The need for a health insurance plan is felt by all, especially since medical costs have been increasing at an alarming rate. While the middle and higher-income individuals can easily afford a health plan for covering the medical costs, the poor often ignored the coverage for lack of funds. Therefore, to bring parity and access to quality healthcare to the poor and low-income class, the Prime Minister, Mr. Narendra Modi, launched the Pradhan Mantri Jan Arogya Yojana scheme on 23rd September 2018. Let’s understand the details of the scheme –

What is Pradhan Mantri Jan Arogya Yojana?

The Pradhan Mantri Jan Arogya Yojana (PMJAY) popularly called the Ayushman Bharat scheme, is a health insurance scheme for the poor and backward class families. The PMJAY scheme is the largest Universal Health Coverage (UHC) scheme which offers health insurance coverage of Rs.5 lakhs to about 50 crore beneficiaries or 10.74 crore poor families of India.

Pradhan Mantri Jan Arogya Yojana Features

The salient features of the PMJAY scheme are as follows –

  • The PMJAY scheme offers cashless coverage of Rs.5 lakhs on a family floater basis per family. Coverage of the scheme can be used for availing secondary as well as tertiary care hospitalisation across empanelled hospitals in India
  • Coverage for pre-existing illnesses is allowed from the first day of the policy
  • The scheme is free of cost for the beneficiaries. The premium cost is shared by the Central and State Governments in the ratio of 60%:40%

PMJAY Eligibility

The beneficiaries who would be covered under the scheme have been selected based on the occupational and deprivation criteria of the Socio-Economic Caste Census (SECC) conducted in 2011 for rural and urban areas. Thus, only eligible families and individuals can be covered under the PMJAY scheme. So, the PMJAY eligibility criteria include the following –

  • Families covered under the Rashtriya Swasthya Bima Yojana (RSBY) scheme launched in 2008 would be covered under PMJAY even if they are not in the SECC database
  • Individuals who belong to the SC/ST category
  • Poor households which do not have any male member aged between 16 and 59 years
  • Beggars who survive on alms
  • Poor families which do not have any member aged between 16 and 59 years
  • Households which have a minimum of one physically challenged member and no healthy adult
  • Families who don’t own land and those who work as casual labourers to earn a livelihood
  • Legally released bonded workers
  • Manual scavenger families
  • Primitive tribal communities
  • People who live in one-room makeshift houses that have no proper walls or roof

In the urban areas, coverage under the PMJAY scheme can be availed by the following –

  • Rag pickers
  • Washer men
  • Chowkidars
  • Domestic help
  • Repair workers
  • Tailors
  • Sanitation workers
  • Gardeners
  • Cobblers or hawkers or any other people who work on streets or pavements
  • Transport workers
  • Shopkeepers, peons, assistants, waiters, etc. who work in small organizations

There is no limit on the entry age, number of members to be covered and the exit age under the scheme for eligible beneficiaries.

So, individuals who own any type of vehicle, have mechanized farming equipment, are employed by the Government, have a Kisan card with an Rs.50,000 limit, who earn Rs.10, 000 or more a month, work in non-agricultural enterprises which are managed by the Government, who own refrigerator and landlines, 5 acres of agricultural land or live in decently built houses cannot be covered under the PMJAY scheme.

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Coverage under PMJAY

Coverage under the Pradhan Mantri Jan Arogya Yojana scheme is offered for the following types of medical expenses –

  • Pre-hospitalisation expenses for 3 days
  • Post hospitalisation expenses for 15 days
  • Medical consultations, examinations and treatments at a hospital
  • Non ICU and ICU related treatments
  • Medical implantation services
  • Diagnostic and lab tests
  • Food services
  • Hospitalisation and room rent
  • Specified medical treatments
  • COVID related treatments

Moreover, there are specially created packages for various treatments which you can avail as and when required.

However, there are some treatments which are not covered under the scheme. These include cosmetic treatments, drug rehabilitation costs, organ transplant surgeries, OPD expenses, fertility-related treatments and individual diagnosis for evaluating your health.

Benefit of PMJAY

The PMJAY scheme has provided the much-needed health insurance coverage to the backward class individuals who could not afford quality healthcare services. The scheme provides cashless treatments thereby making it easier for individuals to get treated at empanelled hospitals. Moreover, the scope of coverage of the scheme is comprehensive making sure that most medical costs get covered.

How to enrol under the PMJAY scheme?

Identified beneficiaries have been automatically enrolled under the PMJAY scheme by the Government. A health card has been issued to identified families and they can avail cashless treatments by presenting the card at the time of hospitalisation. You can check whether you are eligible for the scheme by visiting the Common Service Centre (CSC), calling the helpline number 14555 or 1800 111 565 or through the official PMJAY website.

To apply for the PMJAY scheme, you would have to submit your documents which include the following –

  • A certified document which contains your identification and age
  • Contact details
  • Caste certificate
  • Income certificate
  • A document which shows your current family status

How to make a claim under PMJAY?

The claim process of PMJAY is quite simple. You have to find out the empanelled hospital which covers PMJAY treatments. Get admitted at the hospital and present your PMJAY health card for identification. Some paperwork would be completed to verify the identity of the insured and then treatments would be allowed on a cashless basis. You would not have to pay for the medical costs yourself as the scheme would pay the expenses itself.

The PMJAY scheme is a welfare scheme which aims to provide the poor with quality treatments in a medical emergency. It is a Government-funded scheme which works like a group health insurance scheme and provides free coverage. The Government has launched this scheme for the welfare of the backward classes and with the progress that the scheme has made, the potential for growth is good.

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