Pradhan Mantri Jan Arogya Yojna (PM-JAY)

In Context

• The Pradhan Mantri Jan Arogya Yojana (PM-JAY) provided a cushion to only 14.25 per cent of people hospitalized for the COVID-19, between April 2020 and June 2021. 

Pradhan Mantri Jan Arogya Yojna (PM-JAY)

• About:
  • The scheme was launched in September 2018 and recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC).
  • It is a Centrally Sponsored Scheme having a central sector component under Ayushman Bharat Mission
  • PM-JAY was earlier known as the National Health Protection Scheme (NHPS) before being rechristened. 
    • It subsumed the then-existing Rashtriya Swasthya Bima Yojana (RSBY) which had been launched in 2008. 
• Key Features: 
  • It is the world’s largest health insurance/ assurance scheme fully financed by the government and the cost of implementation is shared between the Central and State Governments.
  • It provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empanelled hospitals in India.
  • It covers up to 3 days of pre-hospitalization and 15 days of post-hospitalization expenses such as diagnostics and medicines.
  • There is no restriction on the family size, age or gender.
    • The RSBY had a family cap of five members. 
  • All pre-existing conditions are covered from day one.
• Eligibility: 
  • The households included are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. 
    • The coverage mentioned under PM-JAY, therefore, also includes families that were covered in RSBY but are not present in the SECC 2011 database. 
• Cover Under PM-JAY
  • The cover under the scheme includes all expenses incurred on the following components of the treatment.
    • Medical examination, treatment and consultation
    • Pre-hospitalization
    • Medicine and medical consumables
    • Non-intensive and intensive care services
    • Diagnostic and laboratory investigations
    • Medical implantation services (where necessary)
    • Accommodation benefits.
    • Food services
    • Complications arising during treatment
    • Post-hospitalization follow-up care up to 15 days

• Aims and Objectives:
  • To accelerate health system preparedness for immediate responsiveness for early prevention, detection and management, with a focus on health infrastructure development including for Paediatric Care and with measurable outcomes.

• Benefits: 
  • It provides cashless access to health care services for the beneficiary at the point of service, that is, the hospital.
  • It envisions to help mitigate catastrophic expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year.

• Achievements 
  • In the last three years, the AB PM-JAY scheme has achieved several milestones in achieving the target of Universal Health Coverage.
  • The scheme has widened its arm across 33 States/Union Territories bringing ease to the beneficiary’s life while availing the treatment. 
    • More than 2 crore treatments have been provided to the beneficiary under the scheme. 
    • More than 17 crore beneficiaries have been verified through Beneficiary Identification System (BIS) and have been provided with Ayushman cards.
    • It has proved to be a boon for women.
      • Of the total number of beneficiaries who have got benefitted under the scheme, over half of them are women.

• Issues 
  • PM-JAY paid for only 0.52 million COVID-19 hospitalisations across the country. 
    • the share is negligible keeping in mind that the scheme claims to cover 165 million beneficiaries across the country.
  • The government insurance schemes did not cover all the target groups and eligible individuals, even those enrolled under insurance schemes were forced to fight the pandemic on their own and cough up large amounts of money to avail themselves of treatment. 
  • Under PM-JAY, beneficiaries can go to only a list of empanelled private hospitals. This has remained a major problem, particularly in smaller towns and villages, where hospitals are few and far between. 
  • PM-JAY has left out certain communities. Thousands of sex workers in Pune’s Budhwar Peth zone, for example, fought a solitary battle against the pandemic. 

What lies ahead?

• The government is re-engineering beneficiary identification systems to facilitate easier and faster enrolment for the scheme’s beneficiaries.

• The government is rationalising packages, rates, and treatment protocols to align the same with the expectations of the medical fraternity. 
  • This will help in making the packages more viable for the empanelled healthcare providers and attractive for newer ones to join the PM-JAY ecosystem. 

• The government is also making the IT platform more robust to streamline and automate claim adjudication protocols for faster claim settlements.
• AB PM-JAY aspires to build a healthcare super-highway in consonance with the National Digital Health Mission (a flagship scheme also driven by the NHA) to offer a holistic continuum of healthcare for innumerable families in the country.

Source: DTE