Ayushman Bharat: Who will get Rs 5 lakh health cover under PM Jan Arogya Yojana and what will be covered

By: | Updated: September 25, 2018 1:47 PM

It is believed to be the world's biggest health insurance scheme which would benefit over 50 crore Indians. So far, 29 out of 36 states and union territories have agreed to join the scheme.

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While launching the Ayushman Bharat health scheme on Sunday at Ranchi, Prime Minister Narendra Modi termed it as the world’s biggest health insurance scheme which would benefit over 50 crore Indians. So far, 29 out of 36 states and union territories have agreed to join the scheme. While Odisha has opted out, the other six are expected to sign up in the coming months.

As PM Jan Arogya Yojana (PMJAY) under the scheme becomes operational on Tuesday, September 25, on the birth anniversary of Pandit Deendayal Upadhyay, let’s have a close look at the scheme.

Eligibility: PMJAY will benefit the poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) 2011 data, both rural and urban. About 50 crore people of 10 crore families, including the existing Rashtriya Swasthya Bima Yojana beneficiaries and those part of similar schemes in the participating states will be covered under the scheme. However, households having government employee(s) or paying income tax or having motorised 2/3/4 wheelers/fishing boat(s) or any member earning more than Rs 10,000 a month or owing a refrigerator or landline telephone etc are excluded from the scheme.

Cover limits: It’s a cashless family floater insurance covering all the members of the household for one year. That means any one or more members of the family may avail cashless treatment together up to Rs 5 lakh in a year. Pre- and post-hospitalisation expenses will be covered, but within the total limit of Rs 5 lakh. Family members can be added after the government’s approval.

Coverage: It covers 1,354 medical and surgical packages categorised under 25 specialties such as cardiology, neurosurgery, oncology (chemotherapy for 50 types of cancers), burns, among others. Patients can’t avail surgical and medical packages at the same time.

Benefits: The benefits include hospitalisation expenses such as registration, nursing and boarding charges in general ward, as well as consultation fees, surgical equipment and procedure charges and cost of implants, medicines, diagnostic tests and food for patients. In case of multiple surgeries, the highest package rate will be waived for the first treatment, and 50 per cent and 25 per cent of the costs will be provided for the second and third treatment, respectively.

Waiting period: Unlike normal health insurance plans, there will be no waiting period for the beneficiaries under PMJAY and all the diseases are covered from day one.

Network hospitals: About 7,826 hospitals have joined the PMJAY network so far, of which 47 per cent are private and the rest are public hospitals. The beneficiaries will get cashless treatment in the network hospitals. All public hospitals get empaneled from day one, while private hospitals have to get themselves registered.

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