What is Ayushman Bharat health insurance? All you need to know about what is covered, eligibility & more

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Exactly three years ago today, Prime Minister Narendra Modi launched the Pradhan Mantri Jan Arogya Yojna (PM-JAY), also known as Ayushman Bharat. According to the government’s National Health Authority (NHA) website, the Ayushman Bharat PM-JAY is the largest health assurance scheme in the world which aims at providing a health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries) that form the bottom 40% of the Indian population.

Along with various diseases, the Ayushman Bharat health insurance scheme also covers Covid-19. According to NHA, the treatment and testing of Covid-19 will be done for free of cost at any of the private hospitals empanelled for the scheme. Quarantine at a private hospital will also be covered under this insurance.

Here is a look at the key features of the scheme, benefits, what is covered, and how to check eligibility.

Who is eligible for Ayushman Bharat?

Rural households which are included (not excluded) are then ranked based on their status of seven deprivation criteria (D1 to D7). Urban households are categorised based on occupation categories.

Rural beneficiaries:

Out of the total seven deprivation criteria for rural areas, PM-JAY covered all such families who fall into at least one of the following six deprivation criteria (D1 to D5 and D7) and automatic inclusion(Destitute/ living on alms, manual scavenger households, primitive tribal group, legally released bonded labour) criteria:

  • D1- Only one room with kucha walls and kucha roof
  • D2- No adult member between ages 16 to 59
  • D3- Households with no adult male member between ages 16 to 59
  • D4- Disabled member and no able-bodied adult member
  • D5- SC/ST households
  • D7- Landless households deriving a major part of their income from manual casual labour

Urban beneficiaries

For urban areas, the following 11 occupational categories of workers are eligible for the scheme:

  • Ragpicker
  • Beggar
  • Domestic worker
  • Street vendor/ Cobbler/hawker / other service provider working on streets
  • Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and other head-load worker
  • Sweeper/ Sanitation worker/ Mali
  • Home-based worker/ Artisan/ Handicrafts worker/ Tailor
  • Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller
  • Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter
  • Electrician/ Mechanic/ Assembler/ Repair worker
  • Washer-man/ Chowkidar

What is the hospitalisation process?

The beneficiaries will not be required to pay any charges and premium for the hospitalisation expenses. The benefit also include pre- and post-hospitalisation expenses.

Each empanelled hospital will have an ‘Ayushman Mitra’ to assist patients and will coordinate with beneficiaries and the hospital. They will run a help desk, check documents to verify the eligibility, and enrolment to the scheme.

Also, all the beneficiaries will be given letters having QR codes which will be scanned and a demographic authentication will be conducted for identification and to verify his or her eligibility to avail the benefits of the scheme.

Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.

What is included?

To ensure that the hospitals do not overcharge and rates do not vary across hospitals, empanelled health care providers (EHCP) are paid based on specified package rates. A package consists of all the costs associated with the treatment, including pre and post hospitalisation expenses. The specified surgical packages are paid as bundled care (explained below) where a single all-inclusive payment is payable to the EHCP by insurer/SHA. The medical packages, however, are payable to the EHCP on a per day rate depending upon the admission unit (general ward, HDU, ICU) with certain pre-decided add-ons payable separately. Day-care packages are payable just like surgical packages. The treatment packages are comprehensive, covering treatment for nearly 24 specialities that include super speciality care like oncology, neurosurgery and cardio-thoracic and cardiovascular surgery, etc. The package rate (in case of surgical or defined day-care benefits) includes:

  • Registration charges
  • Bed charges (General Ward)
  • Nursing and Boarding charges
  • Surgeons, Anaesthetists, Medical Practitioner, Consultants’ fees, etc.
  • Anaesthesia, Blood Transfusion, Oxygen, O.T. Charges, Cost of Surgical Appliances, etc.
  • Medicines and Drugs
  • Cost of Prosthetic Devices, implants (unless payable separately)
  • Pathology and radiology tests: radiology to include but not be limited to X-ray, MRI, CT Scan, etc. (as applicable)
  • Food to patient
  • Pre and Post Hospitalisation expenses: Expenses incurred for consultation, diagnostic tests and medicines before the admission of the patient in the same hospital, and up to 15 days of the discharge from the hospital for the same ailment/ surgery
  • Any other expenses related to the treatment of the patient in the EHCP

Documents required

To get benefits under the Ayushman Bharat Yojana, the eligible person has to show his/her eligibility with proofs such as an Aadhaar card, a Voter ID card or ration card.

How to check if you are eligible for PMJAY?

  • Visit the official government website
  • Click on the tab ‘Am I Eligible?’
  • Enter your phone number, CAPTCHA code and click on ‘Generate OTP’
  • Submit the details, including state, your name, ration card number, and household number
  • If your family is covered under PMJAY, your name will flash on the screen

You can also check by calling 14555 and 1800111565 helpline numbers.

What is the enrolment process? Is there any time period for enrolment?

PM-JAY is an entitlement based mission. There is no enrolment process. Families who are identified by the government on the basis of deprivation and occupational criteria using the SECC database both in rural and urban areas are entitled for PM-JAY.

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.



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