Ayushman Bharat – Prathan mantri Jan Arogya Yojana
Universal Health Coverage access to healthcare services at the primary, secondary and tertiary care levels.
The scheme is entitlement based. No formal enrolment process is required.
Prathan Mantri Jan Arogya Yojana (PMJAY) will target poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) 2011 data, both rural and urban. Additionally, all such enrolled families under Rashtriya Swasthaya Bima Yojana (RSBY) that do not feature in the targeted groups as per SECC data will be included as well.
Who are not covered under the scheme?
As per the SECC 2011, the following beneficiaries are automatically excluded:
- Households having motorized 2/3/4 wheeler/fishing boat
- Households having mechanized 3/4 wheeler agricultural equipment
- Households having Kisan Credit Card with credit limit above Rs. 50,000/-
- Household member is a government employee
- Households with non-agricultural enterprises registered with government
- Any member of household earning more than Rs. 10,000/- per month
- Households paying income tax
- Households paying professional tax
- House with three or more rooms with pucca walls and roof
- Owns a refrigerator
- Owns a landline phone
- Owns more than 2.5 acres of irrigated land with 1 irrigation equipment
- Owns 5 acres or more of irrigated land for two or more crop season
- Owning at least 7.5 acres of land or more with at least one irrigation equipment
There may still be some glaring instances, where some of those who must be automatically excluded in 2011, are figuring in the list of eligible beneficiaries. In such cases, states are advised to authorize the District Collectors/ District Magistrates or Deputy Commissioners to exclude such beneficiaries from the eligible list.
Where can beneficiaries’ avail of services under PM-JAY?
- Beneficiaries can also call the helpline number at 14555
Will a card be given to the beneficiary?
- A dedicated PM-JAY family identification number will be allotted to eligible families. Additionally, an e-card will also be given to beneficiary at the time of hospitalization.
Elaborated process at hospitals:
- For the identification as a PM-JAY beneficiary, the patient can do any of the following:
- Ask the staff at the EHCP registration desk to check through the ‘Am I Eligible’ application either through mobile , app or website
- Approach the PM-JAY Kiosk and check through the ‘Am I Eligible’ application
- Approach the call centre on 14555
- Self-service using the mobile website / application of ‘Am I Eligible’
- Once the patient is identified as a PM-JAY beneficiary, they will be directed to the PM-JAY Kiosk where the Pradhan Mantri Arogya Mitra (PMAM) will verify the beneficiary’s identity and eligibility using the Beneficiary Identification System (BIS) and create a e-card (golden record) for the beneficiary unless he/she already has a e-card.
- The PMAM informs the beneficiary that they are eligible for free treatment under PM-JAY only if they are hospitalized and are not required bear any expenses. Additionally, the beneficiary is informed of the amount of charges they may have to bear in case they are not hospitalized e.g. diagnostics (if any) etc.
- The beneficiary receives consultation from a general doctor or a specialist (on a case by case basis)
- The doctors have a standard template for pre-authorization form (attached as Annexure I) and also a list of packages covered in his/her specific speciality. The hospital will be responsible for printing and providing this list to the doctors and other relevant staff.
- The beneficiary shall be either be prescribed medical drugs, directed for further diagnostics or hospitalization.
- Beneficiaries prescribed medical drugs and not requiring hospitalization will pay relevant consultation and drug charges if and as applicable
- For a beneficiary who has been suggested diagnostics:
- The beneficiary should avail the diagnostic facility within the EHCP or from a EHCP empanelled diagnostic provider.
- The hospital will not collect any money from the beneficiary before the diagnosis and shall ensure that the empanelled diagnostic provider also does not collect any money from the beneficiary
- The beneficiary is informed of the amount of charges for diagnosis they may have to bear in case they are not hospitalized. Only in case of not being hospitalized the beneficiary would be required to pay the relevant charges for diagnosis.
- For beneficiaries requiring hospitalization:
- The standard template for pre-authorization will be filled by the treating specialist doctor / MEDCO (medical coordinator). (Every EHCP may nominate a medical doctor who shall act as a coordinator between the PMAM and the treatment doctor)
- The treating doctor / MEDCO will be responsible for providing the necessary documents (filled pre-authorization form, diagnostic reports, clinical notes etc.) to the PMAM
- The PMAM shall click a picture of the beneficiary / patient on the hospital bed and upload the picture on the TMS portal
- The PMAM shall select the medical package recommended by the specialist doctor / MEDCO and upload the necessary documents required for processing the pre-authorization request in the Transaction Management System.
The PMAM shall also be responsible for handling any follow up queries from the ISA / Trust:
- For packages requiring a pre-authorization from ISA, the request generated shall be approved by within a maximum time of 6 hours by the ISA / Trust.
- For packages not requiring a pre-authorization from ISA, the request shall be approved automatically. However, there needs to be a pre-authorization filed for up to a maximum of 5 days if length of stay is longer than 1 day. Subsequent pre-authorizations will be required as applicable if beneficiary needs to remain hospitalized for more than authorized period.
- During the treatment period or post-surgery, the PMAM shall click another picture of the beneficiary / patient on the hospital bed and upload the picture on the TMS portal
- Once the treatment is complete and the beneficiary is ready to be discharged, the PMAM shall collect the necessary documents such as the discharge summary (Attached as Annexure II) , clinical notes, medical scans etc. which will be required for filing claims. Additionally, the PMAM shall click another picture of the beneficiary / patient at the time of discharge and upload the picture on the TMS portal. A physical copy of discharge summary and other documents such as diagnostic reports etc. may also be provided to the patients.
- Post-discharge, the EHCP will provide the beneficiary with relevant medication and diagnostics as per the package for up to 15 days as applicable. The PMAM will be responsible for informing the beneficiary about these entitlements.
- The PMAM will be responsible for collecting feedback from the beneficiary in a standard feedback form. The feedback shall be further studied by the SHA / NHA to improve upon the overall quality of care.
- Also, to further improve the quality of care, the call centre shall also be assessing feedback by contacting a sample set of discharged beneficiaries.