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| Pradhan Matri Jan Arogya Yojana (Ayushman Bharat) |
Pradhan Matri Jan Arogya Yojana (Ayushman Bharat)
Ayushman Bharat - PRADHAN MANTRI JAN AROGYA YOJANA (AB PM-JAY) WAS LAUNCHED ON SEPTEMBER 23, 2018
Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana
(PM-JAY), is a flagship scheme of Government of India to provide
cashless secondary and tertiary care treatment from the empanelled
public and private hospitals providing coverage to more than 10 crore
poor and vulnerable beneficiary families are eligible for these benefits.
National Health Authority (NHA) is the apex body responsible for the implementation of Ayushman Bharat PM-JAY
Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PM-JAY) provides a cover of up to Rs. 5 lakhs per family per year, for secondary and tertiary care hospitalization.
Benefits
Pradhan Pradhan Mantri Jan Arogya Yojana (PM-JAY) beneficiaries are entitled to following health care benefits:
- Health cover of up to Rs. 5 lakhs per family per year, for secondary and tertiary care hospitalization through a network of empaneled public and private providers
- No restrictions on family size, age or gender
- Cashless access to services for the beneficiary at the hospital
- All pre−existing conditions are covered from day one. Covers up to 3 days of pre-hospitalisation and post-hospitalisation expenses such as diagnostics and medicines
- Benefits of the scheme are portable across the country where a beneficiary can visit any empaneled public or private hospital for cashless treatment
- Services include 1393 procedures covering all the costs related to treatment, including but not limited to drugs, supplies, diagnostics services, physician's, room charges etc.
Eligibility Criteria:
- The 10.74 crore entitled beneficiary families have been identified based on Socio Economic Caste Census (SECC) data by applying deprivation and occupation criteria for rural and urban areas respectively. In addition, such families that were already covered under Rashtriya Swasthya Bima Yojana (RSBY) but are not part of SECC are also covered.
Where to Apply and How to Apply:
- Personalized letter with unique family code are in process of being sent to the identified families in the Additional Data Collective Drive(ADCD). This will drive awareness amongst the beneficiaries and further ease the identification process when they visit point of CARE of CSC center.
- Common service Centres (CSC) will help citizens and will utilize over 3 lakhs village level entrepreneurs for identifying beneficiaries basis SECC list.
Documents required:
- Eligibility under PM-JAY may be checked by visiting nearest Common Service Center or PM-JAY empanelled hospital with individual (Voter id, Adhaar) and family id (Ration card) proof
For more information:
- For more information, assistance, questions and complaints contact 24X7 helpline number − 14555/ 1800 111 565
- Visit: www.pmjay.gov.in
- Check Eligibility: www.mera.pmjay.gov.in
- Twitter: AyushmanNHA
- Facebook: AyushmanBharatGOI
- Download Ayushman Bharat PM-JAY android app
Beneficiary Identification System (BIS) : Click Here
PMAJY FAQs:
Pradhan
Mantri Jan Arogya Yojana(PM-JAY) is a pioneering initiative of Prime
Minister Modi to ensure that poor and vulnerable population is provided
health cover. This initiative is part of the Government’s vision to
ensure that its citizens – especially the poor and vulnerable groups
have universal access to good quality hospital services without anyone
having to face financial hardship as a consequence of using health
services.
PM-JAY provides an insurance cover upto Rs 5 lakh per family, per year for secondary and tertiary hospitalization. All pre-existing conditions are covered from day 1 of implementation of PM-JAY in respective States/UTs.
The
health services covered under the programme include hospitalization
expenses, day care surgeries, follow-up care, pre and post
hospitalization expense benefits and new born child/children services.
The comprehensive list of services is available on the website.
PM-JAY
covers more than 10 crore poor and vulnerable families across the
country, identified as deprived rural families and occupational
categories of urban workers’ families as per the latest Socio-Economic
Caste Census (SECC) data. A list
of eligible families has been shared with the respective state
government as well as ANMs/BMO/BDOs of relevant area. Only families
whose name is on the list are entitled for the benefits of PM-JAY.
Additionally, any family that has an active RSBY card as of 28 February
2018 is covered. There is no capping on family size and age of
members, which will ensure that all family members specifically girl
child and senior citizens will get coverage.
Services
under the scheme can be availed at all public hospitals and empaneled
private health care facilities. Empanelment of the hospitals under
PM-JAY will be conducted through an online portal by the state
government. Information about empaneled hospitals will be made available
at through different means such as government website, mobile app.
Beneficiaries can also call the helpline number at 14555. Regular
updates will also be provided through ASHAs, ANM and other specific
touch points This information will be activated shortly.
No.
All eligible beneficiaries can avail free services for secondary and
tertiary hospital care for identified packages under PM-JAY at public
hospitals and empaneled private hospitals. Beneficiaries will have
cashless and paperless access to health services under PM-JAY.
PM-JAY
is an entitlement based mission. There is no enrolment process.
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 PM-JAY.
The
beneficiaries are identified based on the deprivation categories (D1,
D2, D3, D4, D5, and D7) identified under the SECC (Socio-Economic Caste
Census) database for rural areas and 11 occupational criteria for urban
areas. In addition, RSBY beneficiaries in states where RSBY is active
are also included.
In
this phase, no additional new families can be added under PM-JAY.
However, names of additional family members can be added for those
families whose names are already on the SECC list.
A dedicated PM-JAY family identification number will be allotted to eligible families. Additionally, an e-card will also be given to beneficiary at the time of hospitalization.
At
the time of admission to the hospital, beneficiaries should carry
ration card or any other government recognized photo identity document
like Aadhaar etc.
The
scheme will have portability of benefits across the country.
Beneficiary can avail services all across the implementing States/UTs.
You can call helpline number 14555 for details.
The
scheme will subsume the functional RSBY schemes – Rashtriya Swasthya
Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme
(SCHIS).
A
well-defined three tier complaint and grievance redressal mechanism
will be in place. This includes constitution of various committees, use
of electronic, mobile platform, an All-India helpline number 14555
internet as well as social media. Robust safeguards to prevent
misuse/fraud/abuse by providers and users will also be in place.
CGRMS FAQs:-
CGRMS
(Central Grievance Redressal Management System) is an online portal
used to address the complaints registered from different stakeholders
under AB-PMJAY. Through this mechanism any one can lodge a complaint or
grievance on the portal which will be addressed within a defined time
frame
A complaint can be registered by the beneficiaries, their family members, empaneled
hospitals, insurance companies, ISA, TPA or SHA and any other stakeholder who is relate
to implementation of PMJAY.
Through online grievance redressal portal - CGRMS of AB PMJAY (https://cgrms.pmjay.gov.in/) Offline Mode
- AB PMJAY Call center helpline operated by the State/ NHA.
- Through letter, telephone, e-mail, and fax to the official addresses of the SHA or the NHA
- Directly with the DGNO of the district where such stakeholder is located or where such grievance has arisen
- DGNO shall enter the particulars of grievances received via offline mode in the portal.
No login required. Grievance can be registered directly by filling the form online.
A
Unique Grievance Number will be generated against each grievance case.
The case will appear in the concerned officer login for necessary
action.
Grievance can be tracked on the AB PMJAY Grievance portal (CGRMS), using your Unique Grievance Number - (UGN)
Grievances can be against various stakeholders when there is lack of service or poor quality
service. Ex. Denial of treatment by hospital, Money sought by hospital, misconduct of
PMAM, PMAM not providing correct information, Poor facility in the hospital etc. For more
details drop down in the grievance form can be referred.
Grievance will be sent to concerned authorities for investigation and resolution
Yes,
if complainant is not satisfied with the decision then grievance can be
escalated to the higher authority by reopening the case.
As
per guidelines if the grievance is emergency in nature it shall be
resolved by DGNO within 48 hours. In non-emergency cases it will be 15
days. However, if the case is escalated to DGRC, 30 days will be the
TAT.
TMS FAQs:-
Can the hospitals break the treatment packages?As
a part of hospital empanelment process, hospitals must agree to the
pre-fixed package rates, and it cannot be changed during the contract
period.
The patient may contact the toll-free helpline number 14555 for support or reach out to the Ayushman Mitra in the hospital.
Treatment may be provided as per the guideline issued by NHA on usage of TMS in intermittent / poor connectivity locations
The home state where the benficiary originate from will pay for the treatment expenses
The packages rate applicable in the State where the hospital is situated will be applicable in case of portability
Government has stopped its policy for posting an all India partner
Need to set up a standard definition on HDU/ICU for effective settlement of claims
States can explore the option of group tendering.
The state will work in trust mode until new Insurance company is on board for, the scheme.
Such a case will require enhancement in TMS
Yes, we can use the QR code, or we can use the HHID
No, IP and OP will have different registration number.
The
new Doctor's information should be informed to ISA/IC in writing
immediately after joining. If there is technical delay in updating the
Doctor's information in TMS, "others" option may be selected from the
doctor list in TMS. But it should only be used as a contingency option.
No. Only those specialties specified in the hospital empanelment module will be visible in the Transaction Management Software
The
information will need to be informed to the SHA in writing. The
hospital will either be permitted to update the information through HEM
portal or will be updated in backend by the SHA/ISA/TPA
Patient
mortality details may be updated in the TMS application and discharged.
Payment for the services provided will be determined by the ISA/TPA
after verifying the documents.
When
Medico legal case is added as Yes, the police station number is
mandatory but legal case number is optional. Both should not be
mandatory
Patient should be discharged in TMS and relevant information may be updated in the discharge summary
Patient will not be able to receive the benefits; However, he can utilize the same for next visit.
Yes.
The hospital can challenge the decision in writing to the ISA/TPA. If
the issues are not resolved, the same may be brought to the attention of
grievance redressal committee.
Need to codify enhancements- Days, Surgery+Surgery, Medical+Surgery
Any outpatient care, drug rehabilitation, cosmetic treatments, organ transplants and fertility treatment are not covered.
Any
surgery that is not in the package will need to be pre-authorized after
which the price will be negotiated between the hospital and SHA/IC and
then the procedures can be planned. This is capped to an amount of Rs 1
lakh. This option is available for surgical procedures only.
Yes.
PMJAY benefits will be available from Day 1 of the roll out of the
scheme for inpatient hospital care. Any inpatient hospital care for
pre-existing diseases will be covered. However, OPD will not be covered.
No.
Under PMJAY, medicines will be included in the package for the duration
of treatment, including up to 15 days after discharge from hospital, as
needed.
Normal
Labour and delivery, including high risk deliveries, C-sections and
associated treatments are covered under PMJAY. But JSY and another
voucher scheme benefit are not given under PMJAY
Yes. There is no limit of family size. The neonate will be provided care provided the benefit is not exhausted
There is no provision of payment of transportation charges under the scheme.
A
dedicated Grievance Redressal Committee will be appointed at district,
state and national level and all grievance will be addressed within a
period of 30 days.
Yes – Grievances against the Arogya Mitra can be escalated to the District Grievance Nodal Officer.
This
will be handled on a case to case basis and the required process will
be escalated for resolution within the grievance framework.
No. Only those specialties specified in the hospital empanelment module will be visible in the TMS.
The hospital is required to maintain complete confidentiality of
patient information and must not be shared to unauthorized persons. For
further details please refer to detailed guidelines
Yes,
the hospital can claim if the patient has undergone treatment but does
not survive. The same would be subject to verification / approval of the
CPD.
As of now MEDCO cannot. Currently, TMS application and HEM application have separate login IDs.
No, IP and OP cases will have different registration numbers.
No. Under PMJAY, medicines will be included in the package for the duration of treatment
Yes.
If beneficiary wants an upgrade in room the all expenses for treatment
will not be covered under PMJAY scheme. Admission to ICU for specified
packages is allowed
This
provision is currently not built in TMS. The beneficiary can be
re-registered correctly after discharging or cancelling registration in
TMS.
The
beneficiary has to provide NHPM-ID / Ration Card / Mobile Number /
Aadhaar / Other Valid Identity Proof to the Medco or AM. The details of
the beneficiary if available in the BIS will be retrieved in TMS for
case registration.
In such cases, beneficiary will not be able to claim the benefits retrospectively.
Patient
mortality details may be updated in the TMS application and discharged.
Payment for the services provided will be determined by the ISA/TPA
after verifying the documents.
Yes.
There is no limit of family size. The neonate will be provided care
provided the benefit limit is not exhausted and the neonate is added to a
family with at least one PMJAY verified beneficiary
The TMS application is only available in English
The Hospital TMS has the following types of Users:
- Hospital User - Pradhan Mantri Arogya Mitra or Medical Coordinator (MEDCO)
- Preauthorization Panel Doctor (PPD)
- Claim Executive (CEX)
- Claim Panel Doctor (CPD)
- State Health Agency (SHA)
PRF was earlier a mandatory upload. However, since 23 Oct 2018, PRF has been removed
Post-hospitalization
expense is part of the package amount for the treatment. No expenditure
is to be done by the patient or beneficiary post-discharge. Prior to
discharge, the hospital has to provide a follow-up date for such
treatment
The package amount includes the cost of diagnosis / investigation as needed after the patient has been registered.
TMS application has not been made public for the general public
Please
check that you have entered the word correctly as per the list of words
available in primary diagnosis drop down menu. Therefore, enter valid
characters only.
All
eligible beneficiaries can avail free services for secondary and
tertiary inpatient hospital care as per identified packages under PMJAY
at all public/government hospitals and empanelled private hospitals.
Beneficiaries will have cashless and paperless access to inpatient
hospital care under PMJAY.
In
case of an emergency, when a surgery needs to be done immediately
(emergency cases) telephonic approval is taken from concerned Approvers
and a Telephonic ID is generated. Later the Arogya Mitra / Medco will
need to register the case into TMS as per process.
Certain
procedures do not require pre-authorization approval from PPD. In such
case, approval is done immediately by TMS after initiation by Medco and
the treatment can be started immediately. There 914 such procedures in
the National Package. Certain other procedures are pre-approved for only
the 1st day of admission. For any extension of treatment, approval has
to be taken by Medco from PPD after every 5 days' interval. There are
164 such procedures in the National Package.
A
package includes end to end treatment for the entire episode of care
required. i.e. Diagnosis, doctor and nursing charges,
pre-hospitalization investigation, bed charges, consumables, medicines,
food for the patient and post-surgery investigations and medicines.
Enhancement is allowed only for surgery cases for another surgery. Enhancement to surgery is not allowed for Medical cases.
Please refer to the detailed process flow.
In such cases please reach out to your SHA
As
per guidelines, extension of stay is not applicable for medical cases
which are paid in packages. Extension would be required only for
packages which are paid on ward basis. The same can be done through
Pre-authorization within the existing case.
Hospital
will call Central Helpline and using IVRS enter AB-NHPM ID or Aadhaar
number of the patient. IVRS will speak out the details of all
beneficiaries in the family and hospital will choose the beneficiary who
has come for treatment. It will also inform the verification status of
the beneficiary - If eligible and verified then beneficiary will be
registered for getting treatment by sending an OTP on the mobile number
of the beneficiary. In case beneficiary is eligible but not verified
then she/he can be verified using Aadhaar OTP authentication and can get
registered for getting cashless treatment.
Hospitals with poor connectivity must always keep a print out of the
authorized package list including the package code names and rates.
NHA has issued guidelines for usage of software when there is
intermittent connectivity or no connectivity. This has to be followed in
such hospitals / scenarios.
Such cases will require enhancement to be preauthorized in TMS.
A
hospital can initiate claim after the procedure has been completed and
patient has been either discharged or marked as dead in TMS.
More than 1350 procedures including Medical and Surgical are available under PMJAY in the National Package list.
Please check the file type allowed. Only JPG or PDF file are allowed. The file size should not exceed 500 KB
If
a beneficiary is already registered in another hospital and has not
been discharged, then such beneficiary cannot be registered
In
registered patient view, registered patients will be displayed. After
that primary diagnosis will be done by the MEDCO and then either the
patient will be converted as IP or OP. Case Status is available for IP
cases only.
This
happens if the specialties have not been provided in HEM application.
Procedures would appear in TMS only for specialties which have been
approved in HEM application. Specialties must be updated in HEM
application.
TMS application does not allow file to be uploaded if a file with same name has been uploaded earlier for a patient.
Yes,
however the type and duration of treatment is different for all
cancers. Cancer care treatments need to undergo a whole treatment plan
approval similar to a ‘tumor board concept’ on the best course of
patient management. A clinical treatment approval process is mandated
for cancer care, since it involves a multi-modal approach covering
surgical, chemotherapy and radiation treatments and appropriate
supportive care that could assess to determine the best course of
patient management for such conditions. Pre-authorization is mandatory
for all packages involving cancer treatment. There would be 2-step
approach for Pre-auth Pre-auth for the complete course of treatment
mentioning the various stages of treatment and the detailed Oncology
Treatment Plan Approval form has to be filled, signed & uploaded
(Annexure 1) as part of Pre-auth Pre-auth has to be sought at each
pre-defined stage / selecting package
Packages
have been enlisted under Medical, Radiation and Surgical oncology. In
the case of Surgical packages, they are not exhaustive – since there are
significant overlaps with packages under other specialty domains. Such
packages may be used as deemed necessary.
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