Ayushman Bharat, a flagship scheme of Government of India, was launched as recommended by the

National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been

designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to "leave no

one behind."

Ayushman Bharat is an attempt to move from sectoral and segmented approach of health service

delivery to a comprehensive need-based health care service. This scheme aims to undertake path breaking

interventions to holistically address the healthcare system (covering prevention, promotion and ambulatory care) at

the primary, secondary and tertiary level. Ayushman Bharat adopts a continuum of care approach, comprising of

two inter-related components, which are -

 Health and Wellness Centres (HWCs)

 Pradhan Mantri Jan Arogya Yojana (PM-JAY)

1. Health and Wellness Centers (HWCs)

In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness

Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres. These centres are to

deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people. They

cover both, maternal and child health services and non-communicable diseases, including free essential drugs and

diagnostic services.

Health and Wellness Centers are envisaged to deliver an expanded range of services to address the

primary health care needs of the entire population in their area, expanding access, universality and equity close to

the community. The emphasis of health promotion and prevention is designed to bring focus on keeping people

healthy by engaging and empowering individuals and communities to choose healthy behaviours and make

changes that reduce the risk of developing chronic diseases and morbidities.

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)

The second component under Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojna or PM-JAY

as it is popularly known. This scheme was launched on 23rd September, 2018 in Ranchi, Jharkhand by the

Hon’ble Prime Minister of India, Shri Narendra Modi.

Ayushman Bharat PM-JAY is the largest health assurance scheme in the world which aims at

providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over

10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries) that form the bottom 40% of the

Indian population. 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. 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. The coverage mentioned under PM-JAY,

therefore, also includes families that were covered in RSBY but are not present in the SECC 2011 database. PM-

JAY is fully funded by the Government and cost of implementation is shared between the Central and State

Governments.

Key Features of PM-JAY

 PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government.

 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.

 Over 10.74 crore poor and vulnerable entitled families (approximately 50 crore beneficiaries) are eligible for

these benefits.

 PM-JAY provides cashless access to health care services for the beneficiary at the point of service, that is,

the hospital.

 PM-JAY envisions to help mitigate catastrophic expenditure on medical treatment which pushes nearly 6

crore Indians into poverty each year.

 It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics

and medicines.

 There is no restriction on the family size, age or gender.

 All pre–existing conditions are covered from day one.

 Benefits of the scheme are portable across the country i.e. a beneficiary can visit any empanelled public or

private hospital in India to avail cashless treatment.

 Services include approximately 1,393 procedures covering all the costs related to treatment, including but

not limited to drugs, supplies, diagnostic services, physician's fees, room charges, surgeon charges, OT

and ICU charges etc.

 Public hospitals are reimbursed for the healthcare services at par with the private hospitals.

Benefit Cover Under PM-JAY

Benefit cover under various Government-funded health insurance schemes in India have always been

structured on an upper ceiling limit ranging from an annual cover of INR30,000 to INR3,00,000 per family across

various States which created a fragmented system. PM-JAY provides cashless cover of up to INR5,00,000 to each

eligible family per annum for listed secondary and tertiary care conditions. 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

The benefits of INR 5,00,000 are on a family floater basis which means that it can be used by one or

all members of the family. The RSBY had a family cap of five members. However, based on learnings from those

schemes, PM-JAY has been designed in such a way that there is no cap on family size or age of members. In

addition, pre-existing diseases are covered from the very first day. This means that any eligible person suffering

from any medical condition before being covered by PM-JAY will now be able to get treatment for all those medical

conditions as well under this scheme right from the day they are enrolled.

Why PM-JAY: A Background

Over the last few decades, the world’s eyes have been on India as it’s economy has been one of the

top three fastest growing economies of the world. However, despite making remarkable strides in several sectors,

India is still classified as a Lower Middle-Income Country (LMIC) according to World Bank classification of

countries based on per capita GDP, mostly due to its inconsistent socio-economic and health indicators.

Statistics show that more than 20 per cent of India’s population still lives under $1.9 per day (2011

PPP). According to a World Bank projection, by 2021 more than 34% of India’s population will be in the age group

of 15-35 years. This rich demographic dividend enables India to be highly optimistic about a sustained economic

growth for few more decades before a higher dependency ratio sets in. However, the perceived benefits of the

higher demographic dividend are threatened by the epidemiological transition in India which is currently facing the

unique situation of a “triple burden of disease.” As the mission of eradication of major communicable diseases

remains unfinished, the population is also bearing the high burden of non-communicable diseases (NCDs) and

injuries. This leads to an overall rise in the demand for health care over a prolonged period of time.

However, with a total population of more than 1.3 billion people, the supply side of adequate and

affordable healthcare in India is found wanting. Figures show an overwhelming tilt towards health care services in

the private sector which cater to nearly 70% of all visits for health care needs in India and have 50% of total

hospital beds. But, individually most providers in the private sector are very small (with less than 25 beds). They

are also unregulated, with varying standards of quality of care and are mostly situated in large metros or urban

neighbourhoods leaving a great deficit of health services for the underprivileged population of India.
 But being the second most populous nation in the world, the public sector hospitals in India are

understandably overburdened. Their utilisation varies widely and they often have to work under challenging

circumstancing arising from the lack of sufficient funds, a shortage of trained health workers and the erratic and

often deficient supply of drugs and equipment which adversely impacts their functioning.

One of the major causes of this situation is the persistent underfunding of the country’s public health

care system. Over the last two decades, the Government of India’s overall expenditure on health has remained

stagnant at about 1.2% of its GDP (Source: National Health Accounts, 2015). Of its total expenditure on health,

India spends only 21% from the Government revenue and as high as 62% from out-of-pocket expenses (Source:

National Health Accounts, 2015). Thus, it has been deduced that increasing health care needs, coupled with high

out-of-pocket expenditure, is a leading cause of poverty in India. Not only does it keep people poor, but it also

pushes nearly 6 crore Indians back into poverty each year. The following graph depicts this situation clearly by

comparing the OOP to total expenditure on health in two decades.

In the past, there have been several efforts by the Central and various State Governments to

strengthen demand side financing by launching various Government-funded health insurance schemes. The

Rashtriya Swasthya Bima Yojana (RSBY) was launched with an annual cover of INR30,000 per family at the

central level which catered mostly to secondary care hospitalisation while many State schemes catered to tertiary

care conditions. However, these schemes worked independently of the larger health care system in the country
and resulted in further increasing the fragmentation of risk pools. Additionally, none of these schemes had any

linkage with primary health care.

To address these challenges, the Government of India took a two-pronged approach under the

umbrella of Ayushman Bharat. The first component of this strategy was disease prevention and health promotion

to curb the increasing epidemic of non-communicable diseases. This was to be ensured through upgradation of the

existing network of Sub-centres and Primary Health Centres to Health and Wellness Centres (HWC). Nearly

150,000 HWCs are to be set up in the country over the next few years which will work towards reducing the overall

disease burden and hospitalisation needs of the population.

The second component was the launch of the Pradhan Mantri-Jan Arogya Yojana (PM-JAY) which

aims to create a system of demand-led health care reforms that meet the immediate hospitalisation needs of the

eligible beneficiary family in a cashless manner thus insulating the family from catastrophic financial shock. In the

long run, the PM-JAY, through its system of incentives, aims to expand the availability of its services. With greater

demand, the private sector is likely to expand in the unserved areas of Tier-2 and Tier-3 cities. For public hospitals,

PM-JAY will provide an incentive to prioritise poor patients and shall provide means to generate additional revenue

for strengthening their infrastructure and fill their service gaps. PM-JAY has subsumed the existing RSBY and also

works in convergence with various State Government funded health insurance/ assurance schemes.

Because of its scope, PM-JAY is the world’s largest health insurance/assurance scheme that offers a

health cover to nearly 10.74 crore poor families which comes to a staggering 50 crore Indians that form 40% of its

bottom population. It is fully funded by the Government and provides financial protection for a wide variety of

secondary and tertiary care hospitalisations. The prime objective of PM-JAY is to reduce catastrophic out-of-pocket

health expenditure by improving access to quality health care for its underprivileged population. More details on its

evolution, planning, eligibility and state wise implementation are discussed ahead.

Including the poorest and most vulnerable population of any country in the health
insurance programme is often the most challenging because they cannot pay any premium and are
the hardest to reach. Many times they are also not literate and, therefore, require a very different
approach for awareness generation. This is true for most Lower and Middle-Income Countries (LMIC)
and India is not an exception.

Thus, PM-JAY has been rolled out for the bottom 40 per cent of poor and vulnerable
population. In absolute numbers, this is close to 10.74 crore (100.74 million) households. The
inclusion of households is based on the deprivation and occupational criteria of the Socio-Economic
Caste Census 2011 (SECC 2011) for rural and urban areas, respectively. This number also includes
families that were covered in the RSBY but were not present in the SECC 2011 database.

The SECC involves ranking of the households based on their socio-economic status. It
uses exclusion and inclusion criteria and accordingly decides on the automatically included and
automatically excluded households. 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.

In line with the approach of the Government to use the SECC database for social welfare
schemes, PM-JAY also identifies targeted beneficiary families through this data.
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

Even though PM-JAY uses the SECC as the basis of eligibility of households, many States
are already implementing their own health insurance schemes with a set of beneficiaries already
identified. Thus, States have been provided the flexibility to use their own database for PM-JAY.
However, they will need to ensure that all the families eligible based on the SECC database are also
covered.
Expansion of coverage by States under PM-JAY and convergence

Various States have been implementing their own health insurance/assurance schemes
over the past couple of decades. Most of these schemes provide cover for tertiary care conditions
only. The benefit cover of these schemes is mostly available within the State boundaries except some
smaller States have empanelled a few hospitals outside the State boundaries. Very few States had
converged their schemes with the erstwhile RSBY scheme and many of them were operating
independently. This was due to the lack of flexibility in the design of the RSBY, which although initially
helped in quick scale-up but became a challenge over a period of time and offered limited flexibility to
the States.

Even though these schemes were targeting the poor and vulnerable, there were large
variations across States in terms of eligibility criteria and databases. Few States were using the food
subsidy database while some others had created a separate database for their welfare schemes.

The primary objectives for launching PM-JAY were to ensure comprehensive coverage for
catastrophic illnesses, reduce catastrophic out-of-pocket expenditure, improve access to
hospitalisation care, reduce unmet needs, and to converge various health insurance schemes across
the States. PM-JAY will also establish national standards for a health assurance system and is
providing national portability of care. At the implementation level, the States are given the flexibility to
use their own database if they were already implementing a health insurance/ assurance scheme and
were covering more families than those eligible as per the SECC 2011 database. However, such
States shall ensure that all families eligible as per the SECC data are covered and not denied
benefits.
Implementation Model

Various States are using different models for implementing their own health insurance/ assurance

schemes. Some of them are using the services of insurance companies while others are directly implementing the

schemes in their States.

Considering the fact that States are at different levels of preparedness and have varying capacity to

manage such schemes, PM-JAY provides the States with the flexibility to choose their implementation model. They

can implement scheme through assurance/trust model, insurance model or mixed model.

A. Assurance Model/Trust Model

 This is the most common implementation model adopted by most of the States. Under this model, the

scheme is directly implemented by the SHA without the intermediation of the insurance company. The financial risk

of implementing the scheme is borne by the Government in this model. SHA essentially reimburses health care

providers directly. Even though no insurance company is involved, the SHA employ the services of an

Implementation Support Agency (ISA) for claim management and related activities. As there is no insurance

company in the picture, apart from day-to-day management and administration of the scheme, the SHA also has to

carry out specialised tasks such as hospital empanelment, beneficiary identification, claims management and

audits and other related tasks

B. Insurance Model

In the insurance model, the SHA competitively selects an insurance company through a tendering

process to manage PM-JAY in the State. Based on market determined premium, SHA pays premium to the

insurance company per eligible family for the policy period and insurance company, in turn, does the claims

settlement and payments to the service provider. The financial risk for implementing the scheme is also borne by

the insurance company in this model. However, to ensure that the insurance company does not make an

unreasonable profit, the scheme provides for a mechanism where insurance companies can only get a limited

percentage of the premium for their profit and administrative costs.

After adjusting a defined percentage for expenses of management (including all costs excluding only

service tax and any cess, if applicable) and after settling all claims, if there is surplus then 100 per cent of leftover

surplus should be refunded by the insurer to the SHA within 30 days. The percentage that will need to be refunded

will be as per the following:

a. In Category A States (administrative cost cannot exceed 20%)

 i. Administrative cost allowed 10% if claim ratio less than 60%.

 ii. Administrative cost allowed 15% if claim ratio between 60 to less than 70%.

 iii. Administrative cost allowed 20% if claim ratio between 70 to less than 80%.

b. In Category B States (administrative cost cannot exceed 15%)

 i. Administrative cost allowed 10% if claim ratio less than 60%.

 ii. Administrative cost allowed 12% if claim ratio between 60 to less than 70%.

 iii. Administrative cost allowed 15% if claim ratio between 70 to less than 85%.

In case the claim settlement ratio exceeds 120% (115% in the case of Category B States) in any policy

period, then the excess amount shall be initially shared in equal proportion between the insurance company and

State Government / Union Territory. Thereupon, out of the excess burden amount, which the State Government /

Union Territory has borne, the Central Government shall share the burden in line with the sharing pattern ratio.

However, the total contribution of the Central Government along with the premium share and excess burden
 amount of claim shall not exceed the maximum ceiling amount of share of Central Government, applicable for that

particular States / UTs, respectively. Any amount over and above the Central and State Government’s contribution

amount shall have to be borne by the insurance company, respectively.

C. Mixed Model

Under this, the SHA engages both the assurance/ trust and insurance models mentioned above in

various capacities with the aim of being more economic, efficient, providing flexibility and allowing convergence

with the State scheme. This model is usually employed by brownfield States which had existing schemes covering

a larger group of beneficiaries.

 
Category Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT
A States/ Delhi, Sikkim, Tripura, Uttarakhand and 6 Union Territories (Andaman and Nicobar Islands, Chandigarh, Dadra and
UTs Nagar Haveli, Daman and Diu, Lakshadweep and Puducherry)

Category Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh,
B States Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh and West Bengal
 

Financing of The Scheme

PM-JAY is completely funded by the Government and costs are shared between Central and State

Governments. The Government of India decides a national ceiling amount per family that is used to determine the

maximum limit of the central share of the contribution. The actual premium discovered through open tendering

process or the maximum ceiling of the estimated premium decided by Government of India for the implementation

of PM-JAY, whichever is less, would be shared between Central Government and States/UTs in the ratio as per

the extant directives issued by Ministry of Finance, from time to time. In addition, administrative cost for

implementing the scheme at the State level is also provided under the scheme and shared between Centre and

State in the same sharing pattern.

The existing sharing pattern is in the ratio of 60:40, for States (other than North-Eastern States & three

Himalayan States) and Union Territories with legislature. For North-Eastern States and three Himalayan States

(viz. Jammu and Kashmir, Himachal Pradesh and Uttarakhand), the ratio is 90:10. For Union Territories without

legislatures, the Central Government may provide up to 100% on a case-to-case basis.

Payment of Central Share

 Insurance model – A flat premium per family, irrespective of the number of members under PM-JAY in that

family, is paid to the State Government which in turn pays this to the insurer based on the number of eligible

families.
  Assurance model – Central share of the contribution is paid based on the actual cost of claims or the ceiling

whichever is lower. If the State is using an Implementation Support Agency, then cost of ISA, determined

through tender, is also shared between Centre and State.

Expansion of Coverage By States Under PM-JAY, Convergence and Flexibility to The States

Various States have been implementing their own health insurance/assurance schemes over the past

couple of decades. Most of these schemes provide cover for tertiary care conditions only. The benefit cover of

these schemes is mostly available within the State boundaries except some smaller States who have empanelled

a few hospitals outside the State boundaries. Very few States had converged their schemes with the erstwhile

RSBY scheme and many of them were operating independently. This was due to the lack of flexibility in the design

of the RSBY, which although initially helped in quick scale-up but became a challenge over a period of time and

offered limited flexibility to the States.

Even though these schemes were targeting the poor and vulnerable, there were large variations

across States in terms of eligibility criteria and databases. Few States were using the food subsidy database while

some others had created a separate database for their welfare schemes.

The primary objectives for launching PM-JAY were to ensure comprehensive coverage for catastrophic

illnesses, reduce catastrophic out-of-pocket expenditure, improve access to hospitalisation care, reduce unmet

needs, and to converge various health insurance schemes across the States. PM-JAY will also establish national

standards for a health assurance system and is providing national portability of care.

In the spirit of cooperative federalism and keeping in mind variations across the States, a lot of

flexibility has been built in the PM-JAY design. Therefore, PM-JAY provides a lot of flexibility to States in terms of

scheme design and implementation.

States have been provided the flexibility in terms of the following parameters:

 Mode of implementation – States can choose the implementation model and can implement the scheme

through Trust, Insurance company or Mixed model.

 Usage of beneficiary data – PM-JAY uses SECC data for targeting the beneficiaries, however, States have

been provided flexibility to decide on the dataset for this purpose, if they are covering more beneficiaries than

SECC defined numbers. However, State will need to ensure that all beneficiaries eligible as per SECC data

are also covered.

 Co-branding – States can co-brand their existing health insurance/assurance schemes with PM-JAY as per

co-branding guidelines of the scheme.

 Expansion of cover to more people – States can cover more number of families than those defined as per

SECC data. For these additional families, full cost will need to be borne by the States.
  Increasing benefit cover to higher value – If the State want they can even expand the benefit cover beyond

`5 lakh per family per year. However, in this case cost of additional cover will need to be completely borne by

the State.

 Revision in package numbers and pricing – PM-JAY provides cover of more than 1300 packages and their

prices have been fixed by NHA. However, keeping in view the different disease profile and cost of services

variations across the States, flexibility has been provided to the States to expand the number of packages and

also within a limit State can also revise the package prices.

 Reservation of packages for public hospitals – To ensure that such services that can be provided well by

Government health facilities are not misused by private providers, NHA has defined a set of conditions that

are reserved for only public health care facilities. States can revise list of such conditions that are reserved for

public hospitals.

 IT Systems – Before the launch of PM-JAY some of the States were implementing their own health

insurance schemes and were using their own IT systems. PM-JAY provides flexibility that State can continue

using their own IT system and share data with NHA on a real time basis in specified format.

 Payment to public hospitals – States have also been provided flexibility to deduct a certain percentage of

claims amount that is paid to public hospitals.

Hospital Empanelment

The supply of health care services under PM-JAY must be ensured through pre-selected, well

equipped and well-prepared hospitals to deliver the benefits. Also, the hospitals must be distributed widely enough

over the geography so as to ensure optimal accessibility to the eligible families.

In order to cater to the increased demands under PM-JAY and also to ensure quality care to the

beneficiaries, it is imperative to maintain and grow a network of hospitals that also conform to the quality standards

and criteria. This leads to the need of empanelment of hospitals on a pre-emptive basis so that beneficiaries are

certain of their rights being honoured in the most convenient, cashless and quality manner.

Empanelment Criteria

Considering the supply side characteristics (nearly 71 per cent of the hospitals are running as

proprietorship businesses with less than 25 beds capacity and offering non-specialised general clinical care), two

types of empanelment criteria have been evolved. These criteria have been evolved based on the experience of

the prevalent practice in other Government-funded health insurance schemes, State-specific regulations related to

the quality of care and Clinical Establishment Act 2011.

The detailed criteria for empanelment are available on www.pmjay.gov.in

 General criteria – For hospitals that provide non-specialised general medical and surgical care with or

without ICU and emergency services.

 Special Criteria (for clinical specialties) – For each specialty, a specific set of criteria has been identified.

Under PM-JAY, a hospital is not allowed to select the risk, which means it cannot apply for selected

specialties and must agree to offer all specialties to PM-JAY beneficiaries that are offered by it. However, in

order to offer a specialised clinical service, the hospital must have necessary specific infrastructure and HR in

place as mentioned in the special criteria developed under PM-JAY for the same.

 Process of hospital empanelment in PM-JAY

PM-JAY prescribes a two-tier approach to the empanelment of hospitals which is online,

transparent and efficient and is completely free for all steps of the process. States are in the
stewardship position of the entire process of hospital empanelment and they have the final decision-
making power in this regard. At the State level, a State Empanelment Committee (SEC) has been set
up under the State Health Agency. At the district level, a District Empanelment Committee (DEC) has
been set up.

Each empanelled hospital needs to set up a dedicated help desk for the beneficiaries,
which is manned by a dedicated staff appointed by the Empanelled Health Care Provider (EHCP).
These help desk staff are called Pradhan Mantri Arogya Mitras (PMAMs) and their role is to facilitate
treatment of beneficiaries at the hospitals. Every empanelled hospital receives a unique ID also.

o Hospitals are required to apply online which is free of cost. The progress of the application

can also be tracked online.

o The online applications are scrutinised by the DEC and physical verification of the hospitals

is carried out.
o Following this verification, the DEC submits a recommendation to approve or reject the

hospital to the SEC. The final decision regarding empanelment rests with the SEC.
o Continuous quality improvement and other incentives to empanelled
hospitals

PM-JAY incentivises the empanelled hospitals to continuously strive for the

attainment of higher quality standards. These incentives are certainly a motivation for
the hospitals to attain the said quality standards. The following incentives are being
provided under PM-JAY to the hospitals over and above the package rates

o At the time of empanelment a hospital need not be NABH accredited but if during the course

of association with PM-JAY a hospital attains entry level NABH accreditation, it is paid 10 per
cent higher package rates. Similarly, the hospital attaining a full accreditation is paid 15 percent
higher.
o Hospitals attached to teaching institutions (medical, PG and DNB courses) are entitled for 10

per cent higher packages.

o Also, to promote the hospitals to reach out to the beneficiaries in underserved areas, PM-

JAY has come up with 10% higher package rates for hospitals which are situated in aspirational
districts.

National Health Care Providers (NHCP)

Although States are in charge of the empanelment of hospitals, there are eminent tertiary
care hospitals and specialised care hospitals that operate as autonomous institutes of excellence
directly under the Ministry of Health and Family Welfare (MoHFW) or some other department. Most
popular examples of such hospitals are AIIMS, Safdarjang Hospital, JIPMER, PGI Chandigarh, etc.
The National Health Authority (NHA) has empanelled these hospitals directly by signing an MoU with
each of the facility. Also, all NABH accredited private hospitals in the National Capital Region (NCR)
are directly empanelled by NHA to widen the network of service providers. Empanelment of
 Government hospitals other than those managed by MoHFW is also a major step towards widening
the network of hospitals.

Packages and Rates

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 very 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

As mentioned in the previous section based on a few criteria, hospitals can be paid a higher amount.

For such surgical conditions that are not listed in the package list, an EHCP will need to take approval and fix the

rate from the insurer/ SHA before providing the treatment up to the limit of INR 1,00,000.

Journey from HBP 1.0 to HBP 2.0

 Soon after rollout, NHA started receiving feedback from stakeholders and various other sources on

different aspects of AB PM-JAY including HBP 1.0. Majority of the feedback received on HBP could be broadly

clubbed under the following heads:

 Package rates offered for many packages were inadequate to cover the cost of procedures

 Duplication of packages was observed both within a single specialty and across specialties

 The terminology used for the nomenclature of packages was inconsistent

 Few of the procedures were overlapping with the ongoing National Health Programs

 Some of the high-end procedures / investigations / drugs are not covered in HBP 1.0

 Due to the non-availability of certain treatments, a lot of procedures were being booked under Unspecified

packages

Development of packages and rates under HBP 2.0

All the concerns and feedback received from stakeholders and various other sources of different

aspects of AB PM-JAY were deliberated upon in the first Governing Board meeting of NHA, in the month of April

2019. To address the gross anomalies, a mandate was given to NHA for rationalization of HBP.

For this purpose, 24 Specialist Committees were constituted. A Memorandum of Understanding was

inked between NHA and Tata Memorial Hospital (TMH) for the review of Oncology packages. Department of

Health Research (DHR) was conducting a study “Costing of Health Services in India” (CHSI), the data collection

from Public sector hospitals for 8 specialties had been completed. DHR agreed to share these interim results with

NHA. These results were provided to the specialist committees as an input during deliberations for the

rationalization of HBP pricing (Please see Annex 1: Inputs provided to the specialist committee and decisions

sought). The initial steps in the exercise of rationalization of Health Benefit Package (HBP) were carried out using

three different processes which are detailed in flow chart – “Process for rationalization of HBP”.

Following the due procedure, the recommendations were presented to the Governing Board of NHA.

The Governing Board of NHA approved following changes:

 Increase in price of 270 packages

 Decrease in price of 57 packages

 Retain the price of 469 packages at original level

 Introduction of 237 new packages

 Stratification of 43 existing packages

 Discontinuation of 554 existing packages

 To discontinue the packages of Tubectomy and Vasectomy as the services are provided under National

Family Welfare Program.

  The packages for Cataract were decided to be continued taking into account the existing disease burden

and country’s commitment to reduce the prevalence of Cataract blindness

 It was decided by the Governing Board that the increase in package rates of 270 packages will be

moderated by 10%.

Flexibility to States on packages

States with a State-owned health insurance scheme can keep their own rates for all the packages.

However, they are required to adhere to mandatory 1,391 packages as specified in the PM-JAY list. The list can be

expanded based on additional packages from their own scheme which were not a part of the national package

master.

States with no health scheme other than PM-JAY can adopt the national package master with context-

specific variations such as revision of prices in the range of 10 per cent, reservation of procedures for public

hospitalisation, additional packages under mandatory pre-authorisation, etc. States do have the flexibility to add

packages or modify rates according to their requirements; further, they even have the flexibility to change terms of

pre-authorization and modify the list of the public hospital only packages which was devised to prevent any

misuse. to see the revised list of Health Benefit Packages

Click here to see the revised list of Health Benefit Packages

Advantages of HBP 2.0

 HBP 2.0 has features that facilitates an enhanced coverage of both disease conditions and procedures than

were previously included, while keeping a low count of packages. Features which aid this enhanced coverage

are stratification, cross specialty packages, multiple procedures in a package etc. This is expected to reduce

the burden on PMAMs in selection of packages without compromising on data availability for analysis

 Certain packages are now allowed to be booked with a primary package at a 100% reimbursement contrary

to the principle of 50% reimbursement of the second package in HBP 1.0. Also, some packages have been

identified as Stand-Alone Packages which means that they cannot be booked with any other package.

 Some procedures require prolonged / multiple follow up beyond the limit of 15 days included in a package.

For such procedures, follow – up packages have been included to ensure continuity of care.

 Certain features have been introduced in HBP 2.0 to minimise potential of fraud and abuse. In certain

cases, time interval for booking of sequential packages has been defined, maximum number of permissible

implants has been built in, maximum number of times a package can be booked in an individual has been

defined. Other features such as identification of stand-alone packages, and standardization of rates across

specialties is expected to further reduce incentives for upcoding.

  The HBP 2.0 features a 3-layered IT customization for easier and more accurate package booking. This

allows better analytics and improved dashboards of package utilization and its monitoring. Scientific

nomenclature and coding further strengthen HBP 2.0 towards uniformity and improved acceptance across the

country.

IT System under PM-JAY

In order to enable PMJAY ‘swiftly & effortlessly,’ it was required that information technology is

orchestrated in such as a manner that there is minimum ‘time-to-launch’. Since its launch IT has provided a robust

backbone to the scheme's implementation throughout the nation. The below are the key technology blocks.

Key Technology Blocks

 PMJAY Dashboard : Allows for an aggregated and drill-down view on various datasets integrated into the

PMJAY Data Warehouse. Is used for real-time reporting of transactions, evaluating performance and

understanding utilization trends.

 Hospital Empanelment System : Allows for registration and approval of hospitals for empanelment.

Features for Hospital Quality Assurance are also being made available in this system.
 Beneficiary Identification System (BIS) : Allows for searching beneficiaries through SECC or additional

data sets through APIs and supports Aadhaar eKYC (electronic Know Your Customer) and non-Aadhaar

based KYC for Authentication.

 Transaction Management System (TMS) : Allows for capturing of in-patient data on admission, treatment

and discharge, and onwards to hospital claims and financial settlement. It is integrated with other State based

and external systems through Application Program Interface (APIs).

 Citizen Portal (mera.pmjay.gov.in) : Allows for citizens to search the beneficiary database to ascertain the

eligibility under the scheme. The popular self-help tool has allowed for mass scale searches right at the field

level being mobile responsive.

 Citizen Call Centre (14555) : National Toll-Free number backed with a 400+ multi-lingual, multi-location

call centre services which allows beneficiaries to find out their eligibility, nearest hospital, nearest Common

Service Centre etc. Service offerings through the call centre have been enlarged to allow for beneficiary

feedback and grievance redressal.

 National Health Stack : Followed as a design philosophy, the NHS shall enable PM-JAY to capture data

which can be used in the future to enhance scheme design and allow for further inclusion/ universalization.

Developments underway for National Health Claims Platform (NHCP) and enhancement of existing PM-JAY

systems. These constructs will pave the way for creation of market led service delivery products for regulated

insurance scheme.

 PM-JAY Portal : Single source of all information and content related to the scheme, the platform is being

enhanced to support back-office functions as well. The portal is used to share best-practices, Standard

Operating Procedures (SOPs), Policies and Guidelines, and act as a front end to the Grievance Management

System.

 India Enterprise Architecture (IND-EA): Followed as a principle to enable development of a future ready

enterprise architecture for PM-JAY and NHA.

 Information Security & Data Privacy Policies : Put in perspective the various check-lists enforced on the

IT Ecosystem – Service Providers and Consumers to ensure end to end information security and privacy of

personally identifiable data for beneficiaries. Continuous assessments are undertaken to ensure compliance.

 National Portability : Unique to the scheme, IT system has allowed portability of benefits for the

beneficiary regardless of the location. This has been possible only by designing systems which allow for a

real-time integration and data-exchange across the IT landscape.

 Grievance Management System : Allows for beneficiaries and whistle-blowers to register grievances and

for NHA/ SHAs to ‘take-to-closure’ such grievances. As a key element towards building trust amongst

beneficiaries, the system ensures anonymity of the griever.

 Anti-Fraud Measures : As part of the IT landscape, a ‘Man-Machine’ model has been envisaged to counter

fraudulent transactions and entities. The model shall generate triggers for suspicious transactions and entities,
 and will also allow for closure of investigations of such transactions. National Anti-Fraud Unit and State Anti-

Fraud Unit have been institutionalized to support investigations at the State level.

 Citizen Mobile App : Allows for registered beneficiaries to find out their existing ‘wallet balance’ in the

scheme, search for the nearest hospitals and provide feedback on the services being provided by the

hospitals. As a simple personal tool shall empower the beneficiaries to know their utilization of the entitled

benefits.

 Common Service Centre (CSC) : As a service delivery partner, CSCs further the reach of the scheme in

rural India through their Gram Panchayat level network. CSCs have helped extensively through their network

in not only communicating about the scheme but also helping potential beneficiaries find out about their

eligibility and authenticating eligible beneficiaries.

 B. PM-JAY IT Ecosystem

C. Current IT Enablement Illustration

Awareness and Communication

Since PM-JAY is an entitlement-based scheme where there is no advance enrolment process, making

beneficiaries aware of the scheme is the most critical aspect. Information, Education and Communication activities

need to be carried out to educate beneficiaries about the scheme. Various modes of communication such as

leaflets, booklets, hoardings, TV, radio spots etc are important elements for creating a comprehensive

communication strategy for disseminating the desired messages across the target audience.

A detailed communication strategy has been developed by NHA which is to be implemented at both

national and State levels. NHA is also working on the overall cooperation & capacity-building with the States for

implementation and development of communication strategy required for increasing awareness at the State level.

Due to large quantum of people being covered under PM-JAY, there is a strong need to spread

awareness with the right message, through the right media and within the right timeframe. IEC activities were

initiated immediately after the Cabinet approval to the scheme on 21st March, 2019. The first major

initiative, Additional Data Collection Drive (ADCD) drive was undertaken by participating in “Gram Swaraj

Abhiyaan” of Ministry of Rural Development on 30th April, 2018 named as “Ayushman Bharat Diwas” with an

objective to make people aware about the upcoming scheme benefits and entitlement check by involving ASHA &

ANMs and Gram Sevak covering around 3 lakh villages across the country. Various posters, banners etc. were
designed and deployed in Hindi and regional languages across all camps and village meetings for spreading the

awareness.

A letter from Hon’ble Prime Minister was sent to all beneficiary families to make them aware about

their entitlements under the scheme and also provide them a family card with unique family ID. Standardised

design materials have been prepared by NHA that are being used by States for making beneficiaries aware about

the scheme. Various communication channels like print media, television, radio, social media etc. are being used

to reach beneficiaries and other stakeholders. A communication strategy and IEC guidebook has also been

developed for this purpose. A dedicated web portal for the scheme www.pmjay.gov.in has been also created to

provide all the details about the scheme to various stakeholders. All relevant information and links e.g. list of

empanelled hospitals, Am I eligible portal, grievance redressal portal, gallery, operational guidelines are placed

here.

Support Systems

Apart from above mentioned critical components of PM-JAY's ecosystem following are some other key

components working as the support system for the smooth implementation of the scheme.

Capacity Development

Capacity building activities under PM-JAY attempt to address more than just training and cover all

aspects of building and developing sustainable and robust institutions and human resource. Capacity building in

PM-JAY has three components:

 Setting up sustainable institutional structures,

 Building and strengthening the human resource and institutional capacity, and

 Sustaining knowledge and skill through knowledge management and use of appropriate tools. The roles of

institution as well as each of its personnel at national, State and district level were defined as were their

specific skill sets required. These personnel were further categorised on the basis of role and appropriate

knowledge and skill areas were mapped for capacity development.

The NHA has taken the leadership role in assessing the requirements, making available resources,

devising strategies for enabling States to undertake capacity building activities and providing technical assistance

to States. Standardised learning content on identified thematic areas is being developed by the NHA. States can

customise these materials and deliver through various methodologies as per their annual training plan. Monitoring

and quality assurance measures with feedback mechanism have also been put in place to ensure effectiveness

and efficiency. Partnerships and networks are being created with Government and non-Government institutions

having expertise in various fields to support the capacity building initiatives in PM-JAY.
 Capacity building initiatives in PM-JAY started with the orientation of SHA officials followed by various

workshops for personnel from specific portfolios like IT, fraud control, claim management, etc. Workshops for ISAs

and banking partners were also organised. Master trainers were created at the State level who in turn trained more

than 10,000 Pradhan Mantri Arogya Mitras (PMAMs) at empanelled hospitals before the beginning of the

programme. Learning materials were also made available in the portal to facilitate State and district level trainings.

An e-learning platform is now being developed with the support of the National Skill Development Council (NSDC)

for training and certifying Arogya Mitras. Various workshops, cross learning forums and thematic trainings are

planned in the upcoming days.

Monitoring and Evaluation

Monitoring and Evaluation under PM-JAY Monitoring and Evaluation (M&E) is key for successful

implementation and ensuring the intended results of such a large insurance scheme. The NHA at the Central level

is continuously keeping track on periodic basis on these UHC dimensions (coverage, benefits and financial

protection) through the following functional domains:

 Beneficiary management

 Transaction management

 Provider management

 Support function management (comprising functions such as capacity development, grievances, frauds and

abuse, call centre, etc.)

A strong real-time online MIS is set up at the national level to review Key Performance Indicators

(KPIs) and achievement of results with respect to the targets defined under the domains. The various dashboards

developed using business intelligence tools help in identifying the gaps and provide an overview of the

performance made. To mention a few: the operations dashboard presents an update of KPIs of beneficiary

information system, pre-auth dashboard helps to access state and district wise distribution of pre-auth, status of

empanelled hospitals, portability dashboard gives us the picture of interstate and intrastate portability and their

KPIs on claim portability by specialty, procedure, age and gender.

Most of the States, which do not have their own schemes, are using the NHA software. However,

States with their own schemes are either using the above or their own software followed by API integration to

ensure the flow of data from State to Central servers.

In order to provide a comprehensive picture of the progress made by all the functional domains,

factsheets are developed monthly at the State and National level. The factsheet compares the progress made

since the inception of the scheme across States with the progress made in each month. The average claim size,

total number of pre-auths generated, pending approvals, nomenclature of the packages used at public and private
facilities are some of the important indicators included in the factsheet. The triggers and outliers (if any) identified

through the dashboards and factsheet are further drill down to districts level.

To assess and comprehend the impact of PM-JAY, evidence generation is done through evaluation

studies in collaboration with premiere research institutions and in partnership with development agencies such as

GIZ, WHO and World Bank. The objective of these evaluation studies is to understand the impact of the scheme

on various parameters including but not limited to out-of-pocket expenditure, access to health, health seeking

behaviour, etc. These research studies provide critical inputs for evidence-based decision-making and carrying out

mid-course corrections.

Fraud Prevention, Detection and Control

For a programme of this scale, magnitude and complexity as that of PM-JAY, it is critical to put in a

place a strong anti-fraud mechanism not only from financial perspective but also to safeguard people’s health from

unethical behaviour and malpractices. The National Health Authority is cognizant of the issue and has taken a

number of steps to safeguard the programme from the inception. Some of the key actions taken in this regard are

listed below.

A.Policy and Design Level

 A transparent tendering process implemented for selection of insurance company, Implementing Support

Agency and other service providers. Tightly worded legal document for service delivery as per pre-defined

Service Level Agreements have been developed with penalty clauses and punitive action to deal with

fraudulent activities on the part of any agency involved in delivering services under PM-JAY.

 Hospital empanelment process has been developed with a two-tiered structure approach involving district

level and State level committees, having due representation of senior officials – civil surgeon, chief medical

officer and nodal officers of the district. The entire process is web enabled whereby a hospital can track the

status of its empanelment from application to approval by the State Nodal Age.

 IT system and processes have been designed with checks and balances along with defined roles and

responsibilities, role-based logins and audit trails for all processes – beneficiary identification, transaction

management system, funds flow, claims payment etc. Further, all pre-authorisation and claims transactions

are carried out on-line basis for efficiency and complete transparency.

 The process of pre-authorisation has been designed such as to ensure maximum efficiency while avoiding

abuse and fraud. Minimum requirements for claims investigation and medical audit have been laid down.

 The tendency of health care providers to overcharge, bill extra and other related issues have been taken

care of by introducing all-inclusive package rates. However sufficient flexibility has been given to treat

patients requiring medical management and the list for procedures shall be enhanced as more experience

and insights are gained.

  Comprehensive Anti-fraud Guidelines were released by the Minister of Health and Family Welfare on

August 27, 2018, laying down detailed strategy, processes, systems and manpower for anti-fraud both at

National and State levels.

 National Health Agency Tollfree - 14555 set up on 24x7 basis for facilitating beneficiary reporting and

feedback

 Whistleblower Policy has been adopted at the NHA level and shared with States for adoption on a similar

pattern

B. Operational and System Level

 Capacity building workshop for fraud control and medical audit organised for SHAs, ISAs and Insurance

partners

 Fraud Investigation Manual released for uniform and effective process, data capture

 Monitoring and analysis of utilisation trends done through regular MIS and dashboards, watching abuse

prone packages, suspect transactions/hospitals on regular basis

 Top analytics firms shortlisted for carrying out ‘proof of concept’ for triggering suspect transactions and

entities through rule engines and artificial intelligence layer on top of Transaction Management System

 Mobile App – Kaizala app is being customised for field investigations and medical audit, test deployment

underway

 Procedure specific documentation and checklist being developed for controlling abuse and leakages,

integration with IT underway

 Adjudication guidelines and capacity building programme for SHAs, ISAs to be rolled out

 Watch and action against fake websites, Mobile Apps providing misleading information or collecting money

or data from public

National Anti Fraud Unit

NHA has a “Zero Tolerance” approach towards Fraud and Abuse under PMJAY. Towards this end, the

National Anti Fraud Unit (NAFU) has been set up with the primary responsibility for prevention, detection and

deterrence of fraud and abuse under PM-JAY.

NAFU works closely with State Ant Fraud Units (SAFU) in order to ensure the effective implementation

of the Scheme, free from any fraudulent/ abusive activity from any entity involved in PM-JAY implementation such

as providers, beneficiaries, ISAs or payers.

NAFU carries our following key activities:

 Provide leadership stewardship to the national anti-fraud efforts under PMJAY;

 Develop, review and update the national anti-fraud framework and guidelines based on emerging trends;
  Provide mentoring support to states in setting up and institutionalising their in-state anti- fraud efforts;

 Capacity building of states on anti-fraud measures under PMJAY;

 Liaise with the national IT team / agency to ensure that the IT platform is periodically updated with fraud

triggers based on review of trends;

 Conduct audits and investigation of suspect cases/entities;

 Set up Forensics practice for detection and triangulating fraud/abuse related data with the overall service

utilisation trends emerging under PMJAY;

 Provide evidence-based insights to states on trends emerging from state-specific fraud data analytics;

 Handle all fraud related complaints that the NHA may receive directly and liaise with the states from any

complaints specific to states as per Anti- Fraud Guidelines

 Establish whistle blower mechanism, public disclosure guidelines, and other deterrent measures.

Grievance Redressal

Grievance redressal system is designed to address grievances of all PM-JAY stakeholders based on

the principles of natural justice while ensuring cashless access to timely and quality care remains uncompromised.

A three-tier Grievance Redressal Committee structure has been set up at National, State and district levels for this

purpose. The CEO of NHA will be the Chairperson at the National level while the CEO of SHA will chair the State

Grievance Redressal Committee. The District Magistrate or an officer of the rank of Additional District Magistrate

shall be the Chairperson of the District Grievance Redressal Committee. These committees will track and monitor

the grievances and its status, collect additional information from parties involved, facilitate hearings, review

records, adjudicate and issue orders on grievance and ensure compliance of committee orders.

The aggrieved parties can submit grievances through offline (letter) or through an online portal

(https://cgrms.pmjay.gov.in) developed by NHA. Other communication channels like telephone call, fax, e-mails,

and SMS are also accepted for registering a grievance. The National Call Centre (14555 / 1800 111 565) is also

integrated to the Grievance Portal for addressing grievances received through the call-centre. The committee can

also register grievances based on social media or public forums findings/reports. Based on predefined criteria,

grievances will be handled either by the respective individual/organisation who is responsible to take action or by

the committees at an appropriate level. But at any level, the grievance should be addressed within 30 days of

receipt. The right to appeal for any party is valid for 30 days from the date of the decision. Non-compliance with the

decisions of the committee within another 30 days will also attract a penalty for the defaulter. The online portal has

the provisions to designate and track grievances to respective officials and monitor compliance with the alert

system.

Call Centre
 One of the important aspects of one of the world’s largest government-supported health schemes of

the size and complexity as that of PM-JAY is to ensure that entitled beneficiaries of the programme can reach out

to know the details of the scheme, have recourse to raise a query or a grievance, seek information and support at

any time during day or night, especially during hour of need. If the profile of beneficiaries includes a sizeable

population which is rural based, even less educated and less aware, the mechanism needs to be further simplified

and made easily accessible, involving least effort and no expense. Therefore, a National Helpline – 14555 was set

up by then National Health Agency on August 24, 2018 – which is operating 24x7 since the launch and has

answered more than 42 lakh calls since inception. The call centre is manned by 300 plus trained agents who work

round the clock to manage the calls and further plans are in offing to expand capacity. All major regional languages

are supported by the call centre team.

The Helpline is toll-free which means that the caller does not incur any call charges, the same are

borne by NHA. Operating on 24x7x365 basis, the call centre provides services/information to the beneficiaries

such as details about the scheme – coverage, benefits, how and where to avail benefits, name and address of

empanelled hospitals etc. Besides beneficiaries, other stakeholders like hospitals, Arogya Mitras and field

functionaries also call the Helpline for support.

The call centre is also engaged in outbound calling and more than 3 lakh outbound calls have been

made to beneficiaries for collecting their feedback post discharge from hospital, to know their experience, whether

any difficulty faced during the process, etc. Outbound calls are also made to hospitals to help them complete

application for support, hand-holding and training for providing services to PM-JAY beneficiaries and to encourage

these hospitals to raise pre-authorisation.

Convergence

Convergence between National Health Authority (NHA) and Employee’s State Insurance
Corporation (ESIC)

The National Health Authority (NHA) has entered into a partnership with the Employee’s State

Insurance Corporation (ESIC). This synergy between Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB

PM-JAY)and Employees State Insurance Scheme (ESIS) will create an ecosystem wherein ESIC beneficiaries will

be able to access services at ABPM-JAY empanelled hospitals and vice versa.

The convergence between PM-JAY and ESIC is a landmark initiative for the development of health

systems in the country. This will leverage the presence of an established network of quality services providers

under PM-JAY alongside fixed health benefit packages, thereby standardising services across schemes. Further, it

will create higher demand for health services at ESIC empanelled hospitals that may be currently underutilised.

This will support in improvement of infrastructure and facilities of such facilities, via utilisation of funds reimbursed

under PMJAY.
 In the initial phase, a pilot is being conducted in Ahmednagar, Maharashtra and Bidar, Karnataka

wherein ESIC beneficiaries of these districts will be able to access PM-JAY services in PM-JAY empanelled

hospitals. The beneficiaries will be eligible for all 1,393 secondary and tertiary packages under the scheme and the

initiative will be scaled up to 102 districts with a plan of eventually extending coverage across the country.

Key Benefits of AB PM-JAY and ESIS convergence:

 ESIC beneficiaries will get access to healthcare providers under AB PM-JAY

 AB PM-JAY beneficiaries will be able to avail services in ESIC empanelled hospitals.

 Beneficiaries of ESIC can use their ESIS card to access free treatment at AB PM-JAY empanelled

hospitals.

 Similarly, beneficiaries of AB PM-JAY can use their PM-JAY card to access free treatment at ESIC

empanelled hospitals.

 For more information beneficiaries can call ESIC tollfree number: 1800 112 526/ 1800 113 839

 Click here for the list of empanelled hospitals under AB PM-JAY