The Sustainable Development Goals (SDGs) and their underlying resolve to leave no one behind were the driving forces behind the Government of India's 2017 launch of the Ayushman Bharat Scheme. As part of the government’s National Health Policy 2017 with its vision of universal health coverage, the health insurance programme was created to offer over ten crore families financial security with coverage of INR 500,000 per household per year. Much like most private health insurance schemes, the Ayushman Bharat Yojana or Ayushman Bharat Scheme also provides cashless treatment. This cashless treatment can be availed at public hospitals and empanelled private hospitals. The scheme is jointly funded by the central and state governments.
Who Can Get Cashless Benefits Under the Ayushman Bharat Yojana?
Benefits under the programme are available to deprived rural families and identified occupational categories of families of urban workers as classified by the Socio-Economic Caste Census (SECC-2011) database based on 6 deprivation criteria and 11 occupational criteria across rural and urban areas, respectively. However, some states have expanded the scope of the scheme to include other categories of beneficiaries as well.
The scheme is expected to benefit over ten crore families. This health insurance coverage is provided through the Pradhan Mantri Jan Arogya Yojana (PMJAY), one of the two main components of the Ayushman Bharat Yojana – the other component being the creation of 1,50,000 Health and Wellness Centres . As PMJAY is the rechristened version of the National Health Protection Scheme (an earlier version of it being Rashtriya Swasthya Bima Yojana or RSBY), persons earlier registered under the RSBY can also avail benefits under the scheme. Unlike the earlier schemes, there is absolutely no restriction on family size. Nor are there any restrictions imposed due to age or gender.
Procedures Covered Uder Ayushman Bharat’s PMJAY
PMJAY will cover medical and hospitalisation charges for practically most of the tertiary care procedures and all secondary care procedures. PMJAY promises secondary and tertiary hospitalisation care through a set of 1393 defined packages, including one unspecified surgical package, across 24 specialties. Procedures covered include appendicectomy, coronary artery bypass, bypass-inoperable pancreas, skull base surgery, colostomy, gastrostomy, hernia-related surgical procedures, cleft palate repair, cleft lip repair, varicose veins and a host of other procedures, as well as neo-natal care, neurosurgery and mental disorder related treatment.
Expenses Covered Under the Scheme
The PMJAY covers both pre and post hospitalisation charges and includes the following:
- Medical examination, treatment, and consultation
- Pre-hospitalisation
- Medicine and medical consumables
- Non-intensive and intensive care services
- Diagnostic and laboratory investigations
- Medical implant services (where necessary)
- Accommodation benefits
- Food services
- Complications arising during treatment
Network Hospitals are expected to provide free follow-up consultation, diagnostics, and medicines under the scheme up to 15 days from the date of discharge of the insured. The scheme also covers up to 3 days of pre-hospitalization expenses such as diagnostics and medicines.
Waiting period under Ayushman Bharat’s PMJAY Scheme
There is no waiting period under the PMJAY scheme. This makes it stand out from medical insurance coverage provided by private players. Moreover, there is no waiting period even for complications arising from pre-existing diseases.
Sum Insured/Coverage Under PMJAY
This scheme offers a total cover of INR 500,000/- per year per family. It is a family floater plan and any or all members of the family may avail a benefit of up to INR Five Lakhs a year.
To conclude, it is very much possible to obtain cashless treatment under the Ayushman Bharat Yojana. In fact, it is best to avail benefits under the scheme from the government and empanelled private hospitals through the cashless route. An eligible family is provided coverage up to INR 5 lakhs a year, and the scheme is targeted at the poor and vulnerable. The scheme, if successfully implemented, will fast forward India’s achievement of SDG 3 – “Ensure healthy lives and promote well-being for all at all ages”.
Exclusions Under the Pradhan Mantri Jan Arogya Yojana
As per the Central Government norms, if you have been not been categorised as eligible as per the SECC-2011 norms explained above, earn more than INR 10,000/- per month, have agricultural land of more than five acres, own a four-wheeler motorised vehicle or are a government employee, you cannot avail any benefits under this scheme. The state government issues health cards only to eligible persons. It is only on production of the health card, you can avail of benefits under the scheme.
Read more- 5 Cost Effective Government Sponsored Health Insurance Schemes You Can Avail in India
