Expert advice, Heal
Ayushman Bharat – A Scheme To Empower Health

G Bharathi

CEO, Family Health Plan Insurance TPA Ltd.

6 min read

 

The idea of giving essential healthcare services to the underprivileged Indians gave birth to the Ayushman Bharat Yojana by our PM Narendra Modi in 2018. This scheme covers Rupees five lakh insurance to every (BPL) household annually for their healthcare. Research states that families living under the below poverty line had no hope for saving themselves with curable diseases due to poverty. To make this scheme accessible for the underprivileged, the government empanelled private hospital along with the public hospitals all over the nation.

This scheme paved the way to make India the only country that provides the largest healthcare solely based on government funding in the world. In this honour, 30 April is observed as Ayushman Bharat Diwas across the country.

Initially, this scheme was rejected by West Bengal, Telangana, Odisha, Delhi, Kerala and Punjab. But by 2020, this scheme was embraced by the state of Punjab.

UR Guide To Ayushman Bharat Pradhan Mantri Jan Arogya Yojana

Benefits
  • Cashless and free medical treatment
  • 50 crore beneficiaries in the scheme
  • Covers everyone in the family (Doesn’t apply the condition to the number of family members)
  • No empanelled hospital can deny treatment
  • Quality healthcare
  • Hospitals are not allowed to increase the amount for treatment
  • Any eligible candidate can access the healthcare package from anywhere in India
  • Improves quality of life
Means Of Delivery

Health And Wellness Centres: This scheme envisions providing one and a half lakh health centres that give services like comprehensive health care, maternal and child health care and treats non-communicable diseases. It also aims to provide free pharmaceuticals drugs along with diagnostics.

Network Hospitals, Both Private And Public: The government empanel hospitals to treat PMJAY patients on a cashless basis with fixed costs of procedures/ailments.

Eligibility Criteria

Population covered under the scheme is based on SECC (Socio-Economic Caste Census) 2011 data

For Rural Areas
  • Families living under the Below Poverty line
  • Families without adult supervision (without people under the age limit of 16 to 59 years)
  • A family consisting of disabled members without and able-bodied guardian
  • SC/ST communities household
  • Manual labourers
  • People receiving alms for survival
  • People from the tribal community
  • Families with jobs such as manual scavengers
  • Bonded labourers that are legally released
For Urban Areas
  • Ragpickers
  • Beggars
  • Domestic workers
  • Hawkers
  • Sanitization workers
  • Artisans/ handicraft workers
  • Watchmen
  • Electrician/ mechanics/ repair workers
  • Truck drivers/ conductors/ rickshaw drivers
  • Peons/assistants/ attendants etc.

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The Progress So Far

More than 28,000 healthcare centres are set up in the country.
In less than three months of the introduction, six lakh people benefited from the scheme.
All states and Union Territories have received substantial funds for free drugs and diagnostics centres.
More than 21,000 private hospitals are empanelled with the scheme.
More than 12 crore cards are issued all over the country to avail the benefits of this scheme.
More than 98 Lakh people are admitted in the hospital under this scheme.
Provide a range of packages for treatment that include around 1579 packages for both surgical and medical.
The treatment packages include a diagnostic charge 3 days before hospitalization and free drugs up to 15 days after hospitalization.
Launched an efficient method to curb overcharging and exploitation of the scheme.
A 24*7 grievance response portal is set up.

The Exploitation Of The Scheme

The privileged people found a way to find loopholes in the scheme and are pocketing public funds through these loopholes. The first instance of this exploitation came into the limelight from Nainital, where the claims were fraudulent. As the scheme covers around 24 specialities of the medical sector, hospitals claimed to give these treatments to the patients without being equipped for such services. Dialysis is the first choice of such fraudulent claims.

Overcharging for the treatment and exploitation of public funds by the pretence of hospitalization without having a medical issue also came to light. The Government of India set up a fool-proof verification system to restrain these fraudulent claims by setting up a backend verification technology.

During COVID-19

To reduce the panic during the current pandemic of Coronavirus, the testing and treatment of COVID-19 are now available at all the empanelled hospitals under the Ayushman Bharat Yojana. This also includes free testing to detect the presence of the virus. A helpline number, 1075 has been set up for the same cause.

FHPL

Family Health Plan Insurance (FHPL) is a licensed Third Party Administrator (TPA). We act as a bridge to the beneficiaries and their healthcare providers. FHPL is now tied-up with five states across the country to provide easy access to beneficiaries of PM-JAY and state-sponsored healthcare schemes.

    The Five States are

  • Gujarat
  • Uttarakhand
  • West Bengal
  • Punjab
  • Assam
    Milestones

  • FHPL has helped more than 1.2 crore families.
  • Served more than 5 crore lives.
  • Spread in more than 70 districts.

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Local Implementation

In the 28 states and 8 Union Territories of India, Delhi, Punjab, Odisha, West Bengal and Telangana opted out of ‘Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana’. As of 2019, the state of Punjab embraced the scheme and treated more than 1,33,000 people under this scheme till now.
The healthcare scheme of the states that rejected PM-JAY.

Telangana

The state refused to participate in the Ayushman Bharat Yojana as it already implemented Aarogyasri scheme that provides healthcare to over 80 lakh families. The state healthcare package involves organ transplant that is not a part of the Ayushman Bharat Yojana.

Benefits of Aarogyasri Scheme
  • Financial protection of 2 lakhs per annum for surgery or serious diseases
  • Redeeming 949 treatments under the scheme
  • Covers therapy, surgery and hospitalization
  • Cashless treatment
Odisha

Ayushman Bharat Yojana offered to secure 61 lakh families under the scheme. The requirements of the state were higher by 9 more lakh families. Due to this, the state hasn’t yet implemented this scheme in their state. The state is implementing its healthcare scheme named ‘Biju Swasthya Kalyan Yojana (BSKY)’.

Benefits of Biju Swasthya Kalyan Yojana (BSKY)
  • Free diagnostic services in government hospitals
  • Free dialysis at the district level
  • Spectacles for students
  • Free cataract operations
  • Transportation reimbursement for pregnant women living in inaccessible areas
West Bengal

After comprehensive research on the state implemented scheme and the national scheme, West Bengal opted out of the central scheme. They are implementing Swasthya Sathi (SS) health protection scheme providing protection for 1.5 crore families.

Benefits of Swasthya Sathi (SS) health protection scheme
  • Smart card, paperless and cashless based package
  • Reinforced IT backdrop to reduce fraudulent claims
  • No limit to family size and age
  • Covers severe diseases like cancer and the ones that require neurosurgery
  • 24*7 toll-free call centre
  • Mobile app for assisting beneficiaries

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