Despite enabling over eight crore hospital admissions, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) remains riddled with challenges that make accessing its benefits a daunting ordeal for many. For countless eligible citizens, the promise of free healthcare often gets entangled in a web of bureaucratic hurdles, unclear eligibility criteria, and implementation gaps.
The first part of this series explained how people can apply for benefits under AB-PMJAY. In Part 2, we dive into the systemic gaps and the struggles beneficiaries face in accessing the scheme’s medical benefits.
Proving your eligibility for Ayushman Bharat
As per provisions of the scheme, all Below Poverty Line (BPL) cardholders are eligible for an AB card, but on the ground, the reality is painfully complex. Many people do not have ration cards because of various reasons — migrating from another state without proper documents, lack of awareness about the process, or choosing to avoid the cumbersome and often discriminatory procedure of obtaining a ration card.
“Many people I interact with do not have enough money to even commute to hospitals. It would be helpful if the Aadhaar card alone was considered for eligibility to access the scheme benefits,” says Amruthalakshmi, an ASHA worker in North Bengaluru.
Ration card eligibility is based on income, but this criterion may have significant loopholes. With the rising cost of living, medical expenses, and family obligations, many in the Above Poverty Line (APL) category have hardly any savings. “The government should assess actual expenses and savings through on-ground verification before determining ration card eligibility,” suggests Priya, coordinator at Maarga, a Bengaluru-based community organisation of slum residents.
The process is not without flaws. “Getting a ration card itself can take years, as the portal for applications is only open two or three times a year, and the approval process takes a long time,” adds Kavitha, a community organiser at Maarga, who waited nearly three years to obtain her ration card. Similarly, three Bruhat Bengaluru Mahanagara Palike (BBMP) Paurakarmikas, who requested anonymity, say that they did not apply for AB cards because they are yet to receive their ration cards.
Moreover, the official AB-PMJAY site highlights occupational eligibility, but this criterion is often overlooked during enrollment for the scheme.
State boundaries for central scheme
Sasi came to Bengaluru from Tamil Nadu to work as a house help and support her children’s education as a single mother. Her ration card and other documents are from TN, which restricts her from accessing the AB-PMJAY benefits in Karnataka. “I have to either pay the full amount if I get treated here, or I should travel back home for free treatment. If only I could access free treatment here, at least in government hospitals, it would be helpful,” says Sasi.
The Kalaignar Kaappittu Thittam scheme provides free healthcare services for TN residents with an income cap eligibility, and is integrated with the central scheme. However, guidelines about usage outside the home state remain ambiguous. “Centre schemes’ purpose should be to benefit the migrant population and those without income-related documents,” says Vanessa Peter, founder of the Information and Resource Centre for the Deprived Urban Communities (IRCDUC), Chennai.
Meanwhile, Arogya Mitras in Karnataka are unclear about the migration issue. Some confidently point out that PMJAY cards are issued separately for migrants and can be made in Bangalore One centres or Seva Kendras. A few others insist that migrant workers who want to get the benefits of the scheme must get their PMJAY cards in their hometowns.
Confusion about access to Ayushman Bharat
Government officials themselves offer conflicting information, so people from one state travelling for work to other states are hesitant to seek AB benefits. “People fear that applying for benefits in another state might cancel their entitlements back home,” explains Rajendra Prabhakar, founder of Maarga. He adds that the excessive eligibility criteria are a way of excluding people. “Citizens are not robbers. If they come to the government for aid, it should be given without all this filtering.”
Read more: A poor health report card for Maharashtra ahead of polls: Jan Arogya Abhiyan
In Maharashtra and Karnataka, older state health schemes are merged with the AB scheme, however, there is a lack of clarity about the integration.
“Within the state also, people are confused which scheme is at play since they are not aware of the merger. Mahatma Jyotirao Phule Jan Arogya Yojana was much more effective earlier since it had reached every nook and cranny of Maharashtra. But, since the merger, there is no proper communication to the locals, let alone the migrant population,” says Vikas Waghmare, senior community organiser at YUVA in Mumbai.
Barriers at hospitals
Acquiring the AB card is just one part of the ordeal. Getting medical benefits under the central scheme when a patient seeks hospital admission is a bigger hurdle.
Nalini Shetty*, a senior citizen, told Citizen Matters that her 75-year-old husband was denied benefits at a private, empanelled hospital despite being an Ayushman Vay Vandana card holder, as the hospital claimed benefits were only available for those admitted to the general ward. Senior citizens over 70 years are supposed to get health coverage regardless of their socio-economic status.
“I was able to utilise ₹1 lakh alone from the Ayushman Bharat scheme, while I spent ₹3 lakh from my pocket,” said Pavan Kumar CG, a pharmacist from Bengaluru. Kumar’s late father was diagnosed with fourth-stage cancer in 2022, when he pinned his hopes on the Ayushman Bharat Arogya Karnataka scheme (ABArK), the Karnataka version of the central scheme, to aid him financially.
After the first chemotherapy, his father was struck by paralysis, and since the scheme does not cover the condition, Kumar had to bear the rest of the expenses. “The scheme did help in lowering our hospital bills, however, my expenses far exceeded the benefits, as my father was paralysed mid-treatment. Who has control over that?” asks Kumar.
The fine print
“We have 1,650 codes for different medical conditions. We had our last revision almost three years ago. Taking recommendations from our patients, we are requesting for a revision to include more medical conditions in the scheme, enhancing its usability,” says Mohammad Javeed, Arogya Mitra, Davanagere.
Moreover, the scheme does not cover diagnostic tests carried out before hospital admission. “Some tests like PET scans can cost more than ₹25,000. In many medical conditions, the charges are substantial in the preliminary stages,” says Lalitha, ABArK card holder.
Issues with documents and procedures
Hospitals can reject AB-PMJAY claims if the beneficiaries do not have their Aadhaar cards and ration cards with them during admission. “Even if one has their AB card, they must have their Aadhaar and ration card to avail the scheme benefits. Even if one document is not there, the hospital can cancel their request,” said Siddhartha MA, Arogya Mitra at Mandya Medical College.
Patients are forced to follow a hierarchical process to claim benefits. They must first go to a government hospital, and if facilities are unavailable for the specific treatment, they should collect a referral letter from a doctor there and provide that at an empanelled private hospital for admission under the scheme.
People may go to private hospitals near their homes, however, the hospital may send them back to get a referral letter from a government hospital. “Doctors at government hospitals may refuse a referral since they have not diagnosed the patient. Patients are made to run from pillar to post,” says Amreen Taj, Arogya Mitra at Nelamangala Government Hospital. She suggested that the government should do away with this procedure and develop infrastructure at government hospitals using ABArK funds to reduce dependency on private hospitals.
“It took me three days just to finish the procedures to claim the scheme benefits at NIMHANS and Jayadeva Hospital. We have to get so many signs and seals from doctors and social workers,” adds Priya.
Technical glitches affect patients
Manoj Gowda, Arogya Mitra at BGS Hospital, Bengaluru explains that in many cases when the ration cards are not active or are converted to BPL cards, or if beneficiary details are not updated on the Ayushman Bharat website, hospitals can reject the scheme benefits. “People may not be aware of their card statuses, and this will put them in a pickle during admission.”
Ayushman Bharat Health Account (ABHA) keeps track of patients’ records, but due to technical issues, updated records keep going missing, are deleted or are not updated. “We fill out the patients’ details every time they come. Their records, test results, and details are not updated on ABHA properly. Annual biometrics update also has to be done manually, and cases of names getting deleted are many,” explains Nirmala K, Arogya Mitra at Bowring Hospital.
Furthermore, since Arogya Mitras work in general shifts, if patients come at night, they will have to pay to get admitted, and then the refund is issued. “To what extent they get the refund, we don’t know. It would be much better to ease the admission process and make provisions for immediate admissions,” adds Chandana R, Arogya Mitra at Bengaluru’s Victoria Hospital.
What steps must the government take?
- Simplify eligibility requirements so that people don’t have to run around for multiple documents.
- Ensure portability across states to allow migrant workers to access benefits seamlessly.
- Fix technological issues to ensure patient records are updated regularly in the ABHA.
- Streamline hospital procedures, avoiding the need for referral letters and long wait times.
*name changed
Have you faced difficulties in accessing benefits under the Ayushman Bharat scheme in your State? Let us know in the comments.
Very important piece of reporting! Thanks for reporting this series, Harshitha