Pradhan Mantri Jan Arogya Yojana (PMJAY), also known as Ayushman Bharat, is a transformative healthcare initiative launched by the Government of India. This groundbreaking scheme offers financial protection to millions of Indian families, safeguarding them from the devastating financial burden of medical emergencies. This comprehensive guide will delve into the key features, eligibility criteria, benefits, and the process of availing Pradhan Mantri Jan Arogya Yojana benefits.
By providing cashless hospitalization coverage, PMJAY empowers individuals to access quality healthcare without worrying about exorbitant costs. Whether it’s a critical illness, a major surgery, or a prolonged hospitalization, PMJAY stands as a lifeline, ensuring that no one is denied essential medical care due to financial constraints.
What is Pradhan Mantri Jan Arogya Yojana?
Pradhan Mantri Jan Arogya Yojana, or PMJAY, is a major government health insurance scheme that aims to cover over 50 crore Indians. Launched in September 2018, it provides health insurance coverage of up to Rs. 5 lakh per family per year.
Key Features of PMJAY
- PM-JAY is the world’s largest health insurance scheme, fully funded by the government of India.
- It covers up to Rs. 5 lakhs per family per year for secondary and tertiary care hospitalizations in both public and private empanelled hospitals across India.
- Over 12 crore poor and vulnerable families are eligible.
- Beneficiaries can access cashless healthcare services at empaneled hospitals.
- PM-JAY aims to help people avoid financial hardship due to medical costs.
- It covers pre- and post-hospitalization expenses.
- There are no restrictions on family size, age, or gender.
- All pre-existing conditions are covered.
- Benefits can be used at any enlisted hospital across India.
- It covers approximately 1,929 procedures, including all costs related to treatment such as drugs, supplies, diagnostics, doctor’s fees, room charges, surgery fees, and ICU charges.
- Public hospitals receive reimbursement similar to private hospitals.
What is Covered Under the PMJAY Scheme?
PMJAY covers the following medical expenses during the treatment:
- Medical examination, treatment and consultation fees
- Pre-hospitalization expenses for up to 3 days
- Post-hospitalization expenses for up to 15 days
- Cost of medicine and medical consumables
- Hospital accommodation charges
- Non-intensive and ICU services
- Laboratory and diagnostic procedures
- Medical implantation services, where required
- Complications arising during the medical treatment
- Food services
List of Critical Diseases or Illnesses Covered Under Ayushman Bharat Yojana Scheme
While PM-JAY doesn’t provide a specific list of “critical diseases,” it covers a wide range of medical conditions and procedures. Some of the major categories of diseases and procedures covered include:
- Cardiac diseases such as heart bypass surgery, valve replacements, angioplasty, etc.
- Cancer treatment, including chemotherapy, radiation therapy, surgeries, etc.
- Neurological diseases such as brain and spine surgeries, neurological disorders.
- Kidney diseases, including dialysis and kidney transplants.
- Orthopedic diseases such as joint replacements, fracture repairs, and spinal surgeries.
- Maternal and child health, including maternity care, childbirths, and newborn care.
- Other diseases such as diabetes, hypertension, tuberculosis, and many more.
- COVID-19
Exclusion of the Scheme
Not every health condition is covered under PMJAY. A few exclusions of the scheme include:
- Conditions that do not require hospitalizations such as OPD
- Except for pre- and post-hospitalization expenses, the scheme doesn’t cover additional expenses incurred for evaluation or diagnostic purposes during hospitalization, or costs for vitamins and tonics unless prescribed by the doctor as part of the treatment.
- Dental treatments like cosmetic procedures, tooth fillings, root canals, periodontal diseases, and dental implants are generally not covered. However, dental treatments required due to trauma, injury, tumor, or cyst that necessitate hospitalization for bone treatment are covered.
- Assisted reproductive techniques and infertility treatments are generally not covered unless they are included in the National Health Benefit Package list.
- Vaccination and immunization
- Surgeries related to facial and body aging, laser tattoo removal, augmentation surgeries, and other purely cosmetic procedures like fat grafting, neck lifts, and aesthetic rhinoplasty are not covered.
- Circumcision for children under 2 years of age is generally not covered, unless it’s medically necessary for treating a specific disease or due to an accident.
- Persistent Vegetative State
See Also: What Are The Benefits Of ABHA Card: A Complete Guide
PMJAY Beneficiaries
According to the National Sample Survey Office (NSSO), 85.9% of rural households and 82% of urban households have no access to healthcare insurance/assurance. These healthcare expenditures put the family into debt. Over 24% of households in rural India and 18% of the population in urban areas met their health expenditure needs through borrowing. To overcome such challenges, the government has come up with PMJAY.
PMJAY primarily targets poor and vulnerable rural families and urban workers’ families identified through the Socio-Economic Caste Census (SECC) data and active families under the Rashtriya Swasthya Bima Yojana (RSBY). Let’s look at each of them in detail.
PMJAY Rural Beneficiaries
In rural areas, PMJAY health coverage is available to the following:
- Families with one room with kucha walls and roof
- Households with no adult member in the age group of 16-59 years
- Families with no adult male members in the age group of 16-59 years
- Households without an able-bodied adult member or with a disabled member
- People living in Scheduled Caste and Scheduled Tribe households
- Landless households that earn a major part of their family income from manual casual labor
PMJAY Urban Beneficiaries
Under PMJAY, urban households are categorized based on occupation. Below is the occupational category of workers covered under PMJAY.
- Beggar
- Domestic worker
- Ragpicker
- Mechanic/Electrician/Repair Worker/Assembler
- Cobbler/street vendor/hawker/other service providers on the street.
- Plumber/Construction Worker/Mason/Painter/Labour/Welder/Security Guard/Coolie
- Sweeper/Mali/Sanitation Worker
- Chowkidar/Washer-man
- Artisan/Handicrafts Worker/Tailor/Home-based Worker
- Driver/Transport Worker/Conductor/Cart or Rickshaw Pullers/Helper to Drivers or Conductors
- Shop Workers/Peon in Small Establishment/Assistant/Helper/Attendant/Delivery Assistant/Waiter
Who is not covered under PMJAY?
- People owning a vehicle like a two-wheeler, three-wheeler, or a car
- People with refrigerators and landline phones in their houses
- Those owing a motorized fishing boat
- People with monthly income more than ₹10,000
- People with farming machinery and equipments
- Those who live in properly built houses
- Government employees
- People employed in government-run non-agricultural enterprises
- Those owing agriculture land of more than 5 acres
- People who hold a Kisan card
How do I check the eligibility for Pradhan Mantri Jan Arogya Yojana?
To know your eligibility for PMJAY, follow the below steps:
Step 1: Visit the official website of Ayushman Bharat at https://pmjay.gov.in/.
Step 2: Click on ‘Am I eligible icon.’
Step 3: Fill in the contact details and click verify. This will generate an OTP.
Step 4: Enter the OTP and login to the portal.
Step 5: Select the required scheme, state, subscheme, district, and search by option. This will let you know if you are eligible for the PMJAY scheme.
The system will display the eligibility based on the socio-economic caste census data.
Alternatively, you can also check your eligibility at a nearby Common Service Centre (CSC) or any empanelled Ayushman Bharat hospital. Or you can call on the toll-free numbers: 14555 or 1800-111-565.
Note: You can also click on enroll for the enrolment in the Ayushman Bharat PMJAY scheme.
Documents Required to Apply For PMJAY
Below is the list of documents required to apply for the Ayushman Bharat card or PMJAY scheme:
- ID proof that may include your Aadhar card or any government-issued ID.
- Contact details (mobile, address, email)
- Caste certificate
- Income certificate to check the income status.
- Documents such as a ration card that can verify your family details and economic background.
Pradhan Mantri Jan Arogya Yojana Benefits
- Cashless Hospitalization: PMJAY covers all hospitalization expenses without requiring upfront payments.
- In-Hospital Accommodation: It covers the cost of accommodation during hospitalization.
- Pre and Post-Hospitalization Costs: The scheme covers expenses incurred before and after hospitalization.
- Coverage for Complications: It covers any complications that may arise during treatment.
- Family-Wide Coverage: All family members are eligible for benefits.
- No Age or Gender Restrictions: There are no age or gender limitations for eligibility.
- Pre-existing Conditions Covered: Pre-existing medical conditions are covered from the first day of enrolment.
Conclusion
Access to quality healthcare shouldn’t be a financial burden. PMJAY can help you and your family get the treatment you need without worrying about upfront costs.
Check your eligibility online today and see if you qualify for PMJAY. With PMJAY, you can focus on getting better, knowing the scheme is there to support you.
