The Union Cabinet has recently expanded the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY) to include all senior citizens aged 70 and above, offering them comprehensive health coverage. This initiative is expected to benefit over 6 crore elderly individuals across India.
Expanded Health Coverage for Senior Citizens under PM-JAY
Eligibility Criteria:
- Individuals aged 70 years and older qualify for this program, regardless of their financial background.
- Aadhaar-based electronic Know Your Customer (e-KYC) verification is mandatory for enrollment.
Key Benefits:- Financial Protection: Eligible senior citizens will receive hospital treatment at no cost under this scheme.
- Enhanced Coverage: The program provides an additional Rs. 5 lakh annual health coverage per family, supplementing the existing PM-JAY benefits.
- No Income-Based Exclusions: Enrollment is open to all senior citizens, without any income restrictions.
- Immediate Access to Benefits: There is no waiting period; coverage begins as soon as enrollment is completed.
- Flexibility with Private Insurance: Beneficiaries can avail of PM-JAY benefits even if they hold private health insurance.
- Exclusive Option for Government Retirees: Individuals covered under government health schemes, such as CGHS, must choose between their existing coverage and PM-JAY, as dual benefits are not permitted.
Overview of PM-JAY
Launched in September 2018, Ayushman Bharat aims to achieve Universal Health Coverage (UHC) by providing financial security for healthcare needs, particularly for vulnerable communities.
The program has two key components:- Health and Wellness Centres (HWCs):
- These centers, now referred to as Ayushman Arogya Mandirs (AAMs), provide holistic healthcare services, including preventive, curative, rehabilitative, and palliative care.
- A network of 1,50,000 AAMs is being developed to ensure free, primary healthcare services for all.
- These facilities offer free consultations, medications, and diagnostic services, focusing on maternal and child health, non-communicable diseases (NCDs), and other essential healthcare needs.
- Pradhan Mantri Jan Arogya Yojana (PM-JAY):
- Provides coverage of up to Rs. 5 lakh per family per year for secondary and tertiary healthcare.
- Targets 12 crore vulnerable families (approximately 55 crore individuals), covering the bottom 40% of the population.
- Designed to protect families from high medical costs that could push them into poverty.
- Fully government-funded, with costs shared between the central and state governments.
- Enables beneficiaries to seek treatment at empaneled public and private hospitals nationwide.
Impact of PM-JAY on Individuals and Families- Reducing Financial Burden:
- Over 7.8 crore individuals have accessed PM-JAY benefits in the past six years, preventing millions from incurring catastrophic medical expenses.
- The scheme significantly reduces out-of-pocket healthcare expenses, which declined from 62.6% to 47.1% of total health expenditures in 2019-20.
- Enhanced Support for Senior Citizens:
- The 2024 expansion to include all citizens aged 70 and above addresses the unique health challenges of the elderly, such as chronic diseases and age-related disabilities.
- Unlike private insurers, PM-JAY does not impose waiting periods or deny coverage due to pre-existing conditions.
- Improving Healthcare Access:
- Over 29,000 hospitals, including 13,000 private facilities, are part of the scheme, ensuring widespread availability of quality healthcare.
- More than 57% of hospital admissions take place in private hospitals, highlighting the crucial role of the private sector in delivering healthcare services.
- Promoting Gender Equality:
- Women account for nearly half (49%) of Ayushman cardholders, with over 3.61 crore hospital admissions, ensuring equitable access to healthcare.
- Strengthening Healthcare Services:
- The number of medical procedures covered has increased from 1,393 in 2018 to 1,949 in 2022.
- The scheme allows states to customize pricing based on regional healthcare costs.
- Scientific Backing for PM-JAY’s Effectiveness:
- A study based on Household Consumption Expenditure Survey (2022-23) highlights PM-JAY’s role in preventing financial distress due to healthcare costs, particularly among the economically disadvantaged.
PM Ayushman Bharat Health Infrastructure Mission (PM-ABHIM)
Originally launched as the Prime Minister Atmanirbhar Swasth Bharat Yojana (PMASBY) in 2021, this mission focuses on strengthening India’s healthcare system at all levels. With a budget of Rs. 64,180 crore allocated until FY 25-26, the initiative complements the National Health Mission by:
- Enhancing disease surveillance systems with advanced IT infrastructure.
- Strengthening pandemic preparedness and response mechanisms.
- Promoting research on infectious diseases.
- Implementing the One Health Approach to address human and animal health issues.
Challenges Facing PM-JAY- Fraudulent Activities and Data Issues:
- The 2023 Comptroller and Auditor General (CAG) report highlighted fraud cases, such as deceased individuals receiving treatment and multiple beneficiaries linked to a single mobile number.
- Financial irregularities, including pending penalties worth Rs. 12.32 crore across nine states, indicate the need for stricter oversight.
- Inadequate Healthcare Infrastructure:
- Rural hospitals often lack proper facilities, trained staff, and essential medical equipment.
- Some empaneled hospitals fail to meet quality standards, impacting patient care.
- Regional Disparities Due to State Non-Participation:
- States like West Bengal, Odisha, and Delhi have opted out, limiting the scheme’s reach and creating healthcare access gaps.
- Uncovered Indirect Costs:
- While the scheme covers hospitalization expenses, associated costs such as transportation, income loss, and post-hospitalization care remain unaddressed.
- Weak Primary Healthcare Services:
- The focus remains on secondary and tertiary care, while primary healthcare services are underfunded and lack resources.
- Low Awareness Among Eligible Beneficiaries:
- Many individuals remain unaware of their eligibility, and enrollment challenges prevent them from accessing benefits.
- Inefficient Monitoring Systems:
- Some private hospitals demand advance payments despite the scheme’s cashless nature.
- Fraudulent claims and excessive drug prescriptions require improved regulatory oversight.
Recommendations for Improvement- Enhancing Fraud Detection and IT Systems:
- Implement AI-driven validation to identify duplicate entries and suspicious transactions.
- Enforce stringent penalties on fraudulent claims and improve biometric verification.
- Establish a dedicated fraud detection unit within the National Health Authority (NHA).
- Upgrading Healthcare Infrastructure:
- Invest in rural healthcare facilities, recruit more medical professionals, and modernize medical equipment.
- Strengthen public-private partnerships (PPPs) to expand quality healthcare access.
- Bridging State-Level Disparities:
- Engage with non-participating states and offer tailored incentives to integrate their health programs with PM-JAY.
- Addressing Indirect Healthcare Costs:
- Introduce financial assistance for transportation and post-hospitalization care.
- Establish community health funds to support low-income beneficiaries.
- Expanding Awareness and Outreach:
- Conduct large-scale information campaigns to improve enrollment.
- Simplify the registration process to ensure easy access for eligible individuals.
- Strengthening Monitoring and Compliance:
- Conduct routine audits of empaneled hospitals and improve grievance redressal mechanisms.
- Implement real-time fraud detection to prevent misuse of funds.
By addressing these challenges and implementing targeted reforms, the PM-JAY scheme can further enhance healthcare accessibility, affordability, and efficiency for India’s most vulnerable populations.
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