Ayushman Bharat health insurance scheme: Who all it covers and how
Prime Minister Shri Narendra Modi, in his Independence Day speech of 2018, announced the launch of the Ayushman Bharat-National Health Protection Scheme (AB-NHPS). He said that the national health insurance scheme will be rolled out on a pilot basis in some states. The full-scale roll-out of the project is expected to be in September end. On September 23, 2018, the Prime Minister Narendra Modi launched Ayushman Bharat, world's largest government-funded healthcare scheme in Jharkhand's capital Ranchi. The Centre's flagship scheme has been renamed as PM Jan Arogya Yojana (PMJAY). The scheme will become operational from September 25 on the birth anniversary of Pandit Deendayal Upadhyay. According to the various government websites, here is a look at what the health insurance scheme is all about. Who is the AB-NHPS aimed at? The scheme is targeted at poor, deprived rural families and identified occupational category of urban workers' families. So, if we were to go by the Socio-Economic Caste Census (SECC) 2011 data, 8.03 crore families in rural and 2.33 crore in urban areas will be entitled to be covered under these scheme, i.e., it will cover around 50 crore people. AB-NHPS will have a defined benefit cover of Rs 5 lakh per family (on a family floater basis) per year for secondary and tertiary care hospitalisation. It will offer a benefit cover of Rs 5 lakh per family per year. It will subsume the existing Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008 by the UPA government.
Who all are covered?
To ensure that nobody is left out (especially women, children and the elderly), there will be no cap on the family size and age under the AB-NHPS. The scheme will be cashless and paperless at public hospitals and empanelled private hospitals. How will the entitlement be decided? AB-NHPM will be an entitlement based scheme where it will be decided on the basis of deprivation criteria in the SECC database. The beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC database for rural areas. For the urban areas, the 11 occupational criteria will determine entitlement. In addition, Rashtriya Swasthya Bima Yojna (RSBY) beneficiaries in states where it is active are also included.
Rural area categories: The different categories in rural areas include families having only one room with kucha walls and kucha roof; families having no adult member between the ages of 16 years and 59 years; female-headed households with no adult male member between the ages of 16 years and 59 years; disabled members and no able-bodied adult member in the family; SC/ST households; and landless households deriving major part of their income from manual casual labour. Also, these families in rural areas having any one of the following will be automatically included: households without shelter, destitute, living on alms, manual scavenger families, primitive tribal groups, and legally released bonded labour. Urban area categories: For urban areas, 11 defined occupational categories are entitled under the scheme. Main source of income related to household has been clarified in urban areas as beggars; rag-pickers; domestic workers; street vendors/cobblers/hawkers/other service providers working on the streets; construction workers/ plumbers/ masons/ labor/ painters/ welders/ security guards/coolies and other head-load workers; Sweepers/ sanitation workers/ malis; Home-based workers/ artisans/handicrafts workers/ tailors; Transport workers/ drivers/ conductors/helpers to drivers and conductors/cart pullers/ rickshaw pullers; shop workers/ assistants/ peons in small establishments/ helpers/ delivery assistants / attendants/ waiters; electricians/ mechanics/ assemblers/repair workers; washer-men/ chowkidars; Other work/Non-work ; Non-work (Pension/ Rent/ Interest, etc.)
What is the hospitalisation process?
The beneficiaries will not be required to pay any charges and premium for the hospitalisation expenses. The benefit also include pre- and post-hospitalisation expenses. Each empanelled hospital will have an 'Ayushman Mitra' to assist patients and will coordinate with beneficiaries and the hospital. They will run a help desk, check documents to verify the eligibility, and enrolment to the scheme. Also, all the beneficiaries will be given letters having QR codes which will be scanned and a demographic authentication will be conducted for identification and to verify his or her eligibility to avail the benefits of the scheme. Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.
What are the inclusions?
AB-NHPM will cover medical and hospitalisation expenses for almost all secondary care and most of tertiary care procedures. The health ministry has included 1,354 packages in the scheme under which treatment for coronary bypass, knee replacements and stenting among others would be provided at 15-20 per cent cheaper rates than the Central Government Health Scheme (CGHS).
What is the eligibility criteria for a beneficiary?
There is no enrolment process in AB-NHPM as it is an entitlement-based mission. Families who are identified by the government on the basis of deprivation and occupational criteria using the SECC database, both in rural and urban areas, are entitled for AB-NHPM. Currently the database is based on census for the year 2011. A list of eligible families has been shared with the respective state governments as well as state level departments like the ANMs, BMO, and BDOs of relevant areas. A dedicated AB-NHPM family identification number will be allotted to eligible families. Only families whose name is on the list are entitled for the benefits of AB-NHPM. Additionally, families with an active RSBY cards as of 28 February 2018 will covered. No additional new families can be added under AB-NHPM. However, names of additional family members can be added for those families whose names are already on the SECC list. The official website of AB-NHPM is www.abnhpm.gov.in . One may visit the site to view and download the beneficiary eligibility and empanelled hospitals list as and when it gets updated.
Services under the scheme can be availed at all public hospitals and empaneled private health care facilities. Also, the basic empanelment criteria allows empanelment of a hospital with a minimum of 10 beds, with the flexibility provided to states to further relax this if required. Empanelment of the hospitals under AB-NHPM will be conducted through an online portal by the state government. Information about empaneled hospitals will be made available through different means such as government websites and mobile apps. Beneficiaries can also call the helpline number at 14555. To control costs, the payments for treatment will be done on package rate (to be defined by the Government in advance) basis. However, hospitals with NABH/NQAS accreditation can be incentivised for higher package rates subject to procedure and costing guidelines.