Ayushman Bharat - Pradhan Mantri Jan Arogya Yojna

Pradhan Mantri Jan Arogya Yojana(PM-JAY) is a pioneering initiative of the Government of India to ensure that the poor and vulnerable population is provided with health coverage. This initiative is part of the Government’s vision to ensure that its citizens – especially the poor and vulnerable groups have universal access to good quality hospital services without anyone having to face financial hardship as a consequence of using health services.

PM-JAY provides an insurance cover upto Rs 5 lakh per family, per year for secondary and tertiary hospitalization. All pre-existing conditions are covered from day 1 of implementation of PM-JAY in respective States/UTs.

The health services covered under the programme include hospitalization expenses, day care surgeries, follow-up care, pre and post hospitalization expense benefits and new born child/children services. The comprehensive list of services is available on the website.

PM-JAY covers more than 10 crore poor and vulnerable families across the country, identified as deprived rural families and occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data. A list of eligible families has been shared with the respective state government as well as ANMs/BMO/BDOs of relevant area. Only families whose name is on the list are entitled for the benefits of PM-JAY. Additionally, any family that has an active RSBY card as of 28 February 2018 is covered. There is no capping on family size and age of members, which will ensure that all family members specifically girl child and senior citizens will get coverage.

Services under the scheme can be availed at all public hospitals and empaneled private health care facilities. Empanelment of the hospitals under PM-JAY will be conducted through an online portal by the state government. Information about empaneled hospitals will be made available at through different means such as government website, mobile app. Beneficiaries can also call the helpline number at 14555. Regular updates will also be provided through ASHAs, ANM and other specific touch points This information will be activated shortly.

No. All eligible beneficiaries can avail free services for secondary and tertiary hospital care for identified packages under PM-JAY at public hospitals and empaneled private hospitals. Beneficiaries will have cashless and paperless access to health services under PM-JAY.

PM-JAY is an entitlement based mission. There is no enrollment process. Families who are identified by the government on the basis of deprivation and occupational criteria using the SECC database both in rural and urban areas are entitled for PM-JAY.

The beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC (Socio-Economic Caste Census) database for rural areas and 11 occupational criteria for urban areas. In addition, RSBY beneficiaries in states where RSBY is active are also included.

In this phase, no additional new families can be added under PM-JAY. However, names of additional family members can be added for those families whose names are already on the SECC list.

A dedicated PM-JAY family identification number will be allotted to eligible families. Additionally, an e-card will also be given to beneficiary at the time of hospitalization.

Yes. All existing medical conditions / Illnesses are covered under this scheme.

Yes. New born child can be provided treatment under this scheme. They can also be added into beneficiary family after providing necessary documents.

Any family that has an active RSBY card as of 28 February 2018 is covered under the Ayushman Bharat Pradhan mantra Jan Arogya Yojana.

There is no capping on family size and age of members, which will ensure that all family members specifically girl child and senior citizens will get coverage.

Yes Information about empanelled hospitals will be made available at through different means such as website (www.pmjay.gov.in; www.ayushmanup.in ), Mobile app developed with the name of Aarogya Saarthi.

Beneficiaries can call the helpline number at 14555 at national level and 1800 1800 4444 for Uttar Pradesh dedicated number.

The beneficiaries identified are based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC (Socio-Economic Caste Census) database for rural areas and 11 occupational criteria for urban areas.

Yes. Aadhar card is not mandatory for availing services under this scheme.

In this phase, no additional new families can be added under PM-JAY. However, names of additional family members can be added for those families whose names are already on the SECC list by showing individual id and family id by proving the relation with the family members in the SECC data.

An Ayushman Mitra (AM) is a certified frontline health service professional who is present at each of the EHCP and serves as a first contact point for beneficiaries. They will help in processing documents for Beneficiary identification as well as complete claim process along with Medical Coordinator. They are available at Ayushman Bharat Kiosk in every EHCP to assist patients.

Pre – authorization request is a documentation done to make sure Right Treatment package is selected for right diagnosis to right patient. It’ll be a processed by submitting Doctor’s admission note along with necessary investigation/diagnostic reports. This is a mandatory step to avail any services under Ayushman Bharat Scheme.

Yes. Aadhar card is not mandatory for availing services under this scheme.

Once patient is discharged from the EHCP, the claim submission process is initiated by raising request on online portal with patient’s discharge summary along with other necessary clinical notes and investigation reports. EHCP is required to submit claims within 24 hours of discharge of patient.

Once all claims documents submitted, claim must be approved within 15 days to SHA for final approval and payment processing. SHA will make payment of claims within 15 days after being authenticated by their internal team.

AB PMJAY has a three-tier grievance redressal structure to ensure timely redressal of grievances. This section of the guidelines lays down these structures, their constitution and functions. District Grievance Redressal Committee (DGRC) – will be constituted by the SHA in each district and this is chaired by Head of the District or District Magistrate or District Collector or Deputy Commissioner. The State Grievance Redressal Committee (SGRC) is chaired by CEO of SHA / State Nodal Agency (SNA). The SGRC shall perform all functions related to handling and resolution of all grievances received either directly or escalated through the DGRC. The National Grievance Redressal Committee (NGRC) will be chaired by Deputy CEO of National Health Agency (NHA). The NGRC shall act as the final Appellate Authority at the national level. The NGRC shall only accept appeals and petitions against the orders of the SGRC of a State. The decision of NGRC will be final.

Grievances can be lodged through Online portal or District grievance nodal officer i.e. DGNO or written complaint or call center number - 1800111565 or 14555 SHA will make payment of claims within 15 days after being authenticated by their internal team.