Ayushman Bharat Scheme – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)
Introduction
Healthcare in India has always faced challenges such as affordability, accessibility, and quality. To address these issues and provide universal health coverage, the Government of India launched the Ayushman Bharat Scheme in 2018. The flagship health initiative has two key components:
1. Health and Wellness Centres (HWCs)
2. Pradhan Mantri Jan Arogya Yojana (PMJAY)
The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is one of the world’s largest health insurance schemes, covering more than 50 crore beneficiaries. It is popularly known as Modicare and aims to reduce financial barriers to healthcare, particularly for economically weaker sections.
Historical Background
• Launched on 23rd September 2018 by the Hon’ble Prime Minister of India.
• Announced in the Union Budget 2018-19 by the Ministry of Finance.
• Inspired by the principle of “Sabka Saath, Sabka Vikas, Sabka Vishwas”, ensuring equitable healthcare for all.
• The scheme replaced the earlier Rashtriya Swasthya Bima Yojana (RSBY) and included more benefits with expanded coverage.
Objectives of AB-PMJAY
To provide health insurance coverage up to ₹5 lakh per family per year for secondary and tertiary care hospitalization.
• To reduce out-of-pocket expenditure (OOPE) on healthcare.
• To ensure universal health coverage (UHC) in line with the Sustainable Development Goals (SDGs).
• To provide cashless and paperless access to health services.
• To focus on vulnerable sections of society – poor, deprived rural families, and identified occupational categories of urban workers.
Key Features of AB-PMJAY
1. Coverage: Provides ₹5 lakh per family per year.
2. Target Group: Over 10.74 crore families (approximately 50 crore people).
3. Cashless Facility: Services can be availed without direct payment at the time of treatment.
4. Portability: Beneficiaries can avail services across India.
5. Empanelled Hospitals: Both public and private hospitals are covered.
6. No Restriction: Family size, age, or gender has no bar.
7. Comprehensive Coverage: Covers pre-hospitalization, hospitalization, and post-hospitalization expenses.
Eligibility Criteria
• Based on Socio-Economic Caste Census (SECC) 2011 data.
• Rural Beneficiaries: Includes deprived households such as landless labourers, manual workers, families without shelter, etc.
• Urban Beneficiaries: Includes families of workers like street vendors, rickshaw pullers, domestic workers, construction labourers, etc.
• Exclusions: Families with higher income, government employees, taxpayers, those owning vehicles or pucca houses, etc.
Coverage under AB-PMJAY
• Financial Coverage: Up to ₹5 lakh per family per year.
Services Covered:
• Hospitalization for serious illnesses (e.g., cancer, heart surgery, kidney transplant).
• Day care treatments.
• Pre and post-hospitalization costs (medicines, diagnostics, follow-up care).
• Health Packages: Over 1,500 treatment packages covering surgeries, oncology, cardiology, orthopedics, etc.
Implementation Mechanism
Implemented by National Health Authority (NHA) under the Ministry of Health and Family Welfare.
States may adopt:
1. Insurance Model – State engages an insurance company.
2. Trust Model – State creates a trust/society to directly implement.
3. Mixed Model – Combination of both.
Empanelment of Hospitals: Hospitals fulfilling criteria are authorized to provide services.
IT Platform: Beneficiaries are verified through Aadhaar, ration card, or government ID.
Benefits of AB-PMJAY
1. Financial Protection: Prevents catastrophic health expenditures.
2. Inclusivity: Covers the poorest of the poor.
3. Nationwide Portability: Beneficiaries can access healthcare anywhere in India.
4. Private Sector Participation: Encourages private hospitals to treat poor patients.
5. Employment Generation: Healthcare sector expansion creates jobs.
6. Improved Health Outcomes: Early access to quality treatment reduces mortality.
Challenges in Implementation
1. Awareness Gap: Many eligible beneficiaries are unaware of their entitlement.
2. Infrastructure Deficiency: Rural areas lack sufficient hospitals and doctors.
3. Fraudulent Claims: Misuse by some private hospitals.
4. Funding Issues: Huge cost burden on government finances.
5. Coordination Problems: Different state models lead to uneven implementation.
6. Limited Package Rates: Some hospitals find reimbursement rates too low.
Recent Updates (2023–2025)
• Coverage expanded to include transgender persons.
• Integration with Ayushman Bharat Digital Mission (ABDM) for seamless health records.
• Some states offer additional coverage beyond ₹5 lakh.
• Expansion of empanelled hospitals, especially in Tier-II and Tier-III cities.
Significance of AB-PMJAY
• Promotes equity in healthcare.
• Reduces health-related poverty.
Supports SDG 3: Good Health and Well-being.
• Encourages public-private partnership (PPP).
• Strengthens India’s movement towards Universal Health Coverage (UHC).
Way Forward
1. Increase awareness campaigns at grassroots level.
2. Enhance infrastructure in rural areas.
3. Strengthen fraud detection mechanisms.
4. Review and revise treatment package rates.
5. Expand coverage to include outpatient care and diagnostics.
6. Integrate with telemedicine services.
Exam-Oriented Key Points (Mains/Prelims/Competitive Exams)
1. Launch Year – 2018
2. Launched by – Prime Minister Narendra Modi
3. Ministry/Implementing Body – Ministry of Health & Family Welfare; National Health Authority (NHA)
4. Components –
• Health and Wellness Centres (HWCs)
• Pradhan Mantri Jan Arogya Yojana (PMJAY)
5. Coverage Amount – ₹5 lakh per family per year
6. Target Beneficiaries – 10.74 crore families (approx. 50 crore people) based on SECC 2011
7. Eligibility Basis – Rural and urban occupational categories (SECC 2011)
8. Type of Scheme – Health insurance/cashless scheme
9. Portability – Pan-India
10. No Cap – No limit on family size, age, gender
11. Empanelled Hospitals – Both public and private hospitals
12. Exclusions – High-income families, government employees, taxpayers, vehicle/house owners, etc.
13. World’s Largest Health Insurance Scheme – AB-PMJAY
14. Implementing Models – Insurance model, trust model, mixed model
15. Nodal Agency – National Health Authority (NHA)
16. SDG Alignment – SDG 3: Good Health and Well-being
17. Nicknamed as – Modicare
18. Recent Update – Integration with ABDM, coverage for transgender persons
19. Challenges – Awareness gap, infrastructure shortage, fraud, low reimbursement rates
20. Future Scope – Expansion of outpatient care, telemedicine, higher funding
Conclusion
The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a transformative step towards equitable healthcare in India. By providing cashless coverage of ₹5 lakh per family, it aims to protect vulnerable populations from financial distress caused by medical expenses. However, challenges such as awareness, infrastructure, and funding must be addressed to ensure its sustainability. With effective implementation, AB-PMJAY can serve as a model health insurance program for the world, driving India closer to the dream of “Health for All.”
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Writer: Vandita Singh, Lucknow (GS India Nursing Group)