ABOUT AB PM-JAY
Launched in September 2018, Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is the world’s largest government-funded health assurance scheme and functions as the demand-side pillar of the Ayushman Bharat initiative, designed to advance Universal Health Coverage (UHC) by shielding vulnerable families from catastrophic out-of-pocket medical expenses.
Key Features of the Scheme
- Financial Coverage: Provides a health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalization.
- No Caps on Family Structure: There are strictly no restrictions on family size, age, or gender, ensuring that all dependents are covered.
- Pre-existing Diseases: All pre-existing conditions are covered from day one of the policy.
- Cashless and Paperless: Beneficiaries receive cashless access to healthcare services at the point of service.
- National Portability: The scheme is fully portable across the country. A beneficiary from any state can avail of treatment in any empanelled public or private hospital nationwide.
- Defined Benefit Package: Covers expenses including diagnostics, up to 3 days of pre-hospitalization, 15 days of post-hospitalization, and medication costs.
Target Beneficiaries & Eligibility Criteria
- Base Framework: The original identification of targeted beneficiary families was based on the deprivation and occupational criteria of the Socio-Economic Caste Census (SECC) 2011.
- Frontline Health Workers: The scheme’s umbrella was subsequently broadened to unconditionally include ASHA (Accredited Social Health Activist) workers, Anganwadi workers, and Anganwadi helpers.
- Universal Senior Citizen Coverage (2024 Expansion): In September 2024, the Union Cabinet approved a landmark expansion, extending AB-PMJAY health coverage to all senior citizens aged 70 years and above, completely independent of their income, socio-economic status, or existing insurance.
- Eligible senior citizens receive a distinct health card.
- Seniors aged 70+ belonging to families already covered under AB-PMJAY receive an additional, exclusive top-up cover of ₹5 lakh per year for themselves.
- Seniors aged 70+ who are not part of existing PMJAY families receive a standard ₹5 lakh cover per year on a family basis.
Implementation Architecture
- National Health Authority (NHA): The NHA acts as the apex body at the central level, responsible for the overall design, roll-out, implementation, and management of the scheme.
- State Health Agencies (SHA): At the state level, SHAs are established to operationalize the scheme. States have the flexibility to implement PM-JAY using three distinct models:
- Trust Model: The SHA directly pays healthcare providers from a central corpus fund without involving an insurance company.
- Insurance Model: The state pays a premium to a designated insurance company, which manages the financial risk and settles the claims.
- Mixed Model: A hybrid approach where lower-cost treatments are managed via a trust, and high-cost interventions are covered by an insurance company.
Funding Mechanism
AB-PMJAY is structured as a Centrally Sponsored Scheme. The administrative costs and premium contributions are shared between the Centre and the States in specific ratios:
- 60:40 for standard states and Union Territories with a legislature.
- 90:10 for Northeastern states, Himalayan states (Himachal Pradesh, Uttarakhand), and the UT of Jammu & Kashmir.
- 100% Central Funding for Union Territories without a legislature.
Conclusion
AB-PMJAY marks a paradigm shift toward Universal Health Coverage by providing critical financial risk protection against catastrophic healthcare expenditures. Going forward, its long-term success will hinge on strengthening public healthcare infrastructure, rationalizing package rates, and eliminating regional disparities in tertiary hospital empanelment.
| This concept has been discussed elaborately in the following article: Bridging the Gap: Reforming India’s Public Healthcare System and Financing |