Pradhan Mantri Jan Arogya Yojana: PMJAY Scheme Features And Eligibility Criteria

Health Insurance

Pradhan Mantri Jan Arogya Yojana (PMJAY) or Ayushman Bharat Yojana is a health insurance and protection policy that was introduced in 2018. This government initiative aims to provide medical coverage to the economically weaker section of society. Following is a discussion on the features, benefits, eligibility criteria, and other details related to this scheme.

Features and Benefits of PMJAY

Here are some features and benefits of PMJAY:

• Since Pradhan Mantri Jan arogya yojana is a government-funded scheme, the Central and State Governments cover all expenses.  
• Ayushman Bharat Yojana provides medical coverage to over 50 crore underprivileged individuals.
• This scheme provides medical insurance coverage of up to Rs. 5 lakh per entitled family for tertiary and secondary healthcare. 
• One can enjoy the benefits of this scheme at empanelled private hospitals or any government hospital. 
• The healthcare expenses borne by the government include the cost incurred during the pre-and post-hospitalisation period.
• The medical coverage includes a cashless hospitalisation facility. 
• The amount of money to be paid for medical expenses will be based on a pre-specified package rate. 
• Beneficiaries can claim compensation for more than 1390 procedures, which include ICU as well as OT expenses. 
• The scheme aims to improve the quality of life in the economically weaker segments of India.
• This scheme prioritises women, girls’ child as well as senior citizens. There are no restrictions in relation to family size or age. 

Coverage Available under PMJAY

Pradhan Mantri Jan Arogya Yojana offers coverage for the following expenses:

• Medical examination 
• Diagnostic services availed before hospitalisation
• Hospital accommodation along with meal services
• Post-hospitalisation care and medication for a maximum of 15 days
• Doctor consultation 
• Expenditure incurred owing to complications arising during treatment

Here are some treatments that are covered under the Pradhan Mantri Jan arogya yojana: 

• Paediatric care
• Geriatric care
• Mental health care
• Maternal health care services 
• Non-communicable and communicable diseases 
• Eyecare 
• Pregnancy care
• Health care services for infants

Further, here is a list of diseases that are covered under this scheme: 

• Anterior Lumbar Interbody Fusion
• Skull base surgery
• Prostate cancer
• Pulmonary valve surgery 

Exclusions under PMJAY 

Pradhan mantri jan arogya yojana health protection scheme does not provide medical coverage for expenses incurred due to the following: 

• Fertility procedures
• Cosmetic surgery procedures
• Drug rehabilitation programme
• Individual diagnostics 
• Organ transplantation
• OPD

PMJAY Eligibility Criteria for Urban Population

Here is a list of individuals who can be beneficiaries under the pm jan arogya yojana scheme:

• Domestic workers
• Daily wage workers
• Street vendors, hawkers, cobblers
• Peons 
• Repair workers such as electricians, mechanics, etc. 
• Plumbers, welders, security guards, etc.

PMJAY Eligibility Criteria for Rural Population

The following category of individuals are eligible for pradhan mantri jan arogya yojana health care coverage:

• Individuals belonging to the SC/ST category
• Families that reside in makeshift homes
• Individuals who belong to primitive tribal segments
• Families that do not have any male members between the age of 16 and 59 years

Steps to File Cashless Claim under PMJAY

If you are a beneficiary under Ayushman Bharat Scheme you will get an Aysuhman health card. With this card, you can avail of cashless claims on treatment or hospitalisation under the Ayushman Bharat Yojana. To register for Ayushman Bharat Yojana you have to follow the given steps:

Step 1: Go to the PMJAY portal.

Step 2: Check your eligibility by clicking on ‘Am I Eligible’.

Step 3: Provide your mobile number and the CAPTCHA code to generate OTP.

Step 4: In the next step, choose your state from the list and search by using name/ mobile no./HHD number/ration card number

Step 5: You can see through the search results if you are verified under PMJAY.

Step 6: If you are eligible under PMJAY you can get an e-card. 

You can also visit your nearest Common Service Center or contact on the helpline numbers 14555/1800-111-565.

Who Are Not Eligible for PMJAY Scheme?

These households will not be able to avail benefits of the PMJAY scheme:

• Households that have registered non-agricultural enterprises 
• Any family earning over Rs. 10,000 per month
• Households that have motorised two/three/four-wheeled vehicles 
• Landowners having at least 5 acres of irrigated land for a minimum of two crop seasons
• Households that have a fishing boat or three/4-wheeled mechanised agricultural equipment 
• Households having a refrigerator or a landline
• Income tax or professional tax payees
• Landowners having over 2.5 acres of land and a minimum of 1 irrigation equipment 
• Owners of a pucca house (houses with a roof and permanent walls)

In case an individual is not eligible for this health protection scheme, he or she can opt for a health insurance policy from any leading insurance provider in India. Navi Health Insurance offers medical coverage with cashless claims via a network of over 10,000 hospitals across India. Download the Navi app to know more today!

How Can One Apply for PMJAY Card?

Eligible individuals can gain access to cashless healthcare facilities under the Ayushman Bharat Yojana scheme by using the PMJAY Card. Here’s how they can apply for it:

Step 1: Visit the official PMJAY website

Step 2: Log in to the official portal using your mobile number

Step 3: Enter the captcha code and generate a one-time password, which you will receive on your registered mobile number

Step 4: After logging in, request the Household ID (HHD )code 

Step 5: Submit the HHD code at a Common Service Centre (CSC) 

Step 6: Upon successful verification of all details, the card will be issued to you. You can avail of the card from your nearest CSC or download a digital copy from the official PMJAY website. 

Hospitalisation Process for Ayushman Bharat Yojana

Beneficiaries, being an individual or family can avail of the benefit of Rs. 5 lakh as provided under PMJAY. This cost is enough to cover the medical or surgical treatments. However, one cannot avail of the cost of surgical and medical treatments simultaneously.

If a beneficiary needs multiple surgeries, the one with the highest cost is paid in the first instance, followed by a waiver of 50% on the second and 25% on the third. The filing for cashless claims is also made possible due to the cost-sharing agreement between the Central Government and state government in the ratio of 60:40.

Coverage of COVID-19 under the PMJAY scheme

The Insurance Regulatory and Development Authority has issued notice to all health insurance companies to include COVID-19 treatments under their schemes. Beneficiaries under PMJAY can avail themselves of free treatments and medical facilities for COVID-19 at the empanelled hospitals registered under this scheme. 

Documents Required for PMJAY Scheme 

Eligible applicants must submit these documents to apply for the Ayushman Bharat Yojana scheme: 

• Proof of Identity
• Address proof
• Caste certificate 
• Document affirming the family’s status that is seeking medical coverage
• Income certificate 

Things to Consider before Investing in PMJAY Scheme

You should keep in mind the following aspects before investing in the PMJAY scheme:

• Under this scheme, you can avail of benefits of up to Rs. 5 lakh per year for secondary or tertiary care hospitalisation
• You can avail of cashless claims in the network of hospitals across the country.
• The families included is based on the occupational or deprivation status of Socio-Economic Caste Census 2011 for urban and rural areas
• Individuals enrolled under this scheme can avail of benefits added for COVID-19 treatments and hospitalisation
• Beneficiaries get coverage for 3 days of pre-hospitalisation and 15 days of post-hospitalization expenses. 

Steps to File A Complaint on PMJAY Portal

To file a complaint or grievance you have to follow these steps:

Step 1: Visit the CGRMS portal

Step 2: File your complaint or grievance and they will get back to you

You can also make such complaints offline by dialling the helpline numbers. Alternatively, you can send a letter, email or fax to the official addresses of SHA/NHA or meet the District Grievance Nodal Officer.

Ayushman Bharat Yojana Contact Information

The contact information for Ayushman Bharat Yojana is given below:

Contact no: 14555 or 1800-111-565

Mailing address:

National Health Authority of India

Floor no. 3, 7 and 9

Tower – L

Jeevan Bharati Building

Connaught Place, New Delhi  – 110001

Final Word

Healthcare protection schemes such as pm jan arogya yojana ensure financial protection against life-threatening illnesses or accidents. The above-mentioned guide about this scheme can help prospective applicants avail of its benefits with ease.

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Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.