Which Indian scheme provides health insurance for the poor?

The primary Indian scheme that provides health insurance for the poor and vulnerable is the Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB PM-JAY)

Brief Overview

AB PM-JAY is the world's largest government-funded health assurance scheme, offering a health cover of ₹5,00,000 per family per year for secondary and tertiary care hospitalization. It is designed to provide cashless and paperless access to healthcare services at a vast network of empanelled public and private hospitals across India. The scheme targets over 12 crore poor and vulnerable families (approximately 55 crore beneficiaries), identified based on the Socio-Economic Caste Census (SECC) 2011 data. A key feature is its "family floater" basis, meaning the ₹5 lakh cover can be utilized by one or all members of an eligible family, with no cap on family size or age. Importantly, all pre-existing diseases are covered from day one.

The Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) is a groundbreaking initiative by the Government of India, aimed at providing comprehensive health insurance coverage to the nation's most vulnerable citizens. It represents a significant step towards achieving Universal Health Coverage (UHC) and reducing the catastrophic out-of-pocket health expenditures that push millions into poverty each year.

Brief Overview

AB PM-JAY is the world's largest government-funded health assurance scheme, offering a health cover of ₹5,00,000 per family per year for secondary and tertiary care hospitalization. It is designed to provide cashless and paperless access to healthcare services at a vast network of empanelled public and private hospitals across India. The scheme targets over 12 crore poor and vulnerable families (approximately 55 crore beneficiaries), identified based on the Socio-Economic Caste Census (SECC) 2011 data. A key feature is its "family floater" basis, meaning the ₹5 lakh cover can be utilized by one or all members of an eligible family, with no cap on family size or age. Importantly, all pre-existing diseases are covered from day one.

History

The concept of Ayushman Bharat emerged from the National Health Policy 2017, which laid out the vision for Universal Health Coverage. Recognizing the dire need to protect citizens from debilitating healthcare costs, the Indian government announced the Ayushman Bharat Yojana as a universal health care plan in the Union Budget of February 2018. The scheme was officially approved by the Union Council of Ministers in March 2018

Following an intensive period of planning, stakeholder consultations, and pilot launches in several states and UTs, AB PM-JAY was formally launched by Prime Minister Narendra Modi on September 23, 2018, in Ranchi, Jharkhand. The scheme was designed to learn from previous health insurance initiatives like the Rashtriya Swasthya Bima Yojana (RSBY), addressing their limitations such as a family cap of five members. Since its inception, PM-JAY has continually expanded its reach and impact, becoming a cornerstone of India's social welfare programs.

Benefits

The benefits offered by AB PM-JAY are extensive and designed to alleviate the financial burden of healthcare for the poor:

• Financial Protection: Provides a health cover of ₹5,00,000 per family per year, significantly reducing out-of-pocket expenditure on medical treatments.

• Cashless and Paperless Treatment: Beneficiaries receive cashless access to healthcare at empanelled hospitals, eliminating the need for upfront payments and complex paperwork.

• Comprehensive Coverage: Covers a wide range of medical services, including:

  • Medical examination, treatment, and consultation

  • Pre-hospitalization expenses (up to 3 days)

  • Post-hospitalization expenses (up to 15 days), including diagnostics and medicines

  • Medicine and medical consumables

  • Non-intensive and intensive care services

  • Diagnostic and laboratory investigations

  • Medical implantation services

  • Accommodation benefits (room charges)

  • Food services during hospitalization

  • Complications arising during treatment

  • Approximately 1,929 medical procedures are covered.

• No Cap on Family Size or Age: Ensures that all members of an eligible family, including girl children and senior citizens, are covered.

• Pre-existing Diseases Covered from Day One: Unlike many private insurance policies, PM-JAY covers pre-existing health conditions from the very beginning.

• Portability of Benefits: Beneficiaries can avail treatment at any empanelled public or private hospital across India, regardless of their native state.

• Access to Quality Healthcare: Empanelled hospitals adhere to certain quality standards, ensuring access to essential secondary and tertiary care.

• Reduced Poverty: By mitigating catastrophic health expenditures, the scheme helps prevent millions of Indians from falling into poverty due to medical crises.

Frequently Asked Questions (FAQ)

Q1: Who is eligible for AB PM-JAY? 

A1: Eligibility is primarily based on the deprivation and occupational criteria from the Socio-Economic Caste Census (SECC) 2011 database for rural and urban areas. Additionally, families with an active RSBY card as of February 28, 2018, are also covered.

Q2: How can I check my eligibility?

A2: You can check your eligibility online on the official PM-JAY portal: mera.pmjay.gov.in. You can also inquire at designated PM-JAY kiosks or "Arogya Mitras" at empanelled hospitals.

Q3: Do I need to pay anything to get covered under this scheme? 

A3: No, AB PM-JAY is a fully government-funded scheme. Eligible beneficiaries receive cashless and paperless access to healthcare services for identified packages. There are no premiums or fees to be paid by the beneficiaries.

Q4: Is there an enrollment process for PM-JAY? 

A4: No, PM-JAY is an entitlement-based scheme. There is no enrollment process. If your family is identified in the SECC 2011 database or holds an active RSBY card, you are automatically entitled to the benefits.

Q5: What documents do I need to avail benefits?

A5: Typically, you will need a valid ID proof (like Aadhaar Card, PAN Card, Voter ID) and a document to confirm your family's eligibility (e.g., PM/CM entitlement letter, Ration Card). An "Ayushman Card" or "e-card" is generated at the time of hospitalization for identification.

Q6: Are all hospitals covered under PM-JAY? 

A6: No, only empanelled public and private hospitals are covered. You can find a list of empanelled hospitals on the official PM-JAY website or through the PM-JAY helpline.

Q7: What is a "family floater" basis? 

A7: This means the ₹5,00,000 health cover is available for the entire family collectively, not individually. Any member can utilize the full amount, or multiple members can use portions of it, until the total limit for the year is reached.

Q8: Are pre-existing diseases covered? 

A8: Yes, all pre-existing diseases are covered from day one of the scheme's implementation in the respective state/UT for the eligible family.

Q9: What if I need treatment in another state? 

A9: The benefits of the scheme are portable across the country. You can avail cashless treatment at any empanelled public or private hospital in India, regardless of where your Ayushman Card was issued.

Q10: What if the treatment cost exceeds ₹5 lakh? 

A10: The scheme provides a cover of up to ₹5,00,000. Any expenses beyond this amount for a given year would need to be borne by the beneficiary.