Ayushman Bharat, a flagship scheme of Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to "leave no one behind."
Ayushman Bharat is an attempt to move from sectoral and segmented approach of health service delivery to a comprehensive need-based health care service. This scheme aims to undertake path breaking interventions to holistically address the healthcare system (covering prevention, promotion and ambulatory care) at the primary, secondary and tertiary level. Ayushman Bharat adopts a continuum of care approach, comprising of two inter-related components, which are -
In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres. These centres are to deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people. They cover both, maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.
Health and Wellness Centers are envisaged to deliver an expanded range of services to address the primary health care needs of the entire population in their area, expanding access, universality and equity close to the community. The emphasis of health promotion and prevention is designed to bring focus on keeping people healthy by engaging and empowering individuals and communities to choose healthy behaviours and make changes that reduce the risk of developing chronic diseases and morbidities.
The second component under Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojana or PM-JAY as it is popularly known. This scheme was launched on 23rd September, 2018 in Ranchi, Jharkhand by the Hon’ble Prime Minister of India, Shri Narendra Modi.
Ayushman Bharat PM-JAY is the largest health assurance scheme in the world which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 12 crores poor and vulnerable families (approximately 55 crore beneficiaries) that form the bottom 40% of the Indian population. The households included are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. PM-JAY was earlier known as the National Health Protection Scheme (NHPS) before being rechristened. It subsumed the then existing Rashtriya Swasthya Bima Yojana (RSBY) which had been launched in 2008. The coverage mentioned under PM-JAY, therefore, also includes families that were covered in RSBY but are not present in the SECC 2011 database. PM-JAY is fully funded by the Government and cost of implementation is shared between the Central and State Governments.
Benefit cover under various Government-funded health insurance schemes in India have always been structured on an upper ceiling limit ranging from an annual cover of INR30,000 to INR3,00,000 per family across various States which created a fragmented system. PM-JAY provides cashless cover of up to INR5,00,000 to each eligible family per annum for listed secondary and tertiary care conditions. The cover under the scheme includes all expenses incurred on the following components of the treatment.
The benefits of INR 5,00,000 are on a family floater basis which means that it can be used by one or all members of the family. The RSBY had a family cap of five members. However, based on learnings from those schemes, PM-JAY has been designed in such a way that there is no cap on family size or age of members. In addition, pre-existing diseases are covered from the very first day. This means that any eligible person suffering from any medical condition before being covered by PM-JAY will now be able to get treatment for all those medical conditions as well under this scheme right from the day they are enrolled.
The National Health Authority (NHA) has entered into a partnership with the Employee’s State Insurance Corporation (ESIC). This synergy between Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB PM-JAY)and Employees State Insurance Scheme (ESIS) will create an ecosystem wherein ESIC beneficiaries will be able to access services at ABPM-JAY empanelled hospitals and vice versa.
The convergence between PM-JAY and ESIC is a landmark initiative for the development of health systems in the country. This will leverage the presence of an established network of quality services providers under PM-JAY alongside fixed health benefit packages, thereby standardising services across schemes. Further, it will create higher demand for health services at ESIC empanelled hospitals that may be currently underutilised. This will support in improvement of infrastructure and facilities of such facilities, via utilisation of funds reimbursed under PMJAY.
In the initial phase, a pilot is being conducted in Ahmednagar, Maharashtra and Bidar, Karnataka wherein ESIC beneficiaries of these districts will be able to access PM-JAY services in PM-JAY empanelled hospitals. The beneficiaries will be eligible for all 1,929 secondary and tertiary packages under the scheme and the initiative will be scaled up to 102 districts with a plan of eventually extending coverage across the country.Key Benefits of AB PM-JAY and ESIS convergence:
Over the last few decades, the world’s eyes have been on India as it’s economy has been one of the top three fastest growing economies of the world. However, despite making remarkable strides in several sectors, India is still classified as a Lower Middle-Income Country (LMIC) according to World Bank classification of countries based on per capita GDP, mostly due to its inconsistent socio-economic and health indicators.
Statistics show that more than 20 per cent of India’s population still lives under $1.9 per day (2011 PPP). According to a World Bank projection, by 2021 more than 34% of India’s population will be in the age group of 15-35 years. This rich demographic dividend enables India to be highly optimistic about a sustained economic growth for few more decades before a higher dependency ratio sets in. However, the perceived benefits of the higher demographic dividend are threatened by the epidemiological transition in India which is currently facing the unique situation of a “triple burden of disease.” As the mission of eradication of major communicable diseases remains unfinished, the population is also bearing the high burden of non-communicable diseases (NCDs) and injuries. This leads to an overall rise in the demand for health care over a prolonged period of time.
However, with a total population of more than 1.3 billion people, the supply side of adequate and affordable healthcare in India is found wanting. Figures show an overwhelming tilt towards health care services in the private sector which cater to nearly 70% of all visits for health care needs in India and have 50% of total hospital beds. But, individually most providers in the private sector are very small (with less than 25 beds). They are also unregulated, with varying standards of quality of care and are mostly situated in large metros or urban neighbourhoods leaving a great deficit of health services for the underprivileged population of India.
But being the second most populous nation in the world, the public sector hospitals in India are understandably overburdened. Their utilisation varies widely and they often have to work under challenging circumstancing arising from the lack of sufficient funds, a shortage of trained health workers and the erratic and often deficient supply of drugs and equipment which adversely impacts their functioning.
One of the major causes of this situation is the persistent underfunding of the country’s public health care system. Over the last two decades, the Government of India’s overall expenditure on health has remained stagnant at about 1.2% of its GDP (Source: National Health Accounts, 2015). Of its total expenditure on health, India spends only 21% from the Government revenue and as high as 62% from out-of-pocket expenses (Source: National Health Accounts, 2015). Thus, it has been deduced that increasing health care needs, coupled with high out-of-pocket expenditure, is a leading cause of poverty in India. Not only does it keep people poor, but it also pushes nearly 6 crore Indians back into poverty each year. The following graph depicts this situation clearly by comparing the OOP to total expenditure on health in two decades.
In the past, there have been several efforts by the Central and various State Governments to strengthen demand side financing by launching various Government-funded health insurance schemes. The Rashtriya Swasthya Bima Yojana (RSBY) was launched with an annual cover of INR30,000 per family at the central level which catered mostly to secondary care hospitalisation while many State schemes catered to tertiary care conditions. However, these schemes worked independently of the larger health care system in the country and resulted in further increasing the fragmentation of risk pools. Additionally, none of these schemes had any linkage with primary health care.
To address these challenges, the Government of India took a two-pronged approach under the umbrella of Ayushman Bharat. The first component of this strategy was disease prevention and health promotion to curb the increasing epidemic of non-communicable diseases. This was to be ensured through upgradation of the existing network of Sub-centres and Primary Health Centres to Health and Wellness Centres (HWC). Nearly 150,000 HWCs are to be set up in the country over the next few years which will work towards reducing the overall disease burden and hospitalisation needs of the population.
The second component was the launch of the Pradhan Mantri-Jan Arogya Yojana (PM-JAY) which aims to create a system of demand-led health care reforms that meet the immediate hospitalisation needs of the eligible beneficiary family in a cashless manner thus insulating the family from catastrophic financial shock. In the long run, the PM-JAY, through its system of incentives, aims to expand the availability of its services. With greater demand, the private sector is likely to expand in the unserved areas of Tier-2 and Tier-3 cities. For public hospitals, PM-JAY will provide an incentive to prioritise poor patients and shall provide means to generate additional revenue for strengthening their infrastructure and fill their service gaps. PM-JAY has subsumed the existing RSBY and also works in convergence with various State Government funded health insurance/ assurance schemes.
Because of its scope, PM-JAY is the world’s largest health insurance/assurance scheme that offers a health cover to nearly 12 crore poor families which comes to a staggering 55 crore Indians that form 40% of its bottom population. It is fully funded by the Government and provides financial protection for a wide variety of secondary and tertiary care hospitalisations. The prime objective of PM-JAY is to reduce catastrophic out-of-pocket health expenditure by improving access to quality health care for its underprivileged population. More details on its evolution, planning, eligibility and state wise implementation are discussed ahead.
Including the poorest and most vulnerable population of any country in the health insurance programme is often the most challenging because they cannot pay any premium and are the hardest to reach. Many times they are also not literate and, therefore, require a very different approach for awareness generation. This is true for most Lower and Middle-Income Countries (LMIC) and India is not an exception.
Thus, PM-JAY has been rolled out for the bottom 40 per cent of poor and vulnerable population. In absolute numbers, this is close to 12 crore households. The inclusion of households is based on the deprivation and occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas, respectively. This number also includes families that were covered in the RSBY but were not present in the SECC 2011 database.
The SECC involves ranking of the households based on their socio-economic status. It uses exclusion and inclusion criteria and accordingly decides on the automatically included and automatically excluded households. Rural households which are included (not excluded) are then ranked based on their status of seven deprivation criteria (D1 to D7). Urban households are categorised based on occupation categories.
In line with the approach of the Government to use the SECC database for social welfare schemes, PM-JAY also identifies targeted beneficiary families through this data.
Out of the total seven deprivation criteria for rural areas, PM-JAY covered all such families who fall into at least one of the following six deprivation criteria (D1 to D5 and D7) and automatic inclusion(Destitute/ living on alms, manual scavenger households, primitive tribal group, legally released bonded labour) criteria:
For urban areas, the following 11 occupational categories of workers are eligible for the scheme:
Even though PM-JAY uses the SECC as the basis of eligibility of households, many States are already implementing their own health insurance schemes with a set of beneficiaries already identified. Thus, States have been provided the flexibility to use their own database for PM-JAY. However, they will need to ensure that all the families eligible based on the SECC database are also covered.Expansion of coverage by States under PM-JAY and convergence
Various States have been implementing their own health insurance/assurance schemes over the past couple of decades. Most of these schemes provide cover for tertiary care conditions only. The benefit cover of these schemes is mostly available within the State boundaries except some smaller States have empanelled a few hospitals outside the State boundaries. Very few States had converged their schemes with the erstwhile RSBY scheme and many of them were operating independently. This was due to the lack of flexibility in the design of the RSBY, which although initially helped in quick scale-up but became a challenge over a period of time and offered limited flexibility to the States.
Even though these schemes were targeting the poor and vulnerable, there were large variations across States in terms of eligibility criteria and databases. Few States were using the food subsidy database while some others had created a separate database for their welfare schemes.
The primary objectives for launching PM-JAY were to ensure comprehensive coverage for catastrophic illnesses, reduce catastrophic out-of-pocket expenditure, improve access to hospitalisation care, reduce unmet needs, and to converge various health insurance schemes across the States. PM-JAY will also establish national standards for a health assurance system and is providing national portability of care. At the implementation level, the States are given the flexibility to use their own database if they were already implementing a health insurance/ assurance scheme and were covering more families than those eligible as per the SECC 2011 database. However, such States shall ensure that all families eligible as per the SECC data are covered and not denied benefits.
Various States are using different models for implementing their own health insurance/ assurance schemes. Some of them are using the services of insurance companies while others are directly implementing the schemes in their States.
Considering the fact that States are at different levels of preparedness and have varying capacity to manage such schemes, PM-JAY provides the States with the flexibility to choose their implementation model. They can implement scheme through assurance/trust model, insurance model or mixed model.
This is the most common implementation model adopted by most of the States. Under this model, the scheme is directly implemented by the SHA without the intermediation of the insurance company. The financial risk of implementing the scheme is borne by the Government in this model. SHA essentially reimburses health care providers directly. Even though no insurance company is involved, the SHA employ the services of an Implementation Support Agency (ISA) for claim management and related activities. As there is no insurance company in the picture, apart from day-to-day management and administration of the scheme, the SHA also has to carry out specialised tasks such as hospital empanelment, beneficiary identification, claims management and audits and other related tasksB. Insurance Model
In the insurance model, the SHA competitively selects an insurance company through a tendering process to manage PM-JAY in the State. Based on market determined premium, SHA pays premium to the insurance company per eligible family for the policy period and insurance company, in turn, does the claims settlement and payments to the service provider. The financial risk for implementing the scheme is also borne by the insurance company in this model. However, to ensure that the insurance company does not make an unreasonable profit, the scheme provides for a mechanism where insurance companies can only get a limited percentage of the premium for their profit and administrative costs.
After adjusting a defined percentage for expenses of management (including all costs excluding only service tax and any cess, if applicable) and after settling all claims, if there is surplus then 100 per cent of leftover surplus should be refunded by the insurer to the SHA within 30 days. The percentage that will need to be refunded will be as per the following:a. In Category A States (administrative cost cannot exceed 20%)
In case the claim settlement ratio exceeds 120% (115% in the case of Category B States) in any policy period, then the excess amount shall be initially shared in equal proportion between the insurance company and State Government / Union Territory. Thereupon, out of the excess burden amount, which the State Government / Union Territory has borne, the Central Government shall share the burden in line with the sharing pattern ratio. However, the total contribution of the Central Government along with the premium share and excess burden amount of claim shall not exceed the maximum ceiling amount of share of Central Government, applicable for that particular States / UTs, respectively. Any amount over and above the Central and State Government’s contribution amount shall have to be borne by the insurance company, respectively.C. Mixed Model
Under this, the SHA engages both the assurance/ trust and insurance models mentioned above in various capacities with the aim of being more economic, efficient, providing flexibility and allowing convergence with the State scheme. This model is usually employed by brownfield States which had existing schemes covering a larger group of beneficiaries.
|Category A States/ UTs
|Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi, Sikkim, Tripura, Uttarakhand and 6 Union Territories (Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep and Puducherry)
|Category B States
|Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh and West Bengal
PM-JAY is completely funded by the Government and costs are shared between Central and State Governments. The Government of India decides a national ceiling amount per family that is used to determine the maximum limit of the central share of the contribution. The actual premium discovered through open tendering process or the maximum ceiling of the estimated premium decided by Government of India for the implementation of PM-JAY, whichever is less, would be shared between Central Government and States/UTs in the ratio as per the extant directives issued by Ministry of Finance, from time to time. In addition, administrative cost for implementing the scheme at the State level is also provided under the scheme and shared between Centre and State in the same sharing pattern.
The existing sharing pattern is in the ratio of 60:40, for States (other than North-Eastern States & three Himalayan States) and Union Territories with legislature. For North-Eastern States and three Himalayan States (viz. Jammu and Kashmir, Himachal Pradesh and Uttarakhand), the ratio is 90:10. For Union Territories without legislatures, the Central Government may provide up to 100% on a case-to-case basis.Payment of Central Share
Various States have been implementing their own health insurance/assurance schemes over the past couple of decades. Most of these schemes provide cover for tertiary care conditions only. The benefit cover of these schemes is mostly available within the State boundaries except some smaller States who have empanelled a few hospitals outside the State boundaries. Very few States had converged their schemes with the erstwhile RSBY scheme and many of them were operating independently. This was due to the lack of flexibility in the design of the RSBY, which although initially helped in quick scale-up but became a challenge over a period of time and offered limited flexibility to the States.
Even though these schemes were targeting the poor and vulnerable, there were large variations across States in terms of eligibility criteria and databases. Few States were using the food subsidy database while some others had created a separate database for their welfare schemes.
The primary objectives for launching PM-JAY were to ensure comprehensive coverage for catastrophic illnesses, reduce catastrophic out-of-pocket expenditure, improve access to hospitalisation care, reduce unmet needs, and to converge various health insurance schemes across the States. PM-JAY will also establish national standards for a health assurance system and is providing national portability of care.
In the spirit of cooperative federalism and keeping in mind variations across the States, a lot of flexibility has been built in the PM-JAY design. Therefore, PM-JAY provides a lot of flexibility to States in terms of scheme design and implementation.States have been provided the flexibility in terms of the following parameters:
In order to enable PMJAY ‘swiftly & effortlessly,’ it was required that information technology is orchestrated in such as a manner that there is minimum ‘time-to-launch’. Since its launch IT has provided a robust backbone to the scheme's implementation throughout the nation. The below are the key technology blocks.
Since PM-JAY is an entitlement-based scheme where there is no advance enrolment process, making beneficiaries aware of the scheme is the most critical aspect. Information, Education and Communication activities need to be carried out to educate beneficiaries about the scheme. Various modes of communication such as leaflets, booklets, hoardings, TV, radio spots etc are important elements for creating a comprehensive communication strategy for disseminating the desired messages across the target audience.
A detailed communication strategy has been developed by NHA which is to be implemented at both national and State levels. NHA is also working on the overall cooperation & capacity-building with the States for implementation and development of communication strategy required for increasing awareness at the State level.
Due to large quantum of people being covered under PM-JAY, there is a strong need to spread awareness with the right message, through the right media and within the right timeframe. IEC activities were initiated immediately after the Cabinet approval to the scheme on 21st March, 2019. The first major initiative, Additional Data Collection Drive (ADCD) drive was undertaken by participating in “Gram Swaraj Abhiyaan” of Ministry of Rural Development on 30th April, 2018 named as “Ayushman Bharat Diwas” with an objective to make people aware about the upcoming scheme benefits and entitlement check by involving ASHA & ANMs and Gram Sevak covering around 3 lakh villages across the country. Various posters, banners etc. were designed and deployed in Hindi and regional languages across all camps and village meetings for spreading the awareness.
A letter from Hon’ble Prime Minister was sent to all beneficiary families to make them aware about their entitlements under the scheme and also provide them a family card with unique family ID. Standardised design materials have been prepared by NHA that are being used by States for making beneficiaries aware about the scheme. Various communication channels like print media, television, radio, social media etc. are being used to reach beneficiaries and other stakeholders. A communication strategy and IEC guidebook has also been developed for this purpose. A dedicated web portal for the scheme www.pmjay.gov.in has been also created to provide all the details about the scheme to various stakeholders. All relevant information and links e.g. list of empanelled hospitals, Am I eligible portal, grievance redressal portal, gallery, operational guidelines are placed here.
Apart from above mentioned critical components of PM-JAY's ecosystem following are some other key components working as the support system for the smooth implementation of the scheme.Capacity Development
Capacity building activities under PM-JAY attempt to address more than just training and cover all aspects of building and developing sustainable and robust institutions and human resource. Capacity building in PM-JAY has three components:
The NHA has taken the leadership role in assessing the requirements, making available resources, devising strategies for enabling States to undertake capacity building activities and providing technical assistance to States. Standardised learning content on identified thematic areas is being developed by the NHA. States can customise these materials and deliver through various methodologies as per their annual training plan. Monitoring and quality assurance measures with feedback mechanism have also been put in place to ensure effectiveness and efficiency. Partnerships and networks are being created with Government and non-Government institutions having expertise in various fields to support the capacity building initiatives in PM-JAY.
Capacity building initiatives in PM-JAY started with the orientation of SHA officials followed by various workshops for personnel from specific portfolios like IT, fraud control, claim management, etc. Workshops for ISAs and banking partners were also organised. Master trainers were created at the State level who in turn trained more than 10,000 Pradhan Mantri Arogya Mitras (PMAMs) at empanelled hospitals before the beginning of the programme. Learning materials were also made available in the portal to facilitate State and district level trainings. An e-learning platform is now being developed with the support of the National Skill Development Council (NSDC) for training and certifying Arogya Mitras. Various workshops, cross learning forums and thematic trainings are planned in the upcoming days.Monitoring and Evaluation
Monitoring and Evaluation under PM-JAY Monitoring and Evaluation (M&E) is key for successful implementation and ensuring the intended results of such a large insurance scheme. The NHA at the Central level is continuously keeping track on periodic basis on these UHC dimensions (coverage, benefits and financial protection) through the following functional domains:
A strong real-time online MIS is set up at the national level to review Key Performance Indicators (KPIs) and achievement of results with respect to the targets defined under the domains. The various dashboards developed using business intelligence tools help in identifying the gaps and provide an overview of the performance made. To mention a few: the operations dashboard presents an update of KPIs of beneficiary information system, pre-auth dashboard helps to access state and district wise distribution of pre-auth, status of empanelled hospitals, portability dashboard gives us the picture of interstate and intrastate portability and their KPIs on claim portability by specialty, procedure, age and gender.
Most of the States, which do not have their own schemes, are using the NHA software. However, States with their own schemes are either using the above or their own software followed by API integration to ensure the flow of data from State to Central servers.
In order to provide a comprehensive picture of the progress made by all the functional domains, factsheets are developed monthly at the State and National level. The factsheet compares the progress made since the inception of the scheme across States with the progress made in each month. The average claim size, total number of pre-auths generated, pending approvals, nomenclature of the packages used at public and private facilities are some of the important indicators included in the factsheet. The triggers and outliers (if any) identified through the dashboards and factsheet are further drill down to districts level.
To assess and comprehend the impact of PM-JAY, evidence generation is done through evaluation studies in collaboration with premiere research institutions and in partnership with development agencies such as GIZ, WHO and World Bank. The objective of these evaluation studies is to understand the impact of the scheme on various parameters including but not limited to out-of-pocket expenditure, access to health, health seeking behaviour, etc. These research studies provide critical inputs for evidence-based decision-making and carrying out mid-course corrections.Fraud Prevention, Detection and Control
For a programme of this scale, magnitude and complexity as that of PM-JAY, it is critical to put in a place a strong anti-fraud mechanism not only from financial perspective but also to safeguard people’s health from unethical behaviour and malpractices. The National Health Authority is cognizant of the issue and has taken a number of steps to safeguard the programme from the inception. Some of the key actions taken in this regard are listed below.
NHA has a “Zero Tolerance” approach towards Fraud and Abuse under PMJAY. Towards this end, the National Anti Fraud Unit (NAFU) has been set up with the primary responsibility for prevention, detection and deterrence of fraud and abuse under PM-JAY.
NAFU works closely with State Ant Fraud Units (SAFU) in order to ensure the effective implementation of the Scheme, free from any fraudulent/ abusive activity from any entity involved in PM-JAY implementation such as providers, beneficiaries, ISAs or payers.
NAFU carries our following key activities:
Grievance redressal system is designed to address grievances of all PM-JAY stakeholders based on the principles of natural justice while ensuring cashless access to timely and quality care remains uncompromised. A three-tier Grievance Redressal Committee structure has been set up at National, State and district levels for this purpose. The CEO of NHA will be the Chairperson at the National level while the CEO of SHA will chair the State Grievance Redressal Committee. The District Magistrate or an officer of the rank of Additional District Magistrate shall be the Chairperson of the District Grievance Redressal Committee. These committees will track and monitor the grievances and its status, collect additional information from parties involved, facilitate hearings, review records, adjudicate and issue orders on grievance and ensure compliance of committee orders.
The aggrieved parties can submit grievances through offline (letter) or through an online portal (https://cgrms.pmjay.gov.in) developed by NHA. Other communication channels like telephone call, fax, e-mails, and SMS are also accepted for registering a grievance. The National Call Centre (14555 / 1800 111 565) is also integrated to the Grievance Portal for addressing grievances received through the call-centre. The committee can also register grievances based on social media or public forums findings/reports. Based on predefined criteria, grievances will be handled either by the respective individual/organisation who is responsible to take action or by the committees at an appropriate level. But at any level, the grievance should be addressed within 30 days of receipt. The right to appeal for any party is valid for 30 days from the date of the decision. Non-compliance with the decisions of the committee within another 30 days will also attract a penalty for the defaulter. The online portal has the provisions to designate and track grievances to respective officials and monitor compliance with the alert system.Call Centre
One of the important aspects of one of the world’s largest government-supported health schemes of the size and complexity as that of PM-JAY is to ensure that entitled beneficiaries of the programme can reach out to know the details of the scheme, have recourse to raise a query or a grievance, seek information and support at any time during day or night, especially during hour of need. If the profile of beneficiaries includes a sizeable population which is rural based, even less educated and less aware, the mechanism needs to be further simplified and made easily accessible, involving least effort and no expense. Therefore, a National Helpline – 14555 was set up by then National Health Agency on August 24, 2018 – which is operating 24x7 since the launch and has answered more than 42 lakh calls since inception. The call centre is manned by 300 plus trained agents who work round the clock to manage the calls and further plans are in offing to expand capacity. All major regional languages are supported by the call centre team.
The Helpline is toll-free which means that the caller does not incur any call charges, the same are borne by NHA. Operating on 24x7x365 basis, the call centre provides services/information to the beneficiaries such as details about the scheme – coverage, benefits, how and where to avail benefits, name and address of empanelled hospitals etc. Besides beneficiaries, other stakeholders like hospitals, Arogya Mitras and field functionaries also call the Helpline for support.
The call centre is also engaged in outbound calling and more than 3 lakh outbound calls have been made to beneficiaries for collecting their feedback post discharge from hospital, to know their experience, whether any difficulty faced during the process, etc. Outbound calls are also made to hospitals to help them complete application for support, hand-holding and training for providing services to PM-JAY beneficiaries and to encourage these hospitals to raise pre-authorisation.
To ensure that the hospitals do not overcharge and rates do not vary across hospitals, empanelled health care providers (EHCP) are paid based on specified package rates. A package consists of all the costs associated with the treatment, including pre and post hospitalisation expenses. The specified surgical packages are paid as bundled care (explained below) where a single all-inclusive payment is payable to the EHCP by insurer/SHA. The medical packages, however, are payable to the EHCP on a per day rate depending upon the admission unit (general ward, HDU, ICU) with certain pre-decided add-ons payable separately. Day-care packages are payable just like surgical packages. The treatment packages are very comprehensive, covering treatment for nearly 24 specialities that include super speciality care like oncology, neurosurgery and cardio-thoracic and cardiovascular surgery, etc. The package rate (in case of surgical or defined day-care benefits) includes:
As mentioned in the previous section based on a few criteria, hospitals can be paid a higher amount. For such surgical conditions that are not listed in the package list, an EHCP will need to take approval and fix the rate from the insurer/ SHA before providing the treatment up to the limit of INR 1,00,000.
Soon after rollout, NHA started receiving feedback from stakeholders and various other sources on different aspects of AB PM-JAY including HBP 1.0. Majority of the feedback received on HBP could be broadly clubbed under the following heads:
All the concerns and feedback received from stakeholders and various other sources of different aspects of AB PM-JAY were deliberated upon in the first Governing Board meeting of NHA, in the month of April 2019. To address the gross anomalies, a mandate was given to NHA for rationalization of HBP.
For this purpose, 24 Specialist Committees were constituted. A Memorandum of Understanding was inked between NHA and Tata Memorial Hospital (TMH) for the review of Oncology packages. Department of Health Research (DHR) was conducting a study “Costing of Health Services in India” (CHSI), the data collection from Public sector hospitals for 8 specialties had been completed. DHR agreed to share these interim results with NHA. These results were provided to the specialist committees as an input during deliberations for the rationalization of HBP pricing (Please see Annex 1: Inputs provided to the specialist committee and decisions sought). The initial steps in the exercise of rationalization of Health Benefit Package (HBP) were carried out using three different processes which are detailed in flow chart – “Process for rationalization of HBP”.
Following the due procedure, the recommendations were presented to the Governing Board of NHA. The Governing Board of NHA approved following changes:
States with a State-owned health insurance scheme can keep their own rates for all the packages. However, they are required to adhere to mandatory 1,391 packages as specified in the PM-JAY list. The list can be expanded based on additional packages from their own scheme which were not a part of the national package master.
States with no health scheme other than PM-JAY can adopt the national package master with context-specific variations such as revision of prices in the range of 10 per cent, reservation of procedures for public hospitalisation, additional packages under mandatory pre-authorisation, etc. States do have the flexibility to add packages or modify rates according to their requirements; further, they even have the flexibility to change terms of pre-authorization and modify the list of the public hospital only packages which was devised to prevent any misuse. to see the revised list of Health Benefit PackagesClick here to see the revised list of Health Benefit Packages
The supply of health care services under PM-JAY must be ensured through pre-selected, well equipped and well-prepared hospitals to deliver the benefits. Also, the hospitals must be distributed widely enough over the geography so as to ensure optimal accessibility to the eligible families.
In order to cater to the increased demands under PM-JAY and also to ensure quality care to the beneficiaries, it is imperative to maintain and grow a network of hospitals that also conform to the quality standards and criteria. This leads to the need of empanelment of hospitals on a pre-emptive basis so that beneficiaries are certain of their rights being honoured in the most convenient, cashless and quality manner.Empanelment Criteria
Considering the supply side characteristics (nearly 71 per cent of the hospitals are running as proprietorship businesses with less than 25 beds capacity and offering non-specialised general clinical care), two types of empanelment criteria have been evolved. These criteria have been evolved based on the experience of the prevalent practice in other Government-funded health insurance schemes, State-specific regulations related to the quality of care and Clinical Establishment Act 2011.
The detailed criteria for empanelment are available on www.pmjay.gov.in
PM-JAY prescribes a two-tier approach to the empanelment of hospitals which is online, transparent and efficient and is completely free for all steps of the process. States are in the stewardship position of the entire process of hospital empanelment and they have the final decision-making power in this regard. At the State level, a State Empanelment Committee (SEC) has been set up under the State Health Agency. At the district level, a District Empanelment Committee (DEC) has been set up.
Each empanelled hospital needs to set up a dedicated help desk for the beneficiaries, which is manned by a dedicated staff appointed by the Empanelled Health Care Provider (EHCP). These help desk staff are called Pradhan Mantri Arogya Mitras (PMAMs) and their role is to facilitate treatment of beneficiaries at the hospitals. Every empanelled hospital receives a unique ID also.
PM-JAY incentivises the empanelled hospitals to continuously strive for the attainment of higher quality standards. These incentives are certainly a motivation for the hospitals to attain the said quality standards. The following incentives are being provided under PM-JAY to the hospitals over and above the package rates
Although States are in charge of the empanelment of hospitals, there are eminent tertiary care hospitals and specialised care hospitals that operate as autonomous institutes of excellence directly under the Ministry of Health and Family Welfare (MoHFW) or some other department. Most popular examples of such hospitals are AIIMS, Safdarjang Hospital, JIPMER, PGI Chandigarh, etc. The National Health Authority (NHA) has empanelled these hospitals directly by signing an MoU with each of the facility. Also, all NABH accredited private hospitals in the National Capital Region (NCR) are directly empanelled by NHA to widen the network of service providers. Empanelment of Government hospitals other than those managed by MoHFW is also a major step towards widening the network of hospitals.