Pradhan Mantri Jan Arogya Yojana (PM-JAY): A Revolutionary Step Towards Universal Health Coverage in India

Health would likely be the most important sector of a country's growth. In India, UHC has been one of its top agenda of highest priority for decades. The government of India, led by Prime Minister Narendra Modi, launched the Ayushman Bharat scheme to revolutionize healthcare in India so that every Indian citizen has access to quality and affordable healthcare services. At its core is the Pradhan Mantri Jan Arogya Yojana (PM-JAY), a health insurance program that has the potential to cover the most vulnerable sections of society.

This blog will go into the specifics of PM-JAY, looking at its objectives, features, benefits, and the recent additions that have made it an even more powerful instrument in India's healthcare system.

The Vision of Ayushman Bharat

Ayushman Bharat, introduced in 2018, is the flagship health programme of the Government of India to deliver affordable and accessible healthcare to the poor and vulnerable. The programme was crafted in consonance with the National Health Policy 2017, which promotes universal health coverage (UHC). The vision of Ayushman Bharat is to offer holistic and comprehensive healthcare services that not only heal but also prevent and promote well-being.

Ayushman Bharat is a paradigm shift from the conventional segmented delivery system of healthcare services to an integrated, patient-centered, and need-based model of healthcare delivery. It is centered on the achievement of Sustainable Development Goals (SDGs) and leaving no one behind, particularly India's most vulnerable stakeholders.

Components of Ayushman Bharat

Ayushman Bharat comprises two major components:

1. Health and Wellness Centres (HWCs): The module emphasizes the introduction of Health and Wellness Centres with a view to providing the integrated primary health care (IPHC) service. The government will establish 1.5 lakh HWCs across India through the reorganization of existing Sub-Centres and Primary Health Centres. They will provide critical health care such as maternal and child care, treatment of non-communicable diseases, and health promotion. HWCs are poised to take healthcare to the doorstep, especially to poor and rural areas.

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY): The second component of Ayushman Bharat, PM-JAY, is designed to provide health insurance to economically poor families. Under this scheme, families are eligible to get cashless treatment in government and private hospitals for secondary and tertiary care needs.

While HWCs target primary healthcare, PM-JAY takes a giant step in making secondary and tertiary health care services accessible and affordable for the poor and vulnerable.

What is Pradhan Mantri Jan Arogya Yojana (PM-JAY)?

Launched by Prime Minister Narendra Modi on 23rd September 2018 in Ranchi, Jharkhand, PM-JAY is the world's largest health assurance scheme. The scheme will provide health insurance of up to Rs. 5 lakh for a family a year for hospitalization in secondary and tertiary hospitals. It encompasses 12 crore poor and vulnerable families (approx. 55 crore beneficiaries) and is based on the deprivation and occupation norms as defined by the Socio-Economic Caste Census 2011 (SECC 2011).

Before it was renamed to PM-JAY, the scheme was initially known as the National Health Protection Scheme (NHPS) and merged into the existing Rashtriya Swasthya Bima Yojana (RSBY), which had commenced in 2008. Coverage of RSBY beneficiaries under PM-JAY ensures continuity of coverage and extends more comprehensive services to the masses.

PM-JAY is completely financed by the Government of India, with the Central and State Governments bearing the implementation cost.

Key Features of PM-JAY

PM-JAY aims to deliver affordable, accessible, and quality health care to the millions of Indians. The scheme boasts some distinct features that render it unique and effective:

1. Largest Health Insurance Scheme: PM-JAY is the largest health insurance/assurance scheme globally that offers health coverage to the most backward sections of society.

2. Rs. 5 Lakh Coverage per Family per Year: Every eligible family is covered with a health cover of maximum Rs. 5 lakh per annum for secondary and tertiary hospitalization. This can be utilized for treatments in public as well as private empanelled hospitals.

3. Cashless Treatment: PM-JAY facilitates cashless and paperless treatment to the beneficiaries so that health care becomes easily accessible at the point of service. There is no upfront cost for beneficiaries when they receive medical services from an empanelled hospital.

4. Portability of Benefits: PM-JAY benefits are portable anywhere in India. That is to say, beneficiaries can take availed treatment in any empanelled public or private hospital anywhere in India, irrespective of their residence state or place.

5. Extensive Coverage: The program covers a large number of services such as diagnostics, drugs, surgery, room rate, ICU rate, post-hospitalization treatment, and pre-hospitalization costs (within three days prior to hospitalization). PM-JAY has 1,929 procedures under it and provides cover for all the treatment charges of these procedures.

6. No Limit on Family Size: In contrast to earlier health programs such as RSBY, whose family size was capped, PM-JAY has no limit on the number of family members or their age. All members of a family that qualifies are covered under the program, irrespective of age.

7. Pre-existing Disease Coverage: The most notable aspect of PM-JAY is that it covers pre-existing conditions from day one. This way, those suffering from chronic ailments can seek treatment without waiting for any duration.

Biometrics and Device Integration in PM-JAY

For proper identification of beneficiaries and to stop fraud, PM-JAY utilizes high-end biometric systems. They utilize Aadhaar-based biometric authentication using the following devices:

• Morpho MSO e3 L1: Morpho biometric readers offer world-class quality of fingerprint and iris scanning. The equipment is reliable and accurate and can be utilized best in health-care applications where effective patient identification is of utmost importance.

• Mantra MFS110: This is a fingerprint reader hardware that guarantees flawless authentication, decreasing the likelihood of failure in authentication. It significantly reduces impersonation during patient registration and claim settlement during Ayushman Bharat Digital Mission (ABDM).

• Precision PB1000: This is a precision biometric product that gives very accurate readings and offers rapid authentication to ensure rapid provision of healthcare services.

• Startek Acsess FM220 u L1: Startek fingerprint biometric readers provide safe patient identification and authentication. They have been successfully utilized in several health systems under ABDM and are thus fraud-proof authentication.

These biometric technologies, besides ensuring that only eligible people are treated under the PM-JAY, also make verification easy, doing away with administrative delays and improving overall efficiency in the delivery of health care.

Benefits of PM-JAY

PM-JAY offers numerous advantages to the Indian population, above all to vulnerable families. These are the primary advantages

1. Financial Protection: By providing a health cover of Rs. 5 lakh per family a year, PM-JAY reduces out-of-pocket expenses for medical treatment significantly, keeping families away from the financial burden of catastrophic health expenses.

2. Comprehensive Health Coverage: The scheme envisages a variety of secondary and tertiary level health services like surgery, hospitalization, visits to doctors, diagnostics, and intensive care.

3. Accessibility: PM-JAY seeks to minimize geographical and economic barriers to healthcare through the provision of cashless and paperless services. This is particularly relevant in remote and rural areas where it is usually hard to access healthcare facilities.

4. Empowering Marginalized Groups: PM-JAY makes it possible for low-income households, particularly those who are unable to pay for healthcare, to receive high-quality care. It accomplishes this by striving for improved health outcomes while ensuring that no one is left behind.

5. Post-hospitalisation Care: Even post-hospitalisation expenses of up to 15 days come under the ambit of the scheme, which is a very essential feature to confirm full recovery of the patients.

6. Social Protection of Senior Citizens: In a landmark step to widen coverage, the Central Cabinet approved the coverage of senior citizens (70 years and above) under PM-JAY in September 2024. Senior citizens can now avail of free health insurance cover of up to Rs. 5 lakh per year regardless of their income level.

Expansion of PM-JAY: A New Era for Senior Citizens

On September 11th, 2024, the Indian government gave its nod for a huge scaling up of PM-JAY that will cover all the senior citizens over the age of 70 regardless of their financial situation. It will be covering almost 4.5 crore families and 6 crore senior citizens and will be providing free health insurance under the program.

Key features of the expansion include:

1. New Independent Card for Elderly People: The elderly people will be issued with a new, independent PM-JAY card, making them entitled to claim special benefits from the scheme.

2. Top-Up Cover: Already enrolled senior citizens under PM-JAY will receive a top-up cover of Rs. 5 lakh per year to provide end-to-end health cover.

3. Option of Health Plans: Senior citizens who are already covered under some other government health schemes (e.g., CGHS, ECHS, or CAPF) may remain in their existing plan or opt for PM-JAY.

4. Eligibility of Private Insurance Beneficiaries: Senior citizens who are already under private health insurance coverage may also benefit from the coverage of PM-JAY, thereby raising the coverage level of this health insurance scheme.

Conclusion

Pradhan Mantri Jan Arogya Yojana (PM-JAY) is a historic leap in the healthcare of India. With the guarantee of economic security and good quality care to crores of families who live under the poverty line, PM-JAY is filling the gap in the provision of health care. It is not an insurance scheme for health; it is a guarantee to enhance the well-being and health of India's poorest classes.

The addition of elderly citizens to the cover of PM-JAY in the recent period is an indication of the determination of the government to protect the health of all its citizens, be they young or old, and irrespective of being poor or wealthy. With its emphasis on preventive as well as curative care, PM-JAY is building towards a healthier, more equitable India.

As PM-JAY grows and covers more individuals, it is already set to become a model for the world in universal health coverage, showing the strength of a well-designed government program in the ability to tackle the health issues of a nation.