Ayushman Bharat Pradhan Mantri Jan Arogya Yojana : The salient features of AB PM-JAY

LOK SABHA 

AYUSHMAN BHARAT SCHEME 

726. COL. RAJYAVARDHAN RATHORE

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:

(a) the salient features, procedure involved, targets fixed, progress made, funds  allocated, number of beneficiaries benefited particularly during the COVID-19 pandemic, Ayushman cards issued, medical treatment covered under the Ayushman Bharat Yojana (ABY), State/UT-wise and district-wise;

(b) the number of CHCs, PHCs, AB-HWCs and other hospitals empanelled and super speciality blocks sanctioned thereunder, State/UT and location-wise and the criteria adopted for their selection/ empanelment;

(c) whether the Government proposes to upgrade sub Centres and PHCs to Health and Wellness Centres under Ayushman Bharat Yojana, if so, the details thereof along with the technical and financial assistance provided to the States/UTs in this regard;

(d) whether the Government proposes to cover patients suffering from prolonged chronic diseases including cancer under ABY and if so, the steps taken thereon along with list of ailments covered thereon;

(e) whether the cases of corruption in implementation of the said scheme have come to the notice of the Government so far, if so, the details thereof along with the action taken thereon, State/UT- wise; and

(f) the steps being taken by the Government to post adequate number of doctors/para-medics in medical institutions/hospitals/wellness centres to address the shortage under ABY and the necessary steps taken by the Government for effective implementation of the said Scheme?

(SHRI ASHWINI KUMAR CHOUBEY)

• AB PM-JAY is the world’s largest government funded health protection scheme.

• AB PM-JAY provides health assurance of up to Rs.5 Lakhs per family per year for secondary and tertiary hospitalizations.

• AB PM-JAY is a completely cashless and paperless scheme.

• AB PM-JAY is an entitlement-based scheme, all the eligible beneficiary families are covered from day one of the implementation of the scheme in the State/UT. AB PM-JAY does not require enrolment, however, beneficiary verification process is being undertaken to verify the genuineness of the beneficiary. E-cards are issued to all eligible beneficiaries as part of this process.

• The benefits under AB PM-JAY are portable across the country.

• There is no cap of family size, or age or gender.

• The beneficiary families under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) have been identified from the Socio Economic Caste Census (SECC) of 2011 on the basis of select deprivation and occupational criteria across rural and urban areas. Details provided under Annexure – I.

• The number of eligible beneficiaries under SECC 2011 is 10.74 Crores (50 Crore people). The scheme gives flexibility to States/UTs to run their own health protection schemes in alliance with AB-PMJAY. The States/UTs implementing AB PM-JAY have further expanded the coverage of the scheme to include 13.13 Crore families (65 Crore people)

• AB PM-JAY is being implemented in 32 States and UTs across India apart from West Bengal, NCT of Delhi, Odisha and Telangana.

• The scheme is implemented across the country through a three-tier model. National Health Authority, an attached office of the Ministry of Health and Family Welfare, has been provided with full autonomy, accountability and mandate to implement AB PM-JAY across the country. For effective implementation of AB PM-JAY at States/UTs level, State Health Agencies (SHA) have been established. District Implementation Units (DIUs) have been setup across all district for ensuring on-ground coordination between scheme stakeholders and smooth implementation.

• AB PM-JAY is completely funded by the Government and costs are shared between Central and State Governments in the ratio as per the extant directives issued by Ministry of Finance, from time to time.

• The States/UTs have been given provided with the flexibility to implement the scheme in the operational model best suited to the local conditions. Thus, AB PM-JAY is being implemented in Insurance mode, Mixed mode and Trust mode.

• Targets are not fixed for AB PM-JAY as the scheme operates on the basis of beneficiary demand for healthcare services. All the eligible beneficiaries of the implementing States/UTs are entitled for services under the scheme from the day of launch of the scheme.

• The funds allocated for the scheme for the financial year 2020-21 at BE stage is Rs. 6400 Crores.

• As on 03.02.2021, a total of 14.6 Crore e-cards have been issued to the scheme beneficiaries (including 4.68 Crore cards issued on the State IT systems). Further, a total of 1.58 Crore hospital admissions worth Rs. 19,674 Crores have been authorized through a network of 24,317 empanelled health care providers.

• Following the onset of Covid-19, AB PM-JAY provided valuable support to the healthcare ecosystem by ensuring that beneficiary registration process was kept active and empanelled hospitals continued to provide services to the scheme beneficiaries. However, there was a noticeable impact on the performance of the scheme on account of factors such as restriction of mobility, restrictions on elective surgeries, reluctance from scheme beneficiaries to visit hospitals due to fear of infection and designation of public facilities as dedicated Covid centers. During the period from 24th March to 7th September 2020, a total of 16.45 Lakh e- cards were generated for scheme beneficiaries. Further, 30.15 Lakh hospital admissions worth Rs. 3103 Crores were authorized. The State/UT wise details are provided in Annexure – II. The district wise details are provided in Annexure – III.

(b):     Under Ayushman Bharat Health and Wellness Centre (AB-HWCs), Government of India is committed to create 1,50,000 Health and Wellness Centres by upgrading the Sub Health Centres (SHCs) and rural and urban Primary Health Centres (PHCs) which will bring healthcare closer to the community. These Centres are to provide Comprehensive Primary Health Care (CPHC), by expanding and strengthening the existing Reproductive & Child Health (RCH) and Communicable Diseases services and by including services related to Non-Communicable Diseases (common NCDs such as Hypertension, Diabetes and 3 common cancers of Oral, Breast and Cervix) and incrementally adding primary healthcare services for Mental health, ENT, Ophthalmology, Oral health, Geriatric and Palliative care and Trauma care as well as health promotion and wellness activities like yoga.

Under Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY), NHA has developed two types of empanelment criteria based on the prevalent practice in other Government-funded health insurance schemes, State-specific regulations related to the quality of care and Clinical Establishment Act 2011. These criteria are:

• General Criteria – For hospitals that provide non-specialized general medical and surgical care with or without ICU and emergency services.

• Special Criteria (for clinical specialties) – For each specialty, a specific set of criteria has been identified. Under PM-JAY, a hospital is not allowed to select the risk, which means it cannot apply for selected specialties and must agree to offer all specialties to PM-JAY beneficiaries that are offered by it. However, in order to offer a specialized clinical service, the hospital must have necessary specific infrastructure and HR in place as mentioned in the special criteria developed under PM-JAY for the same.

On the basis of these guidelines, a total of 24,317 hospitals (including 10,935 private hospitals) have been empanelled across the country. The detailed State/UT wise list is provided under Annexure – IV.

(c): As on 02.02.2021, there are 57,240 AB-HWCs operational across the country (State-wise details are given at Annexure-V). These Centres had cumulatively conducted so far 7.76 Cr screenings for Hypertension, 6.32 Cr screenings for Diabetes, 7.42 Cr screenings for common cancers such as Oral, Breast and Cervix Cancer and also follow-up these patients for the management of these chronic illnesses.

State/UTs are provided required technical assistance for the implementation of the Programme.

(d): AB PM-JAY provides treatment corresponding to a total of 1592 procedures under 25 different specialties including chronic diseases like Cancer, Diabetes, Heart Disease and other non-communicable diseases. The specialty wise breakup of packages is provided under Annexure–VI. Chemotherapy and Radiotherapy packages, along with Surgical oncology are covered as part of Cancer treatment under the scheme. Additionally, there is a category of unspecified packages which can be booked for procedures which are not defined in the health benefits package.

(e): The policy of zero-tolerance is adopted under AB-PMJAY towards fraud and abuse and steps have been taken for prevention, detection, and deterrence of different kinds of fraud that could occur in AB PM-JAY at different stages of its implementation. National Anti-Fraud Unit (NAFU) has been established at NHA and works in close coordination with State Anti-Fraud Units (SAFU) to investigate and take joint action against issues related to fraud and abuse. Suitable actions including de-empanelment of hospitals (220), de-activation of e-cards (3,92,301), levying penalty on errant hospitals, and lodging of FIRs (6) have been taken against fraudulent entities as reported by the States/UTs. The State/UT wise list of such anti-fraud actions may be found under Annexure – VII.

(f): All public hospitals (Community Health Centre and above), in the States implementing PMJAY, are deemed empaneled under the Scheme.

The Private hospitals under AB-PMJAY are empaneled based on well-defined criteria. At the time of empanelment, necessary certificates are required to be produced by the intending private hospitals regarding availability of adequate and qualified medical and nursing staff (doctors & nurses), physically in charge round the clock, in the hospital.

Various  steps  taken  to  ensure  the  effective  implementation  of  the  scheme  are  at Annexure-VIII.

 Annexure – I

Detailed list of criteria for eligibility under AB PM-JAY as per SECC 2011 

Automatically included:

1. Households without shelter
2. Destitute/ living on alms
3. Manual scavenger families
4. Primitive tribal groups
5. Legally released bonded labour

Deprivation criteria in rural area:

• D1: Only one room with kucha walls and kucha roof D2: No adult member between age 16 to 59
• D3: Female headed households with no adult male member between age 16 to 59 D4: Disabled member and no able-bodied adult member
• D5: SC/ST households
• D7: Landless households deriving major part of their income from manual casual labour

Occupational criteria in urban area:

1. Rag picker
2. Beggar
3. Domestic worker
4. Street vendor/ Cobbler/hawker / Other service provider working on streets
5. Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and other head-load worker
6. Sweeper/ Sanitation worker / Mali
7. Home-based worker/ Artisan/ Handicrafts worker / Tailor
8. Transport  worker/  Driver/  Conductor/  Helper  to  drivers  and  conductors/  Cart  puller/ Rickshaw puller
9. Shop worker/ Assistant/ Peon in small establishment/ Helper/ Delivery assistant / Attendant/ Waiter
10. Electrician/ Mechanic/ Assembler/ Repair worker/Washer-man/ Chowkidar

 Annexure – II

State wise details of E-cards issued, authorized hospitals admissions by count and amount under AB PM-JAY for period from 24th March 2020 to 07th September 2020

Annexure – III

District wise e-cards generated and authorized hospital admissions (by count and amount) from 24th March 2020 to 07th September 2020 ………………………….. Read more.