New Govt Schemes:: Ayushman Bharat health insurance scheme: Who all it covers and how

New Govt Schemes: Ayushman Bharat health insurance scheme: Who all it covers and how 

Prime Minister Modi's flagship Ayushman Bharat Scheme will cover over 10 crore poor and vulnerable families providing cashless coverage of up to Rs 5 lakh per family per year for secondary and tertiary care hospitalisation. This will be the world's largest government funded health care programme.

Every person listed in the Socio Economic Caste Census (SECC) database will automatically be enrolled in the scheme. While the beneficiaries can avail benefits in both public and empanelled private facilities, the payment for treatment will be done on package rate (to be defined by the government in advance) basis. "It is essential to ensure that we free the poor of India from the clutches of poverty due to which they cannot afford healthcare," Modi said.

SECC survey was taken as a base to calculate the number of beneficiaries under the scheme which would be rolled out from September 25, on the birth anniversary of Pandit Deendayal Upadhyay as announced by prime minister. This scheme stands to benefit 50 crore Indians by providing them cashless cover of upto Rs 5 lakh per family per year without any premium. "It is high time we ensure that the poor of India get access to good quality and affordable healthcare," Prime Minister Modi said.

According to the SECC survey 2011, there were in total 24.49 Ccrore households out of which 17.97 crore were rural households and 6.51 crore were urban households.

People who are eligible to receive benefits under the Ayushman bharat scheme are as follows:

In Rural areas

1. Households living in only one room with kucha walls and kucha roof.

2. Households with no adult member between age 16 to 59

3. Female headed households with no adult male member between age 16 to 59

4. Households having at least one disabled member and no able-bodied adult member

5. SC/ST households

6. Landless households deriving major part of their income from manual casual labour

7. Households without shelter

8. Destitute/ living on alms

9. Manual scavenger families

10. Primitive tribal groups

11. Legally released bonded labour

In Urban areas:

The following occupational category of workers are automatically included in the list

1. Rag picker

2. Beggar

3. Domestic worker

4. Street vendor/ Cobbler/hawker / Other service provider working on streets

5. Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and another head-load worker

6. Sweeper/ Sanitation worker / Mali

7. Home-based worker/ Artisan/ Handicrafts worker / Tailor

8. Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller

9. Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter

10. Electrician/ Mechanic/ Assembler/ Repair worker

11. Washer-man/ Chowkidar

Highlights

Ayushman Bharat aims to provide healthcare facilities to over 10 crore families covering urban and rural poor

PMJAY-Ayushman Bharat is the biggest government-sponsored healthcare scheme in the world

The scheme offers an insurance cover of Rs 5 lakh, which will cover almost 50 crore citizens

Prime Minister Shri Narendra Modi, in his Independence Day speech of 2018, announced the launch of the Ayushman Bharat-National Health Protection Scheme (AB-NHPS). He said that the national health insurance scheme will be rolled out on a pilot basis in some states. The full-scale roll-out of the project is expected to be in September end. 

On September 23, 2018, the Prime Minister Narendra Modi launched Ayushman Bharat, world's largest government-funded healthcare scheme in Jharkhand's capital Ranchi. The Centre's flagship scheme has been renamed as PM Jan Arogya Yojana (PMJAY). The scheme will become operational from September 25 on the birth anniversary of Pandit Deendayal Upadhyay. 

According to the various government websites, here is a look at what the health insurance scheme is all about. 

Who is the AB-NHPS aimed at?

The scheme is targeted at poor, deprived rural families and identified occupational category of urban workers' families. So, if we were to go by the Socio-Economic Caste Census (SECC) 2011 data, 8.03 crore families in rural and 2.33 crore in urban areas will be entitled to be covered under these scheme, i.e., it will cover around 50 crore people. 

AB-NHPS will have a defined benefit cover of Rs 5 lakh per family (on a family floater basis) per year for secondary and tertiary care hospitalisation. It will offer a benefit cover of Rs 5 lakh per family per year. It will subsume the existing Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008 by the UPA government. 

Who all are covered? 

To ensure that nobody is left out (especially women, children and the elderly), there will be

no cap on the family size and age under the AB-NHPS. The scheme will be cashless and

paperless at public hospitals and empanelled private hospitals.

How will the entitlement be decided?

AB-NHPM will be an entitlement based scheme where it will be decided on the basis of

deprivation criteria in the SECC database. The beneficiaries are identified based on the

deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC database

for rural areas. For the urban areas, the 11 occupational criteria will determine entitlement.

In addition, Rashtriya Swasthya Bima Yojna (RSBY) beneficiaries in states where it is

active are also included.

Rural area categories: The different categories in rural areas include families having only

one room with kucha walls and kucha roof; families having no adult member between the

ages of 16 years and 59 years; female-headed households with no adult male member

between the ages of 16 years and 59 years; disabled members and no able-bodied adult

member in the family; SC/ST households; and landless households deriving major part of

their income from manual casual labour.

Also, these families in rural areas having any one of the following will be automatically

included: households without shelter, destitute, living on alms, manual scavenger families,

primitive tribal groups, and legally released bonded labour.

Urban area categories: For urban areas, 11 defined occupational categories are entitled

under the scheme. Main source of income related to household has been clarified in urban

areas as beggars; rag-pickers; domestic workers; street vendors/cobblers/hawkers/other

service providers working on the streets; construction workers/ plumbers/ masons/ labor/

painters/ welders/ security guards/coolies and other head-load workers; Sweepers/

sanitation workers/ malis; Home-based workers/ artisans/handicrafts workers/ tailors;

Transport workers/ drivers/ conductors/helpers to drivers and conductors/cart pullers/

workers; washer-men/ chowkidars; Other work/Non-work ; Non-work (Pension/ Rent/

Interest, etc.)

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 are the inclusions?

AB-NHPM will cover medical and hospitalisation expenses for almost all secondary care

and most of tertiary care procedures. The health ministry has included 1,354 packages in

the scheme under which treatment for coronary bypass, knee replacements and stenting

among others would be provided at 15-20 per cent cheaper rates than the Central

Government Health Scheme (CGHS).

What is the eligibility criteria for a beneficiary?

There is no enrolment process in AB-NHPM as it is an entitlement-based mission. Families

who are identified by the government on the basis of deprivation and occupational criteria

A list of eligible families has been shared with the respective state governments as well as

state level departments like the ANMs, BMO, and BDOs of relevant areas. A dedicated

AB-NHPM family identification number will be allotted to eligible families. Only families

whose name is on the list are entitled for the benefits of AB-NHPM.

Additionally, families with an active RSBY cards as of 28 February 2018 will covered. No

additional new families can be added under AB-NHPM. However, names of additional

family members can be added for those families whose names are already on the SECC

list.

The official website of AB-NHPM is www.abnhpm.gov.in . One may visit the site to view

and download the beneficiary eligibility and empanelled hospitals list as and when it gets

updated.

Hospital eligibility

Services under the scheme can be availed at all public hospitals and empaneled private

health care facilities. Also, the basic empanelment criteria allows empanelment of a

hospital with a minimum of 10 beds, with the flexibility provided to states to further relax

this if required. Empanelment of the hospitals under AB-NHPM will be conducted through

an online portal by the state government. Information about empaneled hospitals will be

made available through different means such as government websites and mobile apps.

Beneficiaries can also call the helpline number at 14555.

To control costs, the payments for treatment will be done on package rate (to be defined

by the Government in advance) basis. However, hospitals with NABH/NQAS accreditation

can be incentivised for higher package rates subject to procedure and costing guidelines.