How can we get treatment under Pradhan Mantri Jan Arogya Yojana and if a hospital says that you have not been approved, what will it mean?

Pradhan Mantri Jan Arogya Yojana is being run by the Central Government in collaboration with the states, in which the Central Government is giving 60 percent share. The objective of this scheme is to liberate the lower 40 percent of the people from the huge expenses incurred in health treatment.

For the eligibility of this scheme, from the data of many socio-economic calculations done in 2011, some different basis has been made for rural and urban people. Those who are fulfilling this, are given a cashless card, so that they can get their treatment up to five lakh rupees in the hospitals prescribed under this scheme, anywhere in the country.

Some states have their own medical scheme. This scheme is not applicable in those states. In this scheme, there are 10 crore families i.e. 50 crore lower population covered in the country.

Families are considered eligible for this scheme in fulfilling any one of the 6 criteria in rural areas. Such as a one-room kutcha house, no male in the age group of 16 to 59 years, a member of SC, ST, landless family whose main work is done by human labor.

For the city, these criteria are made by working like small shop workers, street vendors, washermen, barbers, drivers, gardeners, sweepers means people doing small tasks.

The detailed information of the criteria which is available on the government website is as follows.

Rural Beneficiaries

Out of the total seven deprivation criteria for rural areas, PM-JAY covered all such families who fall into at least one of the following six deprivation criteria (D1 to D5 and D7) and automatic inclusion(Destitute/ living on alms, manual scavenger households, primitive tribal group, legally released bonded labour) criteria:

D1- Only one room with kucha walls and kucha roof

D2- No adult member between ages 16 to 59

D3- Households with no adult male member between ages 16 to 59

D4- Disabled member and no able-bodied adult member

D5- SC/ST households

D7- Landless households deriving a major part of their income from manual casual labour

Urban Beneficiaries

For urban areas, the following 11 occupational categories of workers are eligible for the scheme:

Ragpicker

Beggar

Domestic worker

Street vendor/ Cobbler/hawker / other service provider working on streets

Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and other head-load worker

Sweeper/ Sanitation worker/ Mali

Home-based worker/ Artisan/ Handicrafts worker/ Tailor

Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller

Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter

Electrician/ Mechanic/ Assembler/ Repair worker

Washer-man/ Chowkidar

Even though PM-JAY uses the SECC as the basis of eligibility of households, many States are already implementing their own health insurance schemes with a set of beneficiaries already identified. Thus, States have been provided the flexibility to use their own database for PM-JAY. However, they will need to ensure that all the families eligible based on the SECC database are also covered.

Expansion of coverage by States under PM-JAY and convergence

Various States have been implementing their own health insurance/assurance schemes over the past couple of decades. Most of these schemes provide cover for tertiary care conditions only. The benefit cover of these schemes is mostly available within the State boundaries except some smaller States have empanelled a few hospitals outside the State boundaries. Very few States had converged their schemes with the erstwhile RSBY scheme and many of them were operating independently. This was due to the lack of flexibility in the design of the RSBY, which although initially helped in quick scale-up but became a challenge over a period of time and offered limited flexibility to the States.

Even though these schemes were targeting the poor and vulnerable, there were large variations across States in terms of eligibility criteria and databases. Few States were using the food subsidy database while some others had created a separate database for their welfare schemes.

The primary objectives for launching PM-JAY were to ensure comprehensive coverage for catastrophic illnesses, reduce catastrophic out-of-pocket expenditure, improve access to hospitalisation care, reduce unmet needs, and to converge various health insurance schemes across the States. PM-JAY will also establish national standards for a health assurance system and is providing national portability of care. At the implementation level, the States are given the flexibility to use their own database if they were already implementing a health insurance/ assurance scheme and were covering more families than those eligible as per the SECC 2011 database. However, such States shall ensure that all families eligible as per the SECC data are covered and not denied benefits.