NHPM_AYUSHMAN BHARAT_PMJAY

During his Independence Day speech from Red Fort, Prime Minister announced that Pradhan Mantri
Jan Arogya Abhiyaan, also known as Ayushman Bharat or the National Health Protection Mission
(AB-NHPM) or Modicare, will be launched on 25 September, 2018. However, since the scheme is
meant only for poor and economically-deprived people, not everyone is eligible to get free medical
insurance under Ayushman Bharat scheme.

Key Features

 The government-sponsored health insurance scheme will provide free coverage of up to Rs

5 lakh per family per year at any government or even empanelled private hospitals all over
India for secondary and tertiary medical care facilities.
 Modicare will be available for 74 crore beneficiary families and about 50 crore Indian
citizens. Under the process, 80 percent of beneficiaries, based on the Socio-Economic Caste
Census (SECC) data in the rural and the urban areas, have been identified.  
 There is no restriction on the basis of family size, age or gender.
 Ayushman Bharat is unlike other medical insurance schemes where there is a waiting period
for pre-existing diseases. All kinds of diseases are covered from day one of the Ayushman
Bharat policy. The benefit cover includes both pre and post hospitalization expenses.
 The expenditure incurred in premium payment will be shared between Central and State
Governments in a specified ratio. The funding for the scheme will be shared – 60:40 for all
states and UTs with their own legislature, 90:10 in Northeast states and three Himalayan
states of Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs
without legislature.
 The NHPS will draw additional resources from the Health and Education Cess and also
depend on funding from States to boost the Central allocation. The premiums are expected
to be in the range of `Rs 1,000 – ` 1,200 per annum.
 The NHPM (National Health Protection Mission) will pay for the hospitalisation costs of its
beneficiaries through strategic purchasing from public and private hospitals.

NOTE:

"Strategic purchasing" means active, evidence-based engagement in defining the service-mix and
volume, and selecting the provider mix in order to maximize societal objectives.

 Wellness Centres: The 1.5 lakh sub-centres that are converted into wellness centres will
cater to majority of services such as detection and treatment of cardiovascular diseases,
screening for common cancers, mental health, care of the elderly, eye care, etc. „
 The wellness centres will also offer a set of services including maternal and child health
services, mental health services and vaccinations against selected communicable diseases.

Benefits

 The scheme, if implemented properly could enhance access to health care including early
detection and treatment services by a large section of society who otherwise could not
afford them.
 NHPS could help country move towards universal health coverage and equitable access to
healthcare which is one of the UN Sustainable Development Goals (SDG3: Good health and
well-being). „
  The wellness centres that are planned under the Ayushman Bharat programme can play a
preventive role by reducing the incidence and impact of non-communicable diseases. „ The
proposed NHPS could be the precursor to the Universal Insurance Scheme which will provide
cover to all citizens.

How will NHPS work financially?

 The NHPS operates around the insurance principle of ‘risk pooling’. When a large number of
people subscribe to an insurance scheme, only a small fraction of them will be hospitalised
in any given year. In a tax-funded system or a large insurance programme, there is a large
risk pool wherein the healthy cross-subsidise the sick at any given time. „
 The NHPS will be financially viable, despite a high coverage offered to the few who fall sick in
any year, because the rest in the large pool do not need it that year.

Tasks Ahead

 State governments, which will administer it through their own agency, will have to purchase
care from a variety of players, including in the private sector, at pre-determined rates.
 Reaching a consensus on treatment costs through a transparent consultative process is vital
for a smooth and steady rollout.
 A large-scale Information Technology network for cashless treatment should be set up and
validated.
 Since a majority of the families will be rural, and the secondary and tertiary public hospital
infrastructure suffers from severe efficiency and accountability problems, State governments
should upgrade the administrative systems.

Challenges

 The steady growth of a for-profit tertiary care sector poses the additional challenge of
arriving at a basic care package for those who are covered by the NHPS, at appropriate
costs. 
 The NHPS scheme, which primarily offers support for clinical services such as hospitalization,
fails to address the broken public health system in the country. 
 The most critical issue remains the limited and uneven distribution of human resources at
various levels of health services, with up to 40% of health worker posts lying vacant in some
states. 
 Most primary health care centres suffer from a perennial shortage of doctors and even
district hospitals are without specialists. „
 Without addressing the human resource situation, public sector healthcare will remain of
poor quality and largely unacceptable, forcing patients to go to the private sector. This will
ultimately be unsustainable and even detrimental for the poor for whom the scheme is
intended.

History

The National Health Protection Scheme (NHPS) scheme is formed by subsuming multiple schemes
including Rashtriya Swasthya Bima Yojana, Senior citizen health Insurance Scheme (SCHIS), Central
Government Health Scheme (CGHS), Employees' State Insurance Scheme (ESIS), etc. The National
Health Policy, 2017 has envisioned Health and Wellness Centres as the foundation of India’s health
system which the scheme aims to establish. [3]
The Central Government Health Scheme (CGHS) was started under the Indian Ministry of Health and
Family Welfare in 1954 with the objective of providing comprehensive medical care facilities to
Central Government employees, pensioners and their dependents residing in CGHS covered cities.
This health scheme is now in operation with cities such as Bhubaneswar, Bhopal, Chandigarh, and
Bangalore. The dispensary is the backbone of the Scheme. Instructions on these various matters
have been issued from, time to time for the guidance of specialists and medical Officers. The Central
Government Health Scheme offers health services through Allopathic and Homeopathic systems as
well as through traditional Indian forms of medicine such as Ayurveda, Unani, Yoga and Siddha. [4]

Reach

26 states and union territories accepted the scheme, except four states: Delhi, Odisha, West Bengal
and Telangana.[5] More than a lakh (100,000) people have taken benefit of the scheme till October
2018.[6] By 26th November more than 825,000 e-cards were generated and there was a push to
recruit private hospitals to the scheme. [7]

Controversies

The scheme has been subject to significant criticism, from multiple aspects. [8] There have been media
reports of widespread misuse of the Ayushman Bharat scheme by unscrupulous private hospitals
through submission of fake medical bills. Under the Scheme, surgeries have been claimed to be
performed on persons who had been discharged long ago and dialysis has been shown as performed
at hospitals not having kidney transplant facility. [9] There are at least 697 fake cases in Uttarakhand
State alone, where fine of Rs one crore has been imposed on hospitals for frauds under the Scheme.
[10]
However, unlike the earlier RSBY (Rashtriya Swasthya Bima Yojana) era, plagued by lax monitoring
of insurance fraud, AB-PMJAY involves a robust information technology infrastructure overseeing
transactions and locating suspicious surges across the country. Many hospitals have been blacklisted
and the constantly evolving fraud-control system will play a major role in streamlining the scheme as
it matures.[citation needed] Initial analysis of high-value claims under PMJAY has revealed that a relatively
small number of districts and hospitals account for a high number of these, and some hint of an anti-
women bias, with male patients getting more coverage. Despite all efforts to curb foul-play, the risk
of unscrupulous private entities profiteering from gaming the system is clearly present in AB-PMJAY.
[11]

Launched as recommended by the National Health Policy 2017, to achieve the vision of Universal
Health Coverage (UHC). This initiative has been designed on the lines as to meet SDG and its
underlining commitment, which is “leave no one behind”.

Aim: to undertake path breaking interventions to holistically address health (covering prevention,
promotion and ambulatory care), at primary, secondary and tertiary level.

Includes the on-going centrally sponsored schemes – Senior Citizen Health Insurance Scheme
(SCHIS) and Rashtriya Swasthya Bima Yojana (RSBY).

 Ayushman Bharat adopts a continuum of care approach, comprising of two inter-related

components, which are:

1. Health and Wellness Centres (HWCs).

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

 Key Features of PM-JAY:

 1. The world’s largest health insurance/ assurance scheme fully financed by the government.
2. It provides cover of 5 lakhs per family per year, for secondary and tertiary care
hospitalization across public and private empaneled hospitals in India.
3. Coverage: Over 10.74 crore poor and vulnerable entitled families (approximately 50 crore
beneficiaries) are eligible for these benefits.
4. Provides cashless access to health care services for the beneficiary at the point of service.

 Benefits and significance:

 Helps reduce catastrophic expenditure for hospitalizations, which pushes 6 crore people into
poverty each year.
 Helps mitigate the financial risk arising out of catastrophic health episodes.

Eligibility:

1. No restrictions on family size, age or gender.

2. All pre–existing conditions are covered from day one.
3. Covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as
diagnostics and medicines.
4. Benefits of the scheme are portable across the country.
5. 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.
6. Public hospitals are reimbursed for the healthcare services at par with the private hospitals.

Suggestions made by Indian Medical Association (IMA):

1. Government hospitals should be removed from the ambit of the scheme as services there are
already free of cost.
2. The government should fund public hospitals directly. Under this scheme, it is being done
through insurance companies by paying 15 per cent to them.
3. India should not continue the insurance route for healthcare delivery as the administrative
cost and the “unholy nexus” with insurance companies point towards profit maximization
rather than quality health care delivery.
4. Need of the hour: “Tax funded” universal health coverage rather than the “for profit”
insurance model.

 Why some states have not implemented the health protection plan and what is holding back its
100 per cent implementation?

Few states including Delhi, Telangana, West Bengal and Odisha are not covered. Health is a state
subject, and so far these states have declined joining the central government-led scheme.

1. Delhi government argues that it’s existing health scheme has wider coverage and is “10
times bigger than Ayushman Bharat”.
2. Odisha has pointed out certain flaws, saying that the existing Biju Swastya Kalyan Yojana
has special provisions like an extra Rs 2 lakh cover for women, which the Ayushman scheme
lacks.
3. Telangana too has raised concerns about the rather “narrow ambit” of PM-JAY, saying that
its Aarogyasri scheme. benefits more people. 
4. West Bengal opted out, refusing to pay its share of the expenditure.
--GOI_MOHFW

which will cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries)
providing coverage upto 5 lakh rupees per family per year for secondary and tertiary care
hospitalization. Ayushman Bharat - National Health Protection Mission will subsume the on-going
centrally sponsored schemes - Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health
Insurance Scheme (SCHIS).

Salient Features

 Ayushman Bharat - National Health Protection Mission will have a defined benefit cover of
Rs. 5 lakh per family per year.
 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.
 Ayushman Bharat - National Health Protection Mission will be an entitlement based scheme
with entitlement decided on the basis of deprivation criteria in the SECC database.
 The beneficiaries can avail benefits in both public and empanelled private facilities.
 To control costs, the payments for treatment will be done on package rate (to be defined by
the Government in advance) basis.
 One of the core principles of Ayushman Bharat - National Health Protection Mission is to co-
operative federalism and flexibility to states.
 For giving policy directions and fostering coordination between Centre and States, it is
proposed to set up Ayushman Bharat National Health Protection Mission Council (AB-
NHPMC) at apex level Chaired by Union Health and Family Welfare Minister.
 States would need to have State Health Agency (SHA) to implement the scheme.
 To ensure that the funds reach SHA on time, the transfer of funds from Central Government
through Ayushman Bharat - National Health Protection Mission to State Health Agencies
may be done through an escrow account directly.
 In partnership with NITI Aayog, a robust, modular, scalable and interoperable IT platform will
be made operational which will entail a paperless, cashless transaction.

Implementation Strategy

 At the national level to manage, an Ayushman Bharat National Health Protection Mission
Agency (AB-NHPMA) would be put in place. States/ UTs would be advised to implement the
scheme by a dedicated entity called State Health Agency (SHA). They can either use an
existing Trust/ Society/ Not for Profit Company/ State Nodal Agency (SNA) or set up a new
entity to implement the scheme.
 States/ UTs can decide to implement the scheme through an insurance company or directly
through the Trust/ Society or use an integrated model.

Major Impact. Ayushman Bharat - National Health Protection Mission will have major impact on
reduction of Out of Pocket (OOP) expenditure on ground of:

 Increased benefit cover to nearly 40% of the population, (the poorest & the vulnerable)
 Covering almost all secondary and many tertiary hospitalizations. (except a negative list)
 Coverage of 5 lakh for each family, (no restriction of family size)

This will lead to increased access to quality health and medication. In addition, the unmet needs of
the population which remained hidden due to lack of financial resources will be catered to. This will
lead to timely treatments, improvements in health outcomes, patient satisfaction, improvement in
productivity and efficiency, job creation thus leading to improvement in quality of life.

Expenditure involved. The expenditure incurred in premium payment will be shared between
Central and State Governments in specified ratio as per Ministry of Finance guidelines in vogue. The
total expenditure will depend on actual market determined premium paid in States/ UTs where
Ayushman Bharat - National Health Protection Mission will be implemented through insurance
companies. In States/ UTs where the scheme will be implemented in Trust/ Society mode, the
central share of funds will be provided based on actual expenditure or premium ceiling (whichever is
lower) in the pre-determined ratio.

Number of Beneficiaries. Ayushman Bharat - National Health Protection Mission will target about
10.74 crore poor, deprived rural families and identified occupational category of urban workers'
families as per the latest Socio-Economic Caste Census (SECC) data covering both rural and urban.
The scheme is designed to be dynamic and aspirational and it would take into account any future
changes in the exclusion/ inclusion/ deprivation/ occupational criteria in the SECC data.

--PIB, 01 FEB 2018

The Government today announced two major initiatives in health sector , as part of Ayushman
Bharat programme. The Union Minister for Finance and Corporate Affairs, Shri Arun Jaitely while
presenting the General Budget 2018-19 in Parliament here today said that this was aimed at making
path breaking interventions to address health holistically, in primary, secondary and tertiary care
systems, covering both prevention and health promotion. 

The initiatives are as follows:-  

(i) Health and Wellness Centre:- The National Health Policy, 2017 has envisioned Health and
Wellness Centres as the foundation of India’s health system. Under this 1.5 lakh centres will bring
health care system closer to the homes of people. These centres will provide comprehensive health
care, including for non-communicable diseases and maternal and child health services.  These
centres will also provide free essential drugs and diagnostic services. The Budget has allocated
Rs.1200 crore for this flagship programme. Contribution of private sector through CSR and
philanthropic institutions in adopting these centres is also envisaged.

 (ii) National Health Protection Scheme:- The second flagship programme under Ayushman Bharat is
National Health Protection Scheme, which will cover over 10 crore poor and vulnerable families
(approximately 50 crore beneficiaries) providing coverage upto 5 lakh rupees per family per year for
secondary and tertiary care hospitalization.  This will be the world’s largest government funded
health care programme. Adequate funds will be provided for smooth implementation of this
programme.

 The Finance Minister further said, that these two health sector initiatives under Ayushman Bharat
Programme will build a New India 2022 and ensure enhanced productivity, well being and avert
wage loss and impoverishment. These Schemes will also generate lakhs of jobs, particularly for
women. The Finance Minister said, that in order to further enhance accessibility of quality medical
education and health care, 24 new Government Medical Colleges and Hospitals will be set up, by up-
grading existing district hospitals in the country. This would ensure that there is at least 1 Medical
College for every 3 Parliamentary Constituencies and at least 1 Government Medical College in each
State of the country.
RSBY
The workers in the unorganized sector constitute about 93% of the total work force in the country.
The Government has been implementing some social security measures for certain occupational
groups but the coverage is miniscule. Majority of the workers are still without any social security
coverage. One of the major insecurities for workers in the unorganized sector is the frequent
incidences of illness and need for medical care and hospitalization of such workers and their family
members. Despite the expansion in the health facilities, illness remains one of the most prevalent
causes of human deprivation in India. It has been clearly recognized that health insurance is one
way of providing protection to poor households against the risk of health spending leading to
poverty. The poor are unable or unwilling to take up health insurance because of its cost, or lack of
perceived benefits. Organizing and administering health insurance, especially in rural areas, is also
difficult. Recognizing the need for providing social security to these workers, the Central
Government has introduced the Rashtriya Swasthya Bima Yojana (RSBY). Till March 25, 2013, the
scheme had 34,285,737 Smart Cards and 5,097,128 hospitalization cases.

Gensis of RSBY
In the past, the Government had tried to provide a health insurance cover to selected beneficiaries
either at the State level or National level. However, most of these schemes were not able to achieve
their intended objectives. Often there were issues with either the design and/ or implementation of
these schemes. Keeping this background in mind, Government of India decided to design a health
insurance scheme which not only avoids the pitfalls of the earlier schemes but goes a step beyond
and provides a world class model. A critical review of the existing and earlier health insurance
schemes was done with the objective of learning from their good practices as well as seeks lessons
from the mistakes. After taking all this into account and also reviewing other successful models of
health insurance in the world in similar settings, RSBY was designed. It has started rolling from 1st
April 2008.

The Scheme. RSBY has been launched by Ministry of Labour and Employment, Government of India
to provide health insurance coverage for Below Poverty Line (BPL) families. The objective of RSBY is
to provide protection to BPL households from financial liabilities arising out of health shocks that
involve hospitalization.

Eligibility. Unorganized sector workers belonging to BPL category and their family members (a family
unit of five) shall be the beneficiaries under the scheme. It will be the responsibility of the
implementing agencies to verify the eligibility of the unorganized sector workers and his family
members who are proposed to be benefited under the scheme. The beneficiaries will be issued
smart cards for the purpose of identification.
Benefits
The beneficiary shall be eligible for such in - patient health care insurance benefits as would be
designed by the respective State Governments based on the requirement of the people/
geographical area. However, the State Governments are advised to incorporate at least the following
minimum benefits in the package / scheme:
 The unroganised sector worker and his family (unit of five) will be covered.
 Total sum insured would be Rs. 30,000/- per family per annum on a family floater basis.
 Cashless attendance to all covered ailments
 Hospitalization expenses, taking care of most common illnesses with as few exclusions as
possible
 All pre-existing diseases to be covered
 Transportation costs (actual with maximum limit of Rs. 100 per visit) within an overall limit
of Rs. 1000.
Funding Pattern
 Contribution by Government of India: 75% of the estimated annual premium of Rs. 750,
subject to a maximum of Rs. 565 per family per annum. The cost of smart card will be borne
by the Central Government.
 Contribution by respective State Governments: 25% of the annual premium, as well as any
additional premium.
 The beneficiary would pay Rs. 30 per annum as registration/renewal fee.
 The administrative and other related cost of administering the scheme would be borne by
the respective State Governments

Enrollment Process. An electronic list of eligible BPL households is provided to the insurer, using a
pre-specified data format. An enrollment schedule for each village along with dates is prepared by
the insurance company with the help of the district level officials. As per the schedule, the BPL list is
posted in each village at enrollment station and prominent places prior to the enrollment and the
date and location of the enrolment in the village is publicized in advance. Mobile enrollment stations
are set up at local centres (e.g., public schools) in each village.
These stations are equipped by the insurer with the hardware required to collect biometric
information (fingerprints) and photographs of the members of the household covered and a printer
to print smart cards with a photo. The smart card, along with an information pamphlet, describing
the scheme and the list of hospitals, is provided on the spot once the beneficiary has paid the 30
rupee fee and the concerned Government Officer has authenticated the smart card. The process
normally takes less than ten minutes. The cards shall be handed over in a plastic cover.
Smart Card. Smart card is used for a variety of activities like identification of the beneficiary through
photograph and fingerprints, information regarding the patient. The most important function of the
smart card is that it enables cashless transactions at the empanelled hospital and portability of
benefits across the country. The authenticated smart card shall be handed over to the beneficiary at
the enrollment station itself. The photograph of the head of the family on the smart card can be
used for identification purpose in case biometric information fails.
Service Delivery. A list of the hospitals (both public and private) (External website that opens in a
new window) will be provided at the time of enrollment. A helpline number will also be provided
along with the smart card. Based on the qualifying criteria, both public and private hospitals will be
empanelled by the insurance company. The beneficiary will have the option to choose hospitals
where they want to go. No payment for the treatment cost up to Rs. 30000/- would be paid to the
hospital. In case of Cashless service, the patient will not have to spend any amount for taking the
treatment and hospitalization. It is the job of hospital to claim from the insurer.

A year on, Ayushman Bharat faces multiple challenges ahead

September 24, 2019, The Hindu

The free cashless health insurance scheme for the poor, Pradhan Mantri Jan Arogya Yojana (PM-JAY)
or Ayushman Bharat completed a year on September 23. The National Health Authority (NHA) which
implements the scheme stated that 46.4 lakh had received treatment through hospitalisation under
the scheme. However, the past year has thrown up multiple challenges for the plan.

One such challenge is to strengthen its fraud control mechanisms. NHA said in its press release that
patients availed free treatment worth nearly ₹7,500 crore . This means that the average cost of
treatment per patient in the scheme comes up to ₹16, 164. The average promised annual cover of
five lakh rupees per family is way higher than the average cost of treatment of a patient, considering
that it is highly unlikely that all family members will avail the benefit in the same year.

Health officials had earlier told BusinessLine that a higher cover opens up a window for fraud, where
unrelated ineligible beneficiaries are admitted based on forging a relationship with the head of the
beneficiary family, thus exhausting the wallet of the family. This fraud is perpetrated by forging
marriage certificates or adoption papers, for instance, by local entrepreneurs at common service
centres (CSCs) who make e-cards for enrolling patients. This has led to the NHA filing multiple police
complaints. While NHA claims in its statement that nine hospital admissions are made every minute,
and over ten crore e-cards have been created, there is no full-proof way for the government to
instantly know if that admission is fraudulent or a ghost admission. The challenge that lies ahead for
NHA is to strengthen artificial intelligence to pick up all such instances of fraud.

After a year of rolling out the scheme, political skirmishes have led to Delhi, West Bengal, Odisha and
Telangana keeping an arm’s length from the scheme. NHA has also said that close to 18,236
hospitals, of which 53 per cent are private, especially multi-speciality. Be that as it may, big
corporate hospitals have chosen to stay away saying that the scheme is non-viable and that they are
not able to meet their costs if they met out treatment at prices that the scheme demands.

Even after a year, the cost revisions in PM-JAY for package procedures, for example, an angioplasty,
or a knee replacement have not been made public. Officials have suggested that the cost revisions
will mostly be upward, to attract the big corporate hospitals to participate. Meanwhile, as states
who were already running state-based government-run insurance programmes, like Maharashtra
and Tamilnadu, protested saying PM-JAY procedure rates were non-viable, the centre gave them
levy to stick to old rates designed by the state before the scheme was launched. Thus PM-JAY rates
remained a mere guideline, which has either kept big hospitals at bay or have not been followed by
states.

While patients in 32 states and union territories sought benefit of the scheme since the past year,
including Jammu and Kashmir, what sticks out like a sore thumb in midst of laurels, is the impact that
abrogation of Article 370 and subsequent clampdown on internet has had, on the functioning of the
scheme, in months of August and September.

NHA has said that to enable PM-JAY swiftly and effortlessly, Information Technology provides a
robust backbone to the scheme’s implementation throughout the county. With the internet down,
private hospitals who were earlier striving to keep the scheme functional in Kashmir, on the treat
first pay later offline mode, have incurred pending payments of lakhs of rupees. They are slowly
citing non-affordability as a reason to discontinue treatment under the scheme. In August, hospital
admissions saw a sharp decline, while they were rising month-on-month before August.

Ensuring seamless connectivity in regions of turmoil like Kashmir or empanelling hospitals in remote
areas like the north-east and Leh remains a challenge. Going forward, hopefully, there will be more
equanimity in access for Ayushman Bharat, which remains crucial for the treatment of sick people, a
year down.

--

Pradhan Mantri Jan Arogya Yojana (Ayushman Bharat or AB-NHPM)

• Ayushman Bharat, the government-sponsored health insurance scheme, will provide free coverage
of up to Rs 5 lakh per family per year in any government or even empanelled private hospitals all
over India.
• Launched with an aim to help the poor and the economically deprived, the scheme will be
available for 10.74 crore beneficiary families and about 50 crore Indian citizens.
• This scheme will strengthen the healthcare services in India. Around 13000 hospitals in the country
have been coordinated for the implementation of the scheme.
• The Ayushman Bharat programme will be funded with 60 percent contribution from the Centre
and the remaining from the states.
• The scheme aims to target poor and vulnerable population of the country, based on the Socio
Economic and Caste Census 2011 (SECC) database. There will be no cap on family size and age in the
scheme. The benefit cover will also include pre and post-hospitalisation expenses. All pre-existing
conditions will be covered from day one of the policy.
• A defined transport allowance per hospitalisation will also be paid to the beneficiary.
• The scheme allows the beneficiary to take cashless benefits from any public or private empanelled
hospitals across the country.
• The payment for treatment will be done on package rate which will be defined by the Government
in advance basis. The package rates will include all the costs associated with treatment. The States
and UTs will have the flexibility to modify these rates within a limited bandwidth.
• For beneficiaries, it will be a cashless and paper less transaction.
• The scheme will work in partnership with NITI Aayog to operationalise a robust, modular and
interoperable IT platform which will involve a paperless and cashless transaction.
• The National Health Agency (NHA), the apex body implementing the scheme, has launched a
website (mera.pmjay.gov.in).

Who all can avail of the scheme and how?

The Ayushman Bharat is an entitlement based scheme with entitlement decided on the basis of
deprivation criteria in the SECC database. Here are the different categories of families in rural areas
that can be covered under the scheme:
 The beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and
D7).  These are:
 Families having only one room with kucha walls and kucharoof
 Families having no adult member between age 16 to 59
 Female headed households with no adult male member between age 16 to 59
 Disabled member and no able bodied adult member in the family
 SC/ST households
 Landless households deriving major part of their income from manual casual labour
 The scheme will automatically include families in rural areas having any one of the following-
households without shelter, destitute, living on alms, manual scavenger families, primitive
tribal groups or legally released bonded labour.
 For urban areas, 11 defined occupational categories are entitled under the scheme.
 In addition, the Rashtriya Swasthya Bima Yojna (RSBY) beneficiaries in states where it is
active are also included.
 There is no cap on family size and age in the scheme.

One would only need to establish one's identity to avail benefits under the scheme and it could be
through Aadhaar card or election ID card or ration card. Having an Aadhaar card is not mandatory.  
All the beneficiaries will be given letters having QR codes which will be scanned. A demographic
authentication will be conducted for identification to verify his or her eligibility to avail the benefits
of the scheme. In case of hospitalisation, members of the beneficiary families do not need to pay
anything under the scheme, provided if one goes to a government or an empanelled private
hospital.
Hospital empanelment
• The beneficiaries can avail of the benefits in both public and empanelled private facilities. All public
hospitals in the States implementing the scheme will be considered empanelled for the Scheme.
• Hospitals belonging to Employee State Insurance Corporation (ESIC) will also be empanelled based
on the bed occupancy ratio parameter.
• While, the private hospitals will be empanelled online, based on defined criteria.
• Each empanelled hospital will have an 'Ayushman Mitra help desk' where a prospective beneficiary
can check documents to verify the eligibility and enrolment to the scheme.
• So far, 15686 applications for hospital empanelment have been received and over 8735 hospitals,
both public and private, have been empanelled for the scheme.

Remaining States
As many as 30 states and Union Territories have signed MoUs with the Union Government to
implement the programme over the next two to three months. However, Telangana, Odisha, Delhi,
Kerala and Punjab have still not signed the MoUs, so the scheme will not be implemented in these
states till they come on board. States will be required to form a State Health Agency (SHA) to
implement the scheme and at the district level also, a structure for implementation of the scheme
will be set up. To ensure that the funds reach SHA on time, the transfer of funds from Central
Government to State Health Agencies may be done through an escrow account directly.

IAS Exam prep Portal

  In-patient hospitalization expenditure in India has increased nearly 300% during last ten
years. More than 80% of the expenditure are met by out of pocket (OOP). Rural households
meet this expenditure through ‘household savings’ (68%) and on ‘borrowings’ (25%),
perpetuating the vicious cycle of poverty. Hence In budget 2018, NHPM was announced…

Body#1: How different from predecessors

Previous schemes NHPM

Here Rs. 5 lakh medical insurance per

Rashtriya Swasthya BimaYojana (RSBY): only BPL family.
family per year. SECC-2011 data to cover
Only annual Rs.30,000 insurance.
more than 10 crore families.

ESIC’s schemes cover only workers and their families

(NOT FARMERS), Senior Citizen Health Insurance Here all age groups and occupation groups
Scheme (SCHIS) covers only senior citizens (NOT covered.
INFANTS)

State Government too have their own medical insurance State Governments will be allowed to
schemes such as Gujarat’s Mukhyamantri Amrutam expand AB-NHPM both horizontally and
(MA) Yojana. vertically by adding their own funds.

Cashless paperless treatment in secondary-

and tertiary-care hospitalisation both in
These features were missing in previous schemes: public and private hospitals.

Both pre and post-hospitalisation expenses,

Transportation cost also provided.

Body#2: Fiscal Challenges

 Rs. 25,000-40,000 crores required to fully implement the scheme in letter and spirit.
Government has also hiked MSP to double farmers’ income. So, difficult to manage the fiscal
deficit targets under FRBM Act.
 Cost sharing between Union and States: 60:40 (ordinary), 90:10 (Special category states). But
some states reluctant / already have better schemes of their own.
 Inflated costs, connivance, corruption.
o Janani Suraksha Yojana (JSY) was launched to pay for institutionalized deliveries of
poor women to reduce Maternal Mortality Ratio (MMR). But private doctors
deliberately perform Caesarean surgeries to avail more money from Government.
o In Delhi a case where Rs.15,00,000 rupees extracted for 15 days’ dengue treatment
for a girl.
o Yes, NHPM has ceiling of Rs.5,00,000 but there is a danger of private clinics inflating
the costs, tests and medicines even for ordinary ailments to extract maximum
amount of that annual 5 lakh rupee coverage per family.

Body#3: Administrative Challenges

 CAG observed that 46% of Gujarat’s BPL families don’t have the cards for Gujarat state’s own
health insurance scheme! Door to door, village to village enrollment of the beneficiaries
will require large manpower.
  Improving Doctor to patient ratio. Physical and IT infrastructure, transport & connectivity
upto village level. These issues pose both financial and administrative challenges. Often, we
see disturbing images of poor schedule tribes in Odisha bringing their pregnant wives and
injured kids on bicycle or shoulders for kilometers because there is no hospitals or
ambulances in their vicinity.
 PM Fasal Bima Yojana- another ambitious scheme that provide crop-insurance to farmers.
But there have been many complaints that private insurance companies are not paying the
assured sum on time, in pretext of technicalities. Therefore, effective monitoring and
grievances redressal mechanism will be necessary for the success of NHPM.
 To remove corruption, we’ll have to link the beneficiaries Aadhar numbers with their
medical records. Reliance on contractual-staff in this exercise, may violate the medical
privacy of patient, their database may be misused by the pharma companies for their
clinical trials and commercial motives.
 Specialized personnel will be required for empanelment and supervision of private hospitals
in this scheme.

Conclusion (futuristic note: yes positive step)

 Sustainable Development Goal SDG#3 Ensure healthy lives and well-beings at all ages. NHPM
is a right step in this regard, provided aforementioned challenges are addressed. OR
 Disease burden robs a poor person of his wages and savings. If aforementioned challenges
are addressed, NHPM can greatly help in poverty removal and human development in India.
OR
 If above challenges are addressed, NHPM can improve health outcomes, productivity,
efficiency of Indian population, thus leading to improvement GDP and in quality of life.