Ayushman Bharat PM-JAY: Key Eligibility Criteria, Features, and Challenges

Universal healthcare has been a key focus for governments globally, recognising that access to quality medical care is not just a human right but also an economic necessity. In India, Ayushman Bharat stands as a transformative initiative aimed at providing universal healthcare, particularly to the most vulnerable sections of society.

This article covers the recent Cabinet decision to expand the Ayushman Bharat initiative and its social and economic implications.

What’s Happening?

Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is India’s first universal healthcare initiative, providing free health insurance up to Rs 5 lakhs per family annually. Recently, the Union Cabinet announced that all senior citizens aged 70 and above, regardless of their income, will be eligible for benefits under AB PM-JAY. A special card will be issued to these beneficiaries, and those already covered under the scheme will receive an additional top-up of Rs 5 lakhs per year, separate from their family members under the age of 70.

For those not previously covered, the scheme will offer up to Rs 5 lakhs in annual health insurance on a family basis. While the move aims to improve healthcare access for senior citizens — who often require more intensive care — concerns have been raised about whether the healthcare system can manage this expanded beneficiary base without adjustments to reimbursement rates and payment timelines.

Eligibility Criteria of Ayushman Bharat PM-JAY

The Ayushman Bharat scheme covers the bottom 40% of the poor and vulnerable population, as per SECC 2011. In absolute terms, 12 crore marginalised families are eligible for health coverage of up to Rs 5 lakhs for secondary and tertiary hospitalisation.

Here are the key eligibility criteria for inclusion in this scheme:

Rural Beneficiaries

Rural households that fall into any of the following categories are included in the Ayushman Bharat scheme:

• Households with only one room and a kutcha (makeshift) roof and walls.
• No adult members between the ages of 18 and 59.
• No adult male members between the ages of 18 and 59.
• Households with disabled members and no able-bodied adult members.
• SC/ST households.
• Landless labourers deriving their livelihood from casual manual work.
• Additionally, destitute households, manual scavengers, primitive tribal groups, and legally released bonded labourers are automatically included under the scheme.

Urban Beneficiaries

The following occupational categories of workers are eligible for inclusion under Ayushman Bharat:

• Ragpickers
• Beggars
• Domestic workers
• Street vendors, cobblers, hawkers
• Construction workers, plumbers, masons, painters, security guards, welders
• Sweepers, sanitation workers, gardeners
• Home-based workers, tailors, artisans, handicraft makers
• Transport workers, drivers, conductors, rickshaw pullers
• Shop assistants, peons, delivery assistants, waiters
• Electricians, mechanics, assemblers, repair workers
• Washermen, watchmen

The Union Cabinet’s recent decision to include all senior citizens above the age of 70, irrespective of their socio-economic status, is a historic move.

Key Features of Ayushman Bharat PM-JAY Scheme

Here are some key points about India’s flagship health insurance programme:

Cashless Healthcare: Beneficiaries can access secondary and tertiary healthcare services without out-of-pocket expenditure during treatment.

Poverty Alleviation: The scheme helps prevent nearly six crore Indians from falling into poverty annually due to massive healthcare expenses.

Universal Access: There are no restrictions on the number of family members, age, or gender, ensuring total inclusion.

No Waiting Period: All pre-existing medical conditions are covered immediately after enrolment.

Nationwide Portability: Beneficiaries can access healthcare services at any of the empanelled hospitals across the country, ensuring timely treatment.

Biggest Health Assurance Plan: PM-JAY is one of the largest health assurance plans fully funded by the Indian government, covering 12 crore households and more than 55 crore beneficiaries.

Challenges of Extended Ayushman Bharat

The major challenges in implementing the Ayushman Bharat scheme are as follows:

Lack of Private Participation: Many top-tier private hospitals have opted to stay out of the scheme, jeopardising the lives of those needing advanced, sophisticated treatments.

Delayed Reimbursements: Delays in reimbursements to hospitals disrupt cash flow, particularly for smaller hospitals that rely on timely payments to cover operational expenses.

Stringent Norms: The government has fixed rates for several procedures under AB PM-JAY to ensure affordability. However, this is affecting the quality of treatment. To encourage better private sector participation and improve services, the government is considering proposals to relax price caps.

Economic Significance of AB PM-JAY

Economically, the PM-JAY scheme has been revolutionary for poor families. By providing formal health insurance, the scheme has saved millions of families from falling into poverty due to high healthcare costs. With money saved on healthcare, families have been able to better manage other expenses such as paying off loans, investing in education, or purchasing assets.

What’s Next?

The extension of AB PM-JAY to all senior citizens aged 70 and above is a landmark decision in India’s healthcare system. However, it also presents challenges, particularly for smaller healthcare providers. To ensure the program’s success, the government must address issues related to reimbursement rates, timely payments, and overall system capacity.

India currently spends only 1.9% of its GDP on healthcare — the lowest among all major developing and developed countries. To manage the increased number of beneficiaries, the government will need to explore innovative solutions focused on improving the quality of care, not just reducing costs.

That’s it for today. We hope you’ve found this article informative. Remember to spread the word among your friends. Until we meet again, stay curious!

This article is for informational purposes only. This is not investment advice. Disclaimer: Teji Mandi Disclaimer