Ayushman Bharat Yojana

The National Health Protection Scheme (NHPS) scheme is formed by subsuming multiple schemes including Rashtriya Swasthya Bima Yojana, Senior citizen health Insurance Scheme (SCHIS), Central Government Health Scheme (CGHS), Employees' State Insurance Scheme (ESIS), etc. The National Health Policy, 2017 has envisioned Health and Wellness Centres as the foundation of India’s health system which the scheme aims to establish.[3]

The Central Government Health Scheme (CGHS) was started under the Indian Ministry of Health and Family Welfare in 1954 with the objective of providing comprehensive medical care facilities to Central Government employees, pensioners and their dependents residing in CGHS covered cities. This health scheme is now in operation with cities such as Bhubaneswar, Bhopal, Chandigarh, and Bangalore. The dispensary is the backbone of the Scheme. Instructions on these various matters have been issued from, time to time for the guidance of specialists and medical Officers. The Central Government Health Scheme offers health services through Allopathic and Homeopathic systems as well as through traditional Indian forms of medicine such as Ayurveda, Unani, Naturopathy, Yoga and Siddha.[4]

Every year more than sixty million Indians are pushed into poverty because of out of pocket medical expenses. AB PM-JAY was launched on 23 September, 2018 at Ranchi, Jharkhand . The scheme envisions to alleviate the condition of 50 crore poor and vulnerable Indians.

• PM-JAY is a health assurance scheme that covers 10.74 crores households across India or approx 50 cr Indians.

• It provides a cover of 5 lakh per family per year for medical treatment in empanelled hospitals, both public and private.

• It provides cashless and paperless service to its beneficiaries at the point of service, i.e the hospital.

• E-cards are provided to the eligible beneficiaries based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011).

• There is no restriction on family size, age or gender.

• All previous medical conditions are covered under the scheme.

• It covers 3 days of hospitalisation and 15 days of post hospitalisation, including diagnostic care and expenses on medicines.

• The scheme is portable and a beneficiary can avail medical treatment at any PM-JAY empanelled hospital outside their state and anywhere in the country.

• The Central government has decided to provide free testing and treatment of Coronavirus under the Ayushman Bharat Yojana.

25 States and Union Territories have adopted the PM-JAY scheme, except three states: Odisha, West Bengal and Telangana, and Union territory Delhi [5] By May 2020, more than 12 crore e-cards have been generated and over 1 crore people have taken benefit under this scheme. [6] The number of public and private hospitals empanelled nationwide stands at 22,000. [7]

The scheme has faced challenges in form of fraudulent bills. In response, National Health Authority has revoked empanelment of 171 hospitals and imposed a penalty of 4.6 crore. Another 390 hospitals have been issued show cause notice. [8]

There have been media reports of misuse of the Ayushman Bharat scheme by unscrupulous private hospitals through submission of fake medical bills. Under the Scheme, surgeries have been claimed to be performed on persons who had been discharged long ago and dialysis has been shown as performed at hospitals not having kidney transplant facility.[9] There are at least 697 fake cases in Uttarakhand State alone, where fine of Rs one crore has been imposed on hospitals for frauds under the Scheme.[10] However, unlike the earlier RSBY (Rashtriya Swasthya Bima Yojana) era, plagued by lax monitoring of insurance fraud, AB-PMJAY involves a robust information technology infrastructure overseeing transactions and locating suspicious surges across the country. Many hospitals have been blacklisted and the constantly evolving fraud-control system will play a major role in streamlining the scheme as it matures. Initial analysis of high-value claims under PMJAY has revealed that a relatively small number of districts and hospitals account for a high number of these, and some hint of an anti-women bias, with male patients getting more coverage. Despite all efforts to curb foul-play, the risk of unscrupulous private entities profiteering from gaming the system is clearly present in AB-PMJAY.[11]