PMJAY: ₹5lakh Health Insurance at ₹500/year

Pradhan Mantri Jan Arogya Yojana (PMJAY) is a flagship program under the Ayushman Bharat initiative, envisioned to achieve the universal health coverage goal set by the United Nations. The scheme primarily focuses on providing financial protection to around 50 crores of people, identified as society’s most deprived and marginalized sections. It offers cashless health insurance coverage of up to ₹5 lakhs per family per year for secondary and tertiary healthcare services.

The government of India launched the Pradhan Mantri Jan Arogya Yojana (PMJAY), also known as Ayushman Bharat or the National Health Protection Scheme, in September 2018. This ambitious healthcare initiative aims to provide health insurance coverage to economically vulnerable families, ultimately improving their access to quality medical services. In this blog, we will explore the key features, benefits, and impact of PMJAY on the Indian healthcare landscape.

Why health insurance is essential?

Health insurance plays a crucial role in providing financial protection and access to quality healthcare services. Health insurance offers several financial benefits that can help individuals and families.

• Financial Protection: Health insurance provides a safety net against high medical costs. Medical emergencies, hospitalizations, surgeries, and treatments can be expensive, and having health insurance can help cover these expenses. Health insurance ensures that individuals and families do not face significant financial burdens or go into debt due to unexpected medical expenses.
• Coverage for Medical Expenses: Health insurance provides coverage for a wide range of medical expenses, including hospitalization, surgeries, doctor visits, diagnostic tests, prescription medications, and rehabilitation services. manage their healthcare expenses more effectively
• Cashless Treatment: Many health insurance plans offer cashless treatment facilities at network hospitals. Under this arrangement, policyholders can avail of medical services without having to pay the full amount upfront. The insurance company settles the bills directly with the hospital, minimizing the financial burden on the insured individuals.
• Tax Benefits: health insurance offers tax benefits under the provisions of the Income Tax Act, of 1961. The tax benefits are available under Section 80D of the Income Tax Act and are applicable to both individual taxpayers and Hindu Undivided Families (HUFs)

What is PMJAY?

The primary objective of PMJAY is to provide financial protection against high medical expenses to eligible beneficiaries. It aims to ensure that no eligible person/family is left without access to necessary medical treatment due to financial constraints. PMJAY is an integral component of the Ayushman Bharat program, which encompasses both health insurance coverage and the establishment of health and wellness centers across the country.

Key features of the scheme

• Coverage: PMJAY provides health insurance coverage of up to ₹5 lakhs per family per year. The coverage extends to a range of secondary and tertiary healthcare services, including hospitalization expenses, surgical procedures, pre and post-hospitalization costs, diagnostics, medications, and more.
• Eligibility: The eligibility for PMJAY is determined based on the Socio-Economic and Caste Census (SECC) data, which identifies economically vulnerable households. The scheme primarily targets deprived rural families and occupational categories of urban workers. However, specific eligibility criteria and the identification process may vary slightly from state to state.
• Cashless Treatment: PMJAY offers cashless treatment facilities to the eligible beneficiaries. They can avail of medical services at empaneled hospitals, both public and private, without having to pay for the services upfront. The insurance coverage is directly settled with the hospital.
• Empaneled Hospitals: PMJAY has a network of empaneled hospitals across the country. These hospitals meet specific criteria for infrastructure and quality standards to ensure that beneficiaries receive quality healthcare services.
• Portability: PMJAY provides portability, allowing beneficiaries to access cashless treatment at empaneled hospitals across different states and union territories. This feature is particularly beneficial for individuals who are on the move or residing in different regions of the country.
• Implementation: PMJAY is implemented by the National Health Authority (NHA) in collaboration with state governments and other stakeholders. The scheme is funded through a combination of central and state government contributions.

Eligibility for the scheme

To be eligible for the Pradhan Mantri Jan Arogya Yojana (PMJAY), individuals and families need to meet certain criteria. Here are the eligibility guidelines for the scheme:

• Socio-Economic and Caste Census (SECC) List: PMJAY primarily relies on the data from the SECC to identify eligible beneficiaries. The list includes households that fall under specific deprivation categories.
• Deprivation Criteria: The SECC uses specific deprivation indicators to identify eligible families. The criteria include households without shelter, landless households, households headed by a female with no adult male member between 16 and 59 years, households without any adult member between 16 and 59 years, and households with a disabled member and no able-bodied adult member.
• Rural and Urban Areas: PMJAY covers both rural and urban areas. The SECC data helps identify eligible families in rural areas, while the government has used the Socio-Economic Caste Census (SECC) data and state-specific urban lists for urban areas.
• Family Unit: The scheme covers families, and the definition of a family includes the head of the household, their spouse, and dependent children (up to the age of 25 years).
• No Income Criteria: PMJAY does not have any specific income criteria. The eligibility is primarily based on the deprivation categories mentioned above.

Redeeming the scheme

To redeem the benefits of the Pradhan Mantri Jan Arogya Yojana (PMJAY), eligible beneficiaries can follow these steps:

1. Eligibility Check: First, ensure that you meet the eligibility criteria for PMJAY. The eligibility is primarily based on the Socio-Economic and Caste Census (SECC) data, which identifies economically vulnerable families. You can check if your name is included in the SECC list or contact the relevant authorities to verify your eligibility.
2. Identification Document: If you are eligible, make sure you have the necessary identification documents. This may include your Aadhaar card, ration card, or any other identification document specified by the state government.
3. Empaneled Hospital: Identify and visit an empaneled hospital under PMJAY. These hospitals are part of the network approved by the scheme and have the necessary infrastructure to provide the covered treatments and services. You can find a list of empaneled hospitals on the official PMJAY website or by contacting the helpline number.
4. Verification Process: At the empaneled hospital, provide your identification documents and undergo the verification process. The hospital staff will verify your eligibility for PMJAY and complete the necessary documentation.
5. Treatment and Cashless Transaction: Once your eligibility is verified, you can avail the necessary medical treatment. PMJAY operates on a cashless model, so you will not have to make any direct payments at the time of treatment. The hospital will directly submit the claim to the government for reimbursement.

Conclusion

Health treatment should be accessible to everyone, but treatment costs are inflating at a rate of 14% per annum, which is highest among Asian countries, and 93.2% of Indians being employed in the unorganized sector can not afford health insurance. PMJAY comes in as a savior for them, providing ₹5 lakhs per family per year for ₹500 per year. 

Schemes like this and Kisan Vikas Patra should reach their beneficiaries, help us to achieve that goal, educate your daily help workers, and enrich their lives!