Ayushman Bharat Yojana, also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY), is a scheme that aims to help the economically weaker section of the society who need healthcare facilities.
Rolled out by the Prime Minister on 23 September 2018, this health insurance scheme covers about 50 crore citizens in India and already has several success stories to its credit. As of September 2019, around 18,059 hospitals were empanelled, over 4,406,461 beneficiaries were admitted, and over ten crore e-cards were issued under the scheme.

The Ayushman Bharat Yojana – National Health Protection Scheme has now been renamed Pradhan Mantri Jan Arogya Yojana. This plans to make secondary and tertiary healthcare completely cashless for the underprivileged section of society. The PM Jan Arogya Yojana beneficiaries get an e-card that can be used to avail of 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 three 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. PMJAY provides Rs. 5 lakh coverage to every family per year, thus helping the economically disadvantaged access healthcare services easily.

Ayushman Bharat Yojana in alliance with the States:

The scheme architecture and formulation has undergone a truly federal process, with stakeholder inputs taken from all States and UTs through the national conclaves, sectoral working groups, intensive field exercises and piloting of key modules.

The Scheme is principle based rather than rule based, allowing States enough flexibility in terms of packages, procedures, scheme design, entitlements as well as other guidelines while ensuring that key benefits of portability and fraud detection are ensured at a national level.

States have the option to use an existing Trust/Society or set up a new Trust/Society to implement the Scheme as State Health Agency and will be free to choose the modalities for implementation.

States can implement the Scheme through an insurance company or directly through the Trust/Society/Implementation Support Agency or a mixed approach.

PMJAY health cover categories:

eligibility criteria for rural and urban people

The PMJAY scheme aims to provide healthcare to 10 crore families, mostly poor and have lower middle income, through a health insurance scheme covering Rs. 5 lakh per family. The ten crore families comprise eight 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 categorised on lack of housing, meagre income and other deprivations, the urban list of PMJAY beneficiaries is drawn up based on occupation.

PMJAY rural

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 aims 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 aid 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.

PMJAY urban

According to the National Sample Survey Organisation (71st round), 82% of urban households do not have health insurance. 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 of 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 in the Socio-Economic Caste Census 2011. Further, any family enrolled under the Rashtriya Swasthaya Bima Yojana will benefit from the PM Jan Arogya Yojana.

Features of Ayushman Bharat Yojana

Below are some Ayushman Bharat Yojana details and key features of the PMJAY scheme:

• It is one of the world’s largest health insurance schemes financed by the government of India.
• Coverage of Rs.5 lakh per family per annum for secondary and tertiary care across public and private hospitals.
• Approximately 50 crore beneficiaries (over 10 crore poor and vulnerable entitled families) are eligible for the scheme.
• Cashless hospitalisation.
• Covers up to 3 days of pre-hospitalisation expenses such as medicines and diagnostics.
• Covers up to 15 days of post-hospitalisation expenses which include medicines and diagnostics.
• No restriction on the family size, gender or age.
• Can avail services across the country at any of the empanelled public and private hospitals.
• All pre-existing conditions covered from day one.
• The scheme includes 1,393 medical procedures.
• Includes costs for diagnostic services, drugs, room charges, physician’s fees, surgeon charges, supplies, ICU and OT charges.
• Public hospitals are reimbursed at par with private hospitals.

Benefits of Ayushman Bharat Yojana

• The scheme is targeted at the vulnerable and underprivileged sections of the society. To cater to them, below are the benefits of the PMJAY:
• It covers all hospitalisation expenses with cashless transactions to beneficiaries.
• Accommodation during hospitalisation.
• Pre and post-hospitalisation costs.
• Any complications arising during the treatment.
• Can be used by all family members.
• No cap on family size, age or gender.
• Pre-existing conditions are included from day one.

List of Critical Diseases or Illnesses Covered Under Ayushman Bharat Yojana

The medical care scheme extended coverage for more than 1300 medical packages at empanelled public and private hospitals in the country. Below are some of the critical illnesses covered under the Ayushman Bharat Yojana:

• Prostate cancer.
• Double valve replacement.
• Coronary artery bypass graft.
• COVID-19.
• Pulmonary valve replacement.
• Skull base surgery.
• Anterior spine fixation.
• Laryngopharyngectomy with gastric pull-up
• Tissue expander for disfigurement following burns.
• Carotid angioplasty with stent.

This is a package medical insurance scheme to cover hospitalization for Medical and Surgical procedures through cashless treatment in respect of the following 34 identified specialties. MJPJAY beneficiary gets benefit of 996 Medical and Surgical procedures with 121 follow up procedures and PMJAY beneficiary gets benefit of 1209 Medical and Surgical procedures (Additional 213 Medical and Surgical procedures) with 183 follow up procedures. There are 131 government reserved procedures out of 996 MJPJAY procedures and additional 37 government reserved procedures for PMJAY 1209 procedures.