Prime Minister Narendra Modi launched the world's largest state-funded health scheme, the Pradhan Mantri Jan Arogya Yojana (PMJAY) in Ranchi on Sunday. The scheme which is solely launched to benefit the poor, is touted to change the healthcare scenario in India. Modi said the plan will form a model for other countries to follow and replicate. Addressing an enthusiastic crowd in Ranchi, he said, “A government scheme on such a grand scale is not being carried out anywhere in the world. Even the last person standing in the queue should get better health facility. More than 500 million people will get health insurance up to Rs 5,00,000. This is the world's first such scheme.”
In less than a day after the announcement, over 1,000 patients across the country availed the benefits of the health insurance scheme, with maximum cases reported from Chhatisgarh and Haryana, followed by Jharkhand, Assam, and Madhya Pradesh. Nearly 20 patients were admitted on the inaugural day of the scheme and operated on at the Rajendra Institute of Medical Sciences (RIMS), Ranchi. The first beneficiary of the scheme was Punam Mahato of Jharkhand, who gave birth to a baby girl at a hospital in Jamshedpur.
Around 56,00,000 families in Jharkhand will be covered under the scheme. The Centre has identified 25,00,000 families in Jharkhand, but Chief Minister Raghubar Das added another 32,00,000 and agreed to bear the additional cost of £54 million. The scheme will allow a beneficiary to access healthcare at government as well as private hospitals. There is no cap on family size and age or restriction on pre-existing conditions. An estimated £1.2 billion will be spent under the scheme with 60% being borne by the Centre and 40% by states.
Ayushman Bharat Pilot: The Who and What of It
Currently, 29 out of 36 states and union territories have agreed to join the scheme. While Odisha has opted out, another six are expected to sign up in the coming months. Indu Bhushan, Chief Executive Officer, National Health Agency, said, “Private hospitals may not be enrolled in some states as the purpose of launching the scheme on pilot basis is to test our systems in real time.” He stated that private hospitals will be included later.
Currently, Telangana, Odisha, Kerala, Delhi and Punjab have refrained from signing the MoU on different grounds, including claims that their health care schemes are better than Ayushman Bharat and hence, the scheme won’t be implemented in these states.
The scheme is a Rs 5,00,000 cashless family floater insurance covering all members of the household for one year. New members can be added following the government's approval. It covered 1,354 medical and surgical packages categorised under 25 specialties such as cardiology, neurosurgery, oncology (chemotherapy for 50 types of cancers), burns, and others. Patients however, can't avail surgical and medical packages at the same time.
Benefits
- Hospitalisation expenses include such as registration, nursing and boarding charges in general ward.
- Consultation fees, surgical equipment and procedure charges and cost of implants, medicines, diagnostic tests and food for patients.
- Follow-up care along with pre and post-hospitalisation expenses.
- In case of multiple surgeries, the highest package rate will be waived for the first treatment, and 50 per cent and 25 per cent of the costs will be provided for the second and third treatment, respectively.
Rates for the scheme will be fixed by the state health agency in consultation with the selected insurer and empanelled hospitals for three years. The third year will be contingent to the performance of the insurer in the first two.
The states and UTs have opted to set up trusts or subsidy pools with 60:40 contribution by central and state governments. Funds will be granted at a flat premium of Rs 500 a family for the first six months. The mixed model- which is opted by eight states, claims of up to Rs 1,50,000 will be covered by an insurer and anything exceeding that will be settled by the trust.
How the scheme will be implemented
It will be jointly run by the central and state governments. The National Health Agency (NHA), under the Ministry of Health and Family Welfare will implement the scheme and run the web portal. State health agencies will sign contracts with insurers and empanelled hospitals. They will be responsible for auditing and monitoring the scheme through spot checks. They will also ensure that hospitals have the required IT and allied infrastructure to identify beneficiaries, print e-cards, and provide services. At the district level, the insurer will set up an office within 15 days of signing the insurance contract with the state, and hospitals will be selected after approval and audit through committees. A contract will then be signed between the insurer, the state and the hospital within seven days.
Budget
The overall budget for the scheme, which is still provisional, for 2018-19, was £200 million, as per a written response by the Minister of State for Health and Family Welfare in Parliament.
How hospitals will be selected
While public hospitals will be empanelled from day one, private hospitals can register through the scheme portal. Approximately 7,826 hospitals have joined so far, of which, 47 per cent are private. The government has laid certain conditions for all network hospitals. They must have at least 10 inpatient beds with adequate spacing and supporting staff. Hospitals providing surgical packages must have a minimum of 15 beds. Quality certification from National Accreditation Board for Hospitals & Healthcare Providers will be mandatory for all the selected hospitals within a year of approval.
Eligibility
Beneficiaries have been identified and chosen on the basis of the latest Socio-economic Caste Census (SECC) data. It is reported that they have been identified on the basis of deprivation categories like D1, D2, D3, D4, D5, and D7 respectively. For urban areas, entitlement criteria will be determined on the basis of 11 occupational categories. Beneficiaries of Rashtriya Swasthya Bima Yojna (RSBY) will also be included.
A website has been launched by the NHA, along with a helpline number for prospective beneficiaries to check if their names are there in the final list. Mobile number or ration card number, SECC name, or RSBY URN can be used to find out if an individual is eligible to become a beneficiary. In case one's name does not appear in the list, they can contact a nearby Ayushman Mitra.
Avail the scheme
There is no limitation on the size of the family or age, and an Aadhaar Card is not compulsory to avail the scheme. Beneficiary patients will have to approach an empanelled hospital, where 'Arogya Mitras' will assist them in admission. Each hospital will have an 'Ayushman Mitra Help Desk' where the identity verification will be done using Aadhaar or any other ID like voter or ration card. A letter with QR codes will be given to the beneficiaries which will be scanned by the doctors and a demographic authentication will be conducted for identification which will help to verify the person's eligibility.
After, the hospital will select a package and check balance as well as submit supporting evidence required for the treatment. Members of the beneficiary families will not have to pay anything in case of hospitalisation, provided they visit empanelled hospitals.
BOX
- Scheme to provide cashless and paperless access to healthcare services
- Health insurance cover of Rs 5,00,000 to 500 million poor people
- Scheme will cover 10.74 million rural and urban families as identified in SECC 2011
- Will not cover primary care, only the cost of hospitalisation
- Anti-fraud cells to be established at the national and state level, and strong IT tolls will deployed to prevent and detect fraud
- Over 8,375 hospitals, both public and private, empanelled for the scheme, and as many as 31 states and union territories have signed MoUs with the Centre to implement the scheme
- States settled to decide on mode of implementation with seven states planning to adopt the insurance mode, 18 stated to follow the trust route, while the remaining nine to follow the mixed model
