the Family (Joint or Nuclear).
- Aadhaar Card.
One can download their PM-JAY e-cards on several platforms such as NHA Beneficiary portal, Ayushman app, Umang portal and DigiLocker.
Treatment under AB PM-JAY
AB PM-JAY has coverage extending to 1,650 medical packages. They are divided into four categories:
- 2A- Simple secondary
- 2B- Complex
- 3A- Tertiary
- 4A- Emergency
Official sites mention a few exclusions from the scheme:
- Outpatient Department (OPD) expenses
- Drug rehabilitation programme
- Cosmetic-related procedures
- Fertility-related procedures
- Organ transplants
- Individual diagnostics (for evaluation).
Each empaneled hospital needs to set up a dedicated help desk for the beneficiaries, which is manned by the Arogya Mitra staff, appointed by the Empaneled Health Care Provider (EHCP). Every empaneled hospital also receives a unique ID.
- Hospitals are required to apply online, and this process is free of cost. The progress of the application can also be tracked online.
- The online applications are scrutinised by the District Empanelment Committee (DEC) and physical verification of the hospitals is carried out.
- Following this verification, the DEC submits a recommendation to approve or reject the hospital to the State Empanelment Committee (SEC). The final decision regarding empanelment rests with the SEC.
One can find the empanelled hospitals here.
The second part of the two-part series on AB PM-JAY will explore gaps in the scheme and challenges faced by beneficiaries.