Ayushman Bharat Scheme: A Revolutionary Step Towards Universal Health Coverage in India

India has embarked on a journey to achieve Universal Health Coverage (UHC) and ensure a healthier future for its citizens. The Government of India has introduced Ayushman Bharat, a flagship healthcare initiative that focuses on the holistic development of the healthcare sector. With the vision of “leave no one behind,” Ayushman Bharat is committed to meeting Sustainable Development Goals (SDGs).

Two Components of Ayushman Bharat: Ayushman Bharat consists of two interrelated components – Health and Wellness Centres (HWCs) and Pradhan Mantri Jan Arogya Yojana (PM-JAY).

1. Health and Wellness Centres (HWCs): Strengthening Primary Health Care

• Transforming Existing Infrastructure: The Government of India announced the establishment of 1,50,000 Health and Wellness Centres by transforming existing Sub Centres and Primary Health Centres in February 2018.
• Comprehensive Primary Health Care (CPHC): These centres aim to provide comprehensive primary health care services, covering maternal and child health, non-communicable diseases, free essential drugs, and diagnostic services.
• Expanded Range of Services: HWCs strive to address primary healthcare needs, ensuring access, universality, and equity close to the community.
• Health Promotion and Prevention: The centres emphasize health promotion and prevention by engaging and empowering individuals and communities to adopt healthy behaviours and make changes that reduce the risk of chronic diseases and morbidities.

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY): The World’s Largest Health Assurance Scheme

• Launch and Background: PM-JAY was launched on 23rd September 2018 in Ranchi, Jharkhand, by the Hon’ble Prime Minister of India, Shri Narendra Modi. Initially known as the National Health Protection Scheme (NHPS), it subsumed the Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008.
• Coverage and Eligibility: PM-JAY aims to provide a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crore poor and vulnerable families, benefiting nearly 50 crore citizens. The eligibility criteria are based on the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas.
• Government Funding: The scheme is fully funded by the Government, with the cost of implementation shared between the Central and State Governments.

Key Features of PM-JAY

• Largest health insurance/assurance scheme fully financed by the government.
• Provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization.
• Benefits over 10.74 crore poor and vulnerable entitled families, approximately 50 crore beneficiaries.
• Offers cashless access to healthcare services at the point of service, i.e., the hospital.
• Helps mitigate catastrophic expenditure on medical treatment, which pushes nearly 6 crore Indians into poverty each year.
• Covers up to 3 days of pre-hospitalization and 15 days of post-hospitalization expenses, including diagnostics and medicines.
• No restriction on family size, age, or gender.
• All pre-existing conditions are covered from day one.
• Benefits are portable across the country, allowing beneficiaries to access any empanelled public or private hospital in India.
• Includes approximately 1,393 procedures covering all costs related to treatment, such as drugs, supplies, diagnostic services, physician’s fees, room charges, surgeon charges, OT, and ICU charges.
• Public hospitals are reimbursed for healthcare services at par with private hospitals.

Benefit Cover Under PM-JAY

PM-JAY offers a comprehensive benefit cover that extends beyond previous government-funded health insurance schemes in India. With an annual cover of INR 5,00,000 per family, PM-JAY encompasses a wide range of healthcare services.

Inclusions in the Benefit Cover

• Medical examination, treatment, and consultation
• Pre-hospitalization
• Medicine and medical consumables
• Non-intensive and intensive care services
• Diagnostic and laboratory investigations
• Medical implantation services (where necessary)
• Accommodation benefits
• Food services
• Complications arising during treatment
• Post-hospitalization follow-up care up to 15 days

Family Floater Basis and Pre-existing Conditions

The INR 5,00,000 benefit is available on a family floater basis, which means it can be used by one or all members of the family. Unlike the RSBY, which had a family cap of five members, PM-JAY has no cap on family size or the age of members. Moreover, all pre-existing conditions are covered from the very first day, ensuring that eligible individuals suffering from any medical condition prior to enrollment can receive treatment under PM-JAY.

Why PM-JAY: A Background

India’s Socio-economic and Health Challenges

India’s rapid economic growth over the past few decades has placed it among the top three fastest-growing economies in the world. However, inconsistent socioeconomic and health indicators have led to its classification as a Lower Middle-Income Country (LMIC) according to the World Bank. Over 20% of India’s population still lives under $1.9 per day (2011 PPP), and by 2021, more than 34% of the population will be aged between 15 and 35 years.

India’s burgeoning population is facing the unique challenge of a “triple burden of disease,” with an unfinished mission of eradicating major communicable diseases, a high burden of non-communicable diseases (NCDs), and injuries. This situation leads to an increased demand for healthcare over a prolonged period.

Supply and Demand Imbalance in Healthcare

With a population of over 1.3 billion, India’s healthcare system struggles to meet the demand for adequate and affordable healthcare. The private sector accounts for nearly 70% of all healthcare visits in India, with 50% of the total hospital beds. However, most private providers are small and unregulated, often with less than 25 beds, and are concentrated in urban areas. This situation results in a significant deficit of healthcare services for the underprivileged population.

Public sector hospitals, on the other hand, are overburdened and face challenges due to insufficient funds, a shortage of trained health workers, and an inconsistent supply of drugs and equipment. India’s government expenditure on health has remained stagnant at about 1.2% of its GDP, with 62% of healthcare expenses coming from out-of-pocket (OOP) expenses. High healthcare costs and OOP expenditure contribute to the persistence of poverty in India, pushing nearly 6 crore Indians back into poverty each year.

Previous Government-funded Health Insurance Schemes

Various government-funded health insurance schemes, such as the Rashtriya Swasthya Bima Yojana (RSBY), were launched to strengthen demand-side financing. However, these schemes operated independently of the larger healthcare system, resulting in the fragmentation of risk pools and a lack of linkage with primary healthcare.

Integration with Existing Schemes and State-level Implementation

PM-JAY has subsumed the existing RSBY and operates in convergence with various State Government-funded health insurance and assurance schemes. By integrating and working together with these schemes, PM-JAY aims to create a more cohesive and efficient healthcare system for the country.

The Road Ahead: Expanding Access and Strengthening Healthcare Infrastructure

PM-JAY’s long-term goals involve incentivizing the private sector to expand healthcare services in unserved areas of Tier-2 and Tier-3 cities. For public hospitals, the scheme provides an incentive to prioritize poor patients and generates additional revenue for strengthening infrastructure and filling service gaps. By addressing the unique challenges faced by India’s healthcare system, PM-JAY contributes to the nation’s overall socio-economic development.

Coverage under PM-JAY: Reaching the Poorest and Most Vulnerable

Incorporating the poorest and most vulnerable populations into a health insurance program can be a daunting task, as they often cannot afford premiums and may be difficult to reach due to various factors, such as illiteracy. This challenge is prevalent in many Lower and Middle-Income Countries (LMICs), including India.

PM-JAY aims to cover the bottom 40% of India’s poor and vulnerable population, which amounts to approximately 10.74 crores (100.74 million) households. To identify these households, PM-JAY relies on the SECC 2011 data for both rural and urban areas. This data also includes families that were covered under RSBY but were not present in the SECC 2011 database.

Rural Beneficiaries

Rural households are included based on six of the seven deprivation criteria (D1 to D5 and D7) and the automatic inclusion criteria. The criteria are as follows:

• D1: Households with 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, 11 occupational categories of workers are eligible for the scheme:

1. Ragpicker
2. Beggar
3. Domestic worker
4. Street vendor/Cobbler/hawker/other service provider working on streets
5. Construction worker/Plumber/Mason/Labor/Painter/Welder/Security guard/Coolie and other head-load workers
6. Sweeper/Sanitation worker/Mali
7. Home-based worker/Artisan/Handicrafts worker/Tailor
8. Transport worker/Driver/Conductor/Helper to drivers and conductors/Cart puller/Rickshaw puller
9. Shop worker/Assistant/Peon in small establishment/Helper/Delivery Assistant/Attendant/Waiter
10. Electrician/Mechanic/Assembler/Repair worker
11. Washer-man/Chowkidar

Here’s a list of people who aren’t eligible for health coverage under the Pradhan Mantri Jan Arogya Yojana:

• Those who have a car, bike, or motorized fishing boat
• Those with machinery for farming
• People with Kisan cards that have a credit limit of Rs. 50,000
• Government employees
• People working in non-agricultural businesses run by the government
• Individuals earning more than Rs. 10,000 per month
• If you own a refrigerator or a landline phone
• People with well-constructed, sturdy houses
• Anyone owning 5 or more acres of farmland

State-Level Flexibility in Coverage and Convergence

Several states have implemented their own health insurance or assurance schemes in the past. These schemes often provide coverage for tertiary care conditions and mostly operate within state boundaries.

However, due to PM-JAY’s objective of converging various health insurance schemes across states, states are allowed to use their own databases for PM-JAY implementation, provided that they also cover all families eligible based on the SECC database.

The launch of PM-JAY aimed to address the challenges of comprehensive coverage, reducing catastrophic out-of-pocket expenditure, improving access to hospitalization care, reducing unmet needs, and converging various health insurance schemes across states. Additionally, PM-JAY has established national standards for a health assurance system and offers national portability of care.

PMJAY Coverage: Key Diseases and Treatment Options under Pradhan Mantri Jan Arogya Yojana

The Pradhan Mantri Jan Arogya Yojana (PMJAY) offers financial support to households for secondary and tertiary care, with funding up to Rs. 5 lacks per family per year. This coverage applies to daycare procedures and even pre-existing conditions. PMJAY provides access to over 1,350 medical packages at affiliated public and private hospitals.

The following critical illnesses are included in the coverage:

• Prostate cancer
• Coronary artery bypass grafting
• Double valve replacement
• Carotid angioplasty with stent
• Pulmonary valve replacement
• Skull base surgery
• Laryngopharyngectomy with gastric pull-up
• Anterior spine fixation
• Tissue expander for disfigurement following burns

However, PMJAY does have some exclusions, such as:

• Outpatient department (OPD) services
• Drug rehabilitation programs
• Cosmetic procedures
• Fertility treatments
• Organ transplants
• Individual diagnostic tests (for evaluation purposes)

Ayushman Bharat Yojana: Application Process and E-Card Generation

Checking Eligibility for Ayushman Bharat Yojana (PMJAY)

There is no specific registration process for PMJAY. Beneficiaries are identified through the Socio-Economic and Caste Census (SECC) 2011 and those already enrolled in the RSBY scheme. To check your eligibility for PMJAY, follow these steps:

1. Visit the PMJAY portal and click on ‘Am I Eligible’
2. Enter your mobile number and the CAPTCHA code, then click on ‘Generate OTP’
3. Select your state and search by name, HHD number, ration card number, or mobile number
4. Review the search results to determine if your family is covered under PMJAY

Alternatively, you can contact any Empanelled Health Care Provider (EHCP) or dial the Ayushman Bharat Yojana call centre number: 14555 or 1800-111-565 to check your eligibility.

Obtaining a PMJAY Patient E-Card

Once confirmed as eligible for PMJAY benefits, you can obtain an e-card by following these steps:

1. Visit a PMJAY kiosk with your Aadhaar card or ration card for verification
2. Provide family identification proof, which can include a government-certified list of members, a PM letter, or an RSBY card
3. After verification, an e-card with a unique AB-PMJAY ID will be printed

This e-card can be used as proof for accessing PMJAY benefits at any point in the future.

Implementation Models for PM-JAY

States have the flexibility to choose an implementation model that suits their unique needs and capacities. PM-JAY offers three implementation models: the Assurance Model/Trust Model, the Insurance Model, and the Mixed Model. Let’s delve into the details of each model.

a. Assurance Model/Trust Model

The Assurance Model, also known as the Trust Model, is the most commonly adopted implementation model among States. Under this model, the State Health Agency (SHA) directly implements the scheme without involving an insurance company. The Government bears the financial risk of implementing the scheme.

Key features of the Assurance Model include:

• The SHA directly reimburses healthcare providers.
• No insurance company is involved, but an Implementation Support Agency (ISA) may be employed for claim management and related activities.
• The SHA is responsible for specialized tasks such as hospital empanelment, beneficiary identification, claims management, audits, and more.

b. Insurance Model

In the Insurance Model, the SHA selects an insurance company through a competitive tendering process to manage PM-JAY in the State. The SHA pays a premium to the insurance company for each eligible family, and the insurance company handles claim settlements and payments to service providers. The financial risk is borne by the insurance company.

Key aspects of the Insurance Model include:

• Insurance companies have a limit on the percentage of the premium they can use for profit and administrative costs.
• Any surplus after adjusting for administrative costs and claim settlements must be refunded by the insurer to the SHA within 30 days.
• The scheme provides for different administrative cost ceilings and claim settlement ratios for Category A and Category B States.

c. Mixed Model

The Mixed Model combines elements of both the Assurance and Insurance Models. This approach is often employed by States that have existing schemes covering a larger group of beneficiaries, offering flexibility and economic efficiency.

PM-JAY recognizes two categories of States and Union Territories (UTs) based on administrative cost ceilings and claim settlement ratios:

• Category A States/UTs: Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi, Sikkim, Tripura, Uttarakhand, and six Union Territories (Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep, and Puducherry)
• Category B States: Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh, and West Bengal

The Insurance Model allows for different administrative cost ceilings and claim settlement ratios depending on whether the State falls into Category A or Category B. This ensures that the model is adaptable to each State’s unique needs and capacities.

Financing and Implementation Flexibility of PM-JAY

Financing the Scheme

The government fully funds PM-JAY, with the central and state governments sharing the costs. The government sets a national ceiling amount per family, which helps determine the maximum limit of the central share of the contribution. The actual premium discovered through the open tendering process or the maximum ceiling of the estimated premium decided by the Government of India will be shared between the central government and states/UTs as per the existing sharing patterns.

The current sharing pattern is 60:40 for states (excluding North-Eastern and three Himalayan states) and Union Territories with legislatures. For North-Eastern states and the three Himalayan states (Jammu and Kashmir, Himachal Pradesh, and Uttarakhand), the ratio is 90:10. For Union Territories without legislatures, the central government may provide up to 100% on a case-to-case basis.

Payment of Central Share

• Insurance model: A flat premium per family is paid to the state government, which then pays the insurer based on the number of eligible families.
• Assurance model: Central share of the contribution is paid based on the actual cost of claims or the ceiling, whichever is lower. If the state uses an Implementation Support Agency (ISA), the cost of the ISA is also shared between the centre and the state.

Expansion, Convergence, and Flexibility for States

States have been implementing their own health insurance/assurance schemes over the past couple of decades. PM-JAY’s launch aimed to ensure comprehensive coverage, reduce catastrophic out-of-pocket expenditure, improve access to hospitalization care, reduce unmet needs, and converge various health insurance schemes across states. PM-JAY establishes national standards for a health assurance system and offers national portability of care.

In the spirit of cooperative federalism, PM-JAY offers states flexibility in terms of scheme design and implementation. Some of the flexibilities provided include:

• Implementation model: States can choose between trust, insurance, or mixed models.
• Beneficiary data: PM-JAY uses SECC data, but states can use other datasets if they cover more beneficiaries, as long as all SECC-eligible beneficiaries are included.
• Co-branding: States can co-brand their existing health insurance/assurance schemes with PM-JAY following the scheme’s co-branding guidelines.
• Expanded coverage: States can cover more families than defined by SECC data, but the full cost for additional families must be borne by the states.
• Increased benefit cover: States can expand the benefits cover beyond ₹5 lahks per family per year, but the cost of additional coverage must be borne by the state.
• Package revisions: PM-JAY provides coverage for over 1300 packages, but states have the flexibility to expand the number of packages and revise package prices within limits.
• Reservation for public hospitals: NHA has reserved certain conditions exclusively for public healthcare facilities. States can revise the list of such conditions.
• IT systems: States can continue using their own IT systems, as long as they share data with NHA in real-time in the specified format.
• Payment to public hospitals: States can deduct a certain percentage of claims paid to public hospitals.

With these provisions, PM-JAY aims to accommodate the diverse needs and capacities of different states while ensuring comprehensive health coverage for all eligible beneficiaries.

Hospital Empanelment: Ensuring Quality and Accessibility

To ensure quality care and optimal accessibility for PM-JAY beneficiaries, a wide network of pre-selected, well-equipped, and well-prepared hospitals is necessary. Empanelment guarantees that eligible families have access to cashless, quality care from a network of hospitals distributed across the country.

Empanelment Criteria: General and Special

Given the diverse nature of healthcare facilities in India, the empanelment process includes two types of criteria based on the prevalent practice in other Government-funded health insurance schemes, State-specific regulations related to the quality of care, and the Clinical Establishment Act 2011:

1. General criteria: Applicable for hospitals providing non-specialized general medical and surgical care, with or without ICU and emergency services.
2. Special Criteria (for clinical specialities): For each speciality, a specific set of criteria is identified. Hospitals cannot select the risk and must offer all specialities to PM-JAY beneficiaries that they provide.

Detailed criteria for empanelment can be found at www.pmjay.gov.in.

Process of Hospital Empanelment in PM-JAY

PM-JAY follows a transparent, efficient, and online two-tier approach to hospital empanelment, led by State and District Empanelment Committees (SEC and DEC).

1. Hospitals apply online (free of cost) and can track their application progress.
2. DECs scrutinize online applications and conduct physical verification of hospitals.
3. DECs submit their recommendation to the SEC, which holds the final decision-making power.

Empanelled hospitals receive a unique ID and must establish a dedicated help desk for beneficiaries, staffed by Pradhan Mantri Arogya Mitras (PMAMs).

Continuous Quality Improvement and Incentives

PM-JAY incentivizes empanelled hospitals to strive for higher quality standards through the following incentives:

1. Hospitals attaining entry-level NABH accreditation receive 10% higher package rates; fully accredited hospitals receive 15% higher rates.
2. Hospitals attached to teaching institutions (medical, PG, and DNB courses) are entitled to 10% higher package rates.
3. Hospitals in aspirational districts receive 10% higher package rates to promote outreach to underserved areas.

National Health Care Providers (NHCP)

While States oversee hospital empanelment, the National Health Authority (NHA) directly empanels eminent tertiary care hospitals and specialized care hospitals under the Ministry of Health and Family Welfare (MoHFW) or other departments (e.g., AIIMS, Safdarjang Hospital, JIPMER, PGI Chandigarh). NABH-accredited private hospitals in the National Capital Region (NCR) and Government hospitals outside MoHFW’s purview are also directly empanelled by NHA to expand the network of service providers.

Packages and Rates

To ensure uniformity and prevent overcharging, empanelled healthcare providers (EHCPs) are paid based on specified package rates. A package consists of all costs associated with treatment, including pre and post-hospitalization expenses. The packages are comprehensive, covering treatments for nearly 24 specialities that include super speciality care like oncology, neurosurgery, and cardio-thoracic and cardiovascular surgery, etc.

Package Inclusions

The package rate for surgical or defined day-care benefits includes:

• Registration charges
• Bed charges (General Ward)
• Nursing and Boarding charges
• Surgeons, Anaesthetists, Medical Practitioners, Consultants’ fees, etc.
• Anaesthesia, Blood Transfusion, Oxygen, O.T. Charges, Cost of Surgical Appliances, etc.
• Medicines and Drugs
• Cost of Prosthetic Devices, and implants (unless payable separately)
• Pathology and radiology tests: radiology to include but not be limited to X-ray, MRI, CT Scan, etc. (as applicable)
• Food to patient
• Pre and Post Hospitalisation expenses: Expenses incurred for consultation, diagnostic tests, and medicines before the admission of the patient in the same hospital, and up to 15 days after the discharge from the hospital for the same ailment/ surgery
• Any other expenses related to the treatment of the patient in the EHCP

The Journey from HBP 1.0 to HBP 2.0: Enhancing Healthcare Packages

In response to stakeholder feedback, NHA revised the Health Benefits Packages (HBP), leading to the development of HBP 2.0. Changes approved by the Governing Board of NHA include:

• Increased price for 270 packages
• Decreased price for 57 packages
• Introduction of 237 new packages
• Stratification of 43 existing packages
• Discontinuation of 554 existing packages

Flexibility for States

States can maintain their own package rates and expand the list of packages based on their existing schemes. They also have the flexibility to modify rates, terms of pre-authorization, and the list of public hospital-only packages.

Click here to see the revised list of Health Benefit Packages

Advantages of HBP 2.0

• Enhanced coverage: Improved coverage of both disease conditions and procedures compared to HBP 1.0.
• Reduced burden on PMAMs: Easier package selection process without compromising data availability for analysis.
• Minimized potential for fraud and abuse: Features like defined time intervals for sequential packages, maximum permissible implants, and limits on package booking reduce incentives for upcoding.
• Continuity of care: Follow-up packages are included for procedures requiring prolonged or multiple follow-ups beyond the standard 15-day limit.
• 3-layered IT customization: Allows better analytics and improved dashboards of package utilization and monitoring.
• Scientific nomenclature and coding: Uniformity and improved acceptance across the country.
• Flexibility for states: States can adopt the national package master with context-specific variations, including revising prices within a 10% range or adding packages according to their requirements.

IT System under PM-JAY

To enable the swift and effortless implementation of PMJAY, it was crucial to have a robust information technology system in place. This IT system serves as the backbone of the scheme’s nationwide execution. Below, we explore the key technology blocks that make up the PMJAY IT system.

1. PMJAY Dashboard

• Provides aggregated and drill-down views on various datasets integrated into the PMJAY Data Warehouse.
• Used for real-time reporting of transactions, evaluating performance, and understanding utilization trends.

2. Hospital Empanelment System

• Allows registration and approval of hospitals for empanelment.
• Features for Hospital Quality Assurance are being made available in this system.

3. Beneficiary Identification System (BIS)

• Allows searching beneficiaries through SECC or additional datasets via APIs.
• Supports Aadhaar eKYC (electronic Know Your Customer) and non-Aadhaar-based KYC for authentication.

4. Transaction Management System (TMS)

• Captures in-patient data on admission, treatment, and discharge, and processes hospital claims and financial settlement.
• Integrated with other state-based and external systems through Application Program Interface (APIs).

5. Citizen Portal (mera.pmjay.gov.in)

• Enables citizens to search the beneficiary database to determine eligibility under the scheme.
• A popular self-help tool, mobile responsive for mass-scale searches at the field level.

6. Citizen Call Centre (14555)

• A national toll-free number with 400+ multi-lingual, multi-location call centre services.
• Helps beneficiaries find out eligibility, nearest hospital, nearest Common Service Centre, and more.
• Service offerings expanded to include beneficiary feedback and grievance redressal.

7. National Health Stack

• Followed as a design philosophy for PM-JAY.
• Captures data to enhance scheme design and future inclusion/universalization.
• Developments are underway for the National Health Claims Platform (NHCP) and the enhancement of existing PM-JAY systems.

8. PM-JAY Portal

• Single source of information and content related to the scheme.
• Platform enhanced to support back-office functions.
• Used to share best practices, SOPs, policies, and guidelines, and acts as a front end for the Grievance Management System.

9. India Enterprise Architecture (IND-EA)

• Principle for developing a future-ready enterprise architecture for PM-JAY and NHA.

10. Information Security & Data Privacy Policies

• Checklists enforced on IT Ecosystem – service providers and consumers to ensure end-to-end information security and privacy for beneficiary data.
• Continuous assessments are undertaken to ensure compliance.

11. National Portability

• Unique to the scheme, IT systems allow for the portability of benefits regardless of location through real-time integration and data exchange.

12. Grievance Management System

• Allows beneficiaries and whistle-blowers to register grievances and NHA/ SHAs to address them.
• Builds trust among beneficiaries by ensuring anonymity for the person submitting the grievance.

13. Anti-Fraud Measures

• Man-Machine model in the IT landscape to counter fraudulent transactions and entities.
• Generates triggers for suspicious transactions and entities and allows closure of investigations.
• National Anti-Fraud Unit and State Anti-Fraud Unit support investigations at the state level.

14. Citizen Mobile App

• Allows registered beneficiaries to check their wallet balance, search for the nearest hospitals, and provide feedback on hospital services.
• Empowers beneficiaries to monitor their utilization of entitled benefits.

15. Common Service Centre (CSC)

• Service delivery partner extending the scheme’s reach in rural India through Gram Panchayat level networks.

Awareness and Communication

Since PM-JAY is an entitlement-based scheme with no advance enrollment process, it is crucial to create awareness among beneficiaries. Information, Education, and Communication (IEC) activities play a key role in educating them about the scheme. A comprehensive communication strategy employing various modes of communication is essential for reaching the target audience.

Detailed Communication Strategy

A detailed communication strategy has been developed by the NHA, which is implemented at both national and state levels. The NHA works closely with states for overall cooperation and capacity-building in implementing and developing communication strategies to increase awareness at the state level.

Importance of Timely and Accurate Messaging

Given the large number of people covered under PM-JAY, spreading awareness with the right message, through the right media, and within the right timeframe is of utmost importance. IEC activities began immediately after the Cabinet approved the scheme on 21st March 2019.

Ayushman Bharat Diwas

The first major initiative, the Additional Data Collection Drive (ADCD), was undertaken as part of the Ministry of Rural Development’s “Gram Swaraj Abhiyaan” on 30th April 2018, named “Ayushman Bharat Diwas.” This initiative aimed to make people aware of the upcoming scheme benefits and entitlement checks by involving ASHA & ANMs and Gram Sevaks, covering around 3 lakh villages across the country. Posters, banners, and other materials were designed and deployed in Hindi and regional languages to spread awareness.

Hon’ble Prime Minister’s Letter

A letter from the Hon’ble Prime Minister was sent to all beneficiary families, informing them of their entitlements under the scheme and providing them with a family card containing a unique family ID. The NHA prepared standardized design materials for states to use in making beneficiaries aware of the scheme.

Communication Channels and Tools

Various communication channels, such as print media, television, radio, and social media, are used to reach beneficiaries and other stakeholders. A communication strategy and IEC guidebook have been developed for this purpose.

PM-JAY Web Portal

A dedicated web portal for the scheme, www.pmjay.gov.in, provides all the details about the scheme to various stakeholders. The portal contains relevant information and links, such as the list of empanelled hospitals, the “Am I eligible” portal, the grievance redressal portal, the gallery, and operational guidelines.

Support Systems for PM-JAY

In addition to the critical components of PM-JAY’s ecosystem, several other key components serve as a support system for the smooth implementation of the scheme. These include:

1. Capacity Development

Capacity building activities under PM-JAY address more than just training and cover all aspects of building and developing sustainable and robust institutions and human resources. Capacity building in PM-JAY consists of three components:

• Setting up sustainable institutional structures
• Building and strengthening the human resource and institutional capacity
• Sustaining knowledge and skill through knowledge management and the use of appropriate tools

The National Health Authority (NHA) takes the lead in assessing requirements, providing resources, devising strategies, and offering technical assistance to states. Various workshops and cross-learning forums are planned for the upcoming days.

2. Monitoring and Evaluation

Monitoring and evaluation (M&E) are crucial for the successful implementation of PM-JAY. The NHA at the central level continually tracks the progress through various functional domains such as beneficiary management, transaction management, provider management, and support function management.

To provide a comprehensive picture of the progress made, factsheets are developed monthly at the state and national levels. Evaluation studies are also conducted in collaboration with premiere research institutions and development agencies to assess the impact of PM-JAY and provide critical inputs for evidence-based decision-making.

3. Fraud Prevention, Detection, and Control

To safeguard PM-JAY from fraud and unethical behaviour, the National Health Authority has taken several steps, including:

• Implementing transparent tendering processes
• Developing a web-enabled hospital empanelment process
• Designing IT systems with checks and balances
• Introducing all-inclusive package rates
• Releasing comprehensive anti-fraud guidelines
• Establishing a National Anti-Fraud Unit (NAFU)

4. Grievance Redressal

A three-tier Grievance Redressal Committee structure has been set up at the national, state, and district levels to address the grievances of all PM-JAY stakeholders. Grievances can be submitted through various channels, including an online portal, telephone calls, faxes, e-mails, and SMS.

5. Call Centre

A National Helpline (14555) has been set up to provide information and support to beneficiaries and other stakeholders. Operating 24×7, the call centre is manned by trained agents who speak various regional languages. The call centre also engages in outbound calling to collect feedback from beneficiaries and provide support to hospitals.

A Landmark Partnership: NHA and ESIC Collaboration

In a bid to improve healthcare access for millions of citizens, the National Health Authority (NHA) has entered into a partnership with the Employee’s State Insurance Corporation (ESIC). This convergence between Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) and Employees State Insurance Scheme (ESIS) will result in an ecosystem where ESIC beneficiaries can access services at AB PM-JAY empanelled hospitals and vice versa.

Standardizing Services Across Schemes

By leveraging the established network of quality service providers under PM-JAY and offering fixed health benefits packages, this collaboration aims to standardize services across both schemes. In addition, it will create higher demand for health services at ESIC-empanelled hospitals that may be currently underutilized, supporting the improvement of infrastructure and facilities through the utilization of funds reimbursed under PM-JAY.

Initial Phase: Piloting in Ahmednagar and Bidar

The initial phase of this partnership involves a pilot program in Ahmednagar, Maharashtra, and Bidar, Karnataka. During this pilot, ESIC beneficiaries in these districts will be able to access PM-JAY services in PM-JAY empanelled hospitals. Beneficiaries will be eligible for all 1,393 secondary and tertiary packages under the scheme, with plans to scale up to 102 districts and eventually extend coverage across the country.

Key Benefits of AB PM-JAY and ESIS Convergence

1. Expanded healthcare access for ESIC beneficiaries: By accessing healthcare providers under AB PM-JAY, ESIC beneficiaries will have a broader range of options for their healthcare needs.
2. Increased availability of services for AB PM-JAY beneficiaries: These beneficiaries will be able to avail services in ESIC-empanelled hospitals, further widening their healthcare choices.
3. Seamless integration of ESIC and AB PM-JAY benefits: Beneficiaries of ESIC can use their ESIS card to access free treatment at AB PM-JAY empanelled hospitals, while AB PM-JAY beneficiaries can use their PM-JAY card to access free treatment at ESIC empanelled hospitals.
4. Convenient access to information: Beneficiaries can call ESIC toll-free numbers (1800 112 526 / 1800 113 839) or click here for the list of empanelled hospitals under AB PM-JAY.

Enhancing Healthcare Access Nationwide

The convergence of AB PM-JAY and ESIS is an innovative and impactful step towards improving the overall health system in India. By pooling resources and expertise, this partnership will ensure that a wider range of citizens has access to quality healthcare services, helping to build a healthier and more prosperous future for all.