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Access to quality healthcare is one of the fundamental rights of every individual. However, with healthcare costs rising and a majority of the population below the poverty line, accessing quality healthcare was a challenge. That is why illnesses and diseases were rampant in the lower segments of society. There was a need for a free health insurance cover which gave birth to the Ayushman Bharat scheme.

The Ayushman Bharat scheme, or the Pradhan Mantri Jan Arogya Yojana (PMJAY), was rolled out in September 2018 under the directive of the Prime Minister of India, Mr Narendra Modi. Let’s understand the basics of the scheme.

What is the Ayushman Bharat scheme?

The PMJAY is a scheme of free health cover for the economically backward sections of India. The scheme offers free health insurance coverage of up to Rs.5 lakhs to such families. 

Who is eligible for the Ayushman Bharat scheme?

The PMJAY scheme offers coverage to 10 crore specified families that have been identified through the Socio-Economic Caste Census (SEC) that was conducted in the year 2011. Of the identified families, 8.03 crore families are living in the rural sector while 2.33 crore families live in the urban sector *.

There is also a specified eligibility list for the families in the rural and urban areas. Families that meet the parameters set in the list are eligible to be covered under the Ayushman Bharat scheme. 

Salient features of the PMJAY scheme:

• Every member of the eligible family would be covered under the scheme on a floater basis irrespective of age.

• The families do not have to pay any premium for the coverage as it is free of cost. The cost of the cover is borne by the Government.

• Automatic coverage is granted to eligible families. There is no need for voluntary purchase

• Cashless claim facility is available at empanelled hospitals, both Government and private facilities

Coverage and exclusions 

Coverage under the PMJAY scheme includes pre and post hospitalisation costs and secondary and tertiary care treatments. Outpatient expenses, however, are excluded from the scope of coverage. 

How does the scheme work?

The Ayushman Bharat scheme is an indemnity-oriented health insurance scheme. This means that if the insured member suffers any medical emergency and is hospitalized, the cost of such hospitalisation and eventual treatment would be covered under the policy. 

Every recognised family is issued a ‘Golden Card’ which serves as a health card for availing of cashless treatments. At every empanelled hospital, there is an Ayushman Mitra, a designated individual to help with claims pertaining to the PMJAY scheme. Upon hospitalisation, the insured member can present the health card and avail of cashless treatments. The Ayushman Mitra would check the eligibility of the coverage and help the insured with the documentation process.

Importance of the PMJAY scheme

In a country where poverty is rampant, the PMJAY scheme is a ray of sunshine for the lower strata of society. Its importance stems from the following reasons –

• Free health insurance coverage

• Optimal sum insured

• Coverage for all major types of illnesses and diseases

The scheme, thus, seeks to uplift the economically weaker sections of society by providing them with the healthcare facilities that they need for a healthy lifestyle.