Ayushman Bharat: All about the health insurance scheme

Dimapur, Jan. 23 (EMN): The Ayushman Bharat-Pradhan Mantri Jan ArogyaYojana (AB-PMJAY) is a government-funded health insurance scheme which provides free treatment of up to INR five lakh per family per year.

The government publicity agency the department of Information and Public Relations (IPR) stated in a feature that the scheme provides cover to over 10 crore families in India, and 2.33 lakh poor families in Nagaland.

In Nagaland, there are 64 empanelled hospitals running the scheme, 60 government and 4 private hospitals. The beneficiary can go anywhere in the country with their ecard and get free treatment from any empanelled government or private hospital. The scheme covers around 1500 treatment packages which include majority of secondary and tertiary care. The beneficiary does not have to spend money at the point of service that is the hospital.

The status update of Nagaland as on December 9 2019: The percentage of coverage of families is 36% of the total target. It stated 85,174 families have with at least one ecard in the family. 2.4 lakh individual ecards have been issued. There were 6622 hospital admissions. The hospital admission fee amount is INR 9 crore, the IPR stated. The number of hospital admissions, patients from Nagaland who have availed benefit, from outside the state is 272, the IPR stated.

Eligibility
Eligible households are those whose names appear in the Socio Economic and Caste Census (SECC) 2011 deprived categories. Also, those who possess the RSBY (Rashtriya Swasthya Bima Yojana) 2016 or 2017-issued cards are eligible.

The target group for rural (SECC)
Total deprived households targeted for AB PM-JAY who belong to one of the six criteria among D1, D2, D3, D4, D5 and D7:

D1: Only one room with ‘kucha’ walls and ‘kucha’ roof.

D2: No adult member between the ages 16 and 59.

D3: Female-led households with no adult male member between the ages 16 and 59.

D4: Disabled member and no able-bodied adult member. (D4)

D5: SC/ST households. (D5)

D7: Landless households deriving major part of their income from manual casual labour.

Automatically included: Households without shelter, destitute or living on alms, manual scavenger families, primitive tribal groups, and legally released bonded labour

Target Group for urban (SECC)
Occupational categories of workers: Rag pickers, beggars, domestic workers, street vendors, cobblers, hawkers, and other service providers working on streets; construction workers, plumbers, masons, labours, painters, welders, security guards, coolies, and another head-load workers; sweepers, sanitation workers, ‘mali,’ home-based workers, artisans, handicrafts workers, tailors, transport workers, drivers, conductors, helpers to drivers and conductors; cart pullers, rickshaw pullers, shop workers, assistants, and peons in small establishments; helpers, delivery assistants, attendants, waiters, electricians, mechanics, assemblers, repair workers, washer men and chowkidars.

Exclusion criteria
According to the SECC 2011, the following beneficiaries are automatically excluded: Households having motorised 2/3/4 wheelers, fishing boat, households having mechanised 3/4 wheeler agricultural equipment; households having Kisan Credit Card with credit limit above INR 50,000; household member is a government employee; households with non-agricultural enterprises registered with government; any member of household earning more than INR 10,000 per month; households paying income tax and households paying professional tax; house with three or more rooms with ‘pucca’ walls and roof, owns a refrigerator, owns a landline phone, owns more than 2.5 acres or more of irrigated land with one irrigation equipment, owns five acres or more of irrigated land for two or more crop season, owning at least 7.5 acres of land or more with at least one irrigation equipment, the IPR stated.  

Checking eligibility
•             Empanelled hospital PMJAY helpdesk – Each empanelled hospital has a helpdesk

•             Common Service Centre – Village level entrepreneurs, IT department

•             mera.pmjay.gov.in – Online search SECC category

•             PMJAY mobile app – from Google Playstore

•             NGO partners – District specific

1.            Clairvoyance: Kohima, state manager at the number 9366149822 and Clairvoyance Tech at the number 9612499537, Dimapur and Mokokchung

2.            Kalos/KK: Phek

3.            ECS/KBBB/TASU: Mon, Tuensang, and Longleng

•             WhatsApp eligibility check Nagaland at the number 9089776177

If eligible, the documents required to make PMJAY card
•             Personal ID – Aadhaar, voter’s ID, driving license, government-issued photo ID and RSBY card if a beneficiary.

•             Family ID – Ration card, village or ward chairman family proof format

•             Each individual will get own card

•             Cost of card – In government hospital: Free (ordinary paper); CSC/NGO on outreach mode: INR 30 a card, ordinary paper.

•             Members of the same household whose names are not there can be added on producing proof: Ration card, birth certificate, marriage certificate, and adoption certificate.

•             Entitlement-based scheme, no new family can be enrolled.

Where to get the benefits
•             In Nagaland 64 hospitals ie., 60 public, four private; district hospitals, CHCs and some PHCs, Faith, CIHSR or Referral, House of Hope (ECS) and Impur Christian Hospital.

•             National portability, all empanelled hospitals, public and private – E.g. Ganga Ram, Apollo Hospital Guwahati, NEIGRIHMS, Shija, AIIMS, etc. Visit pmjay.gov.in and check hospital list.

Benefits
•             IPD at least 24 hours hospitalization services including day-care procedures

•             1534 treatment packages

•             Cashless service

•             Covers all costs associated with the treatment including medicines, diagnostics, consultations, implants, pre-hospitalisation and post hospitalisation cost

•             Exclusions: outpatient care, individual diagnostics for evaluation, drug rehabilitation programs, cosmetic related, fertility related, transplants involving organs etc.

List of ‘empanelled’ hospitals in Kohima district
•             Naga Hospital Authority, State Mental Health Institute Kohima, community health centers of Viswema, Chiephobozou, Tseminyu, and Seikhazou UPHC, and primary health centers of Sechu Zubza, Botsa and Chunlikha, the updates stated.

The number of beneficiaries identified so far is 20,810, 86% of Aadhar-linked ecards and 10,581 of families reached with at least one ecard, the IPR added.