Why in the News? 

Union Cabinet approved health cover for senior citizens under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY).

Details of expansion of Scheme

• Eligibility Criteria: All senior citizens aged 70 and above regardless of their income.
  • The scheme is set to benefit about 6 crore senior citizens. 
• Benefits offered: Senior citizens will receive a family-based cover of Rs. 5 lakh annually.
  • Those already covered by AB PM-JAY will receive an additional top-up of Rs. 5 lakhs annually, separate from their family’s existing cover. 
• Ease of Access: Eligible senior citizens will be issued a distinct card.
• Other Key features: 
  • Senior citizens already availing benefits of other public health insurance schemes may either choose their existing scheme or AB PM-JAY. 
  • Senior citizens under private health insurance or Employees’ State Insurance schemes are also eligible for AB PM-JAY benefits. 

About AB PM-JAY (2018)

• Ministry: Ministry of Health & Family Welfare
• Type: Centrally Sponsored Scheme under Ayushman Bharat Mission
• Background: PM-JAY was earlier known as the National Health Protection Scheme (NHPS).  
  • It subsumed the then-existing Rashtriya Swasthya Bima Yojana (RSBY), 2008. 
• Purpose: To reduce the financial burden on poor and vulnerable groups arising out of catastrophic hospital episodes and ensure their access to quality health services.
  • It aims to achieve the agenda of Universal Health Coverage (UHC).
• Target: 12 crore families (approximately 55 crore beneficiaries), prioritising the poorest 40% of the population.
• Funding: Fully funded by the Government. 
  • Share of Centre and State is 60:40 (90:10 for North Eastern States and the two Himalayan States (Himachal Pradesh and Uttarakhand) and Jammu and Kashmir)
  • Central share is 100% for UTs without legislature, while the ratio of contribution is 60:40 for those with legislature.
• Implementing Agencies: National Health Authority (NHA) an autonomous body chaired by the Union Minister of Health & Family Welfare.
  • State: State HA headed by CEO appointed by the state government. 
  • District: District Implementing Unit (DIU) chaired by DC/DM/Collector of the district.
• Beneficiaries: Identified through Socio-Economic Caste Census-2011 (SECC-2011). 
  • Also, families that were covered under RSBY but did not form part of the SECC-2011.

Key Components of AB PM-JAY 

• Ayushman Arogya Mandirs (AAMs): Creation of 1,50,000 AAMs, erstwhile Ayushman Bharat Health and Wellness Centres (AB-HWCs), to deliver Comprehensive Primary Health Care, that is universal and free to users.
  • They are envisaged to deliver expanded range services, beyond Maternal and child health care services, to include care for non -communicable diseases, palliative and rehabilitative care, Oral, Eye and ENT care, mental health etc.
• Pradhan Mantri Jan Arogya Yojana (PMJAY): Provides Health cover of Rs. 5 lakh/family/year for secondary and tertiary care hospitalization.
  • Covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses. 
  • Cashless and paperless healthcare services at the point of care.
  • No restriction on the family size, age or gender.
  • All pre-existing medical conditions covered from day one of enrolment.
  • Nationwide Portability through empanelled public or private hospital across India.

Concerns/Challenges associated with AB PM-JAY (as per CAG Report, 2023) 

• Errors: Due to the absence of adequate validation controls, several errors were noticed in the beneficiary database such as invalid names, unrealistic date of birth, duplicate PMJAY IDs, unrealistic size of family members in a household etc. 
  • E.g., in Tamil Nadu, 4761 registrations were made against seven Aadhaar numbers
• Poor infrastructure: Some of the Empanelled Health Care Providers (EHCPs) did not fulfil minimum criteria of support system and infrastructure and were not conformed to the prescribed quality standards and criteria.
• Financial irregularities: 
  • Inadequate validation checks such as admission before preauthorization, transaction before inception of the Scheme, surgery after discharge of patient, payment prior to submission of claims, non-availability/invalid dates and other entries etc. 
  • Revenue received from PMJAY was not utilised by Public/Government Hospitals for the purpose defined under PMJAY scheme.
• Delays across implementation: Such as in submission of claims by hospitals, approval of pre-authorisation, resolution of grievances etc.
• Absence of the master data: Due to lack of common format for maintaining the data.

Conclusion

AB PM-JAY has significantly transformed the healthcare landscape, providing essential coverage to millions and reducing financial burdens associated with medical expenses.  NHA needs to take more proactive measures to ensure the implementation of initiatives in letter and spirit such as efficient validation process, improved infrastructure, geo-tagging of hospitals, regular verification, etc.