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PM Modi’s Ayushman Bharat Health Insurance Scheme

modicare health insurance scheme

The Indian health insurance sector is hoping to see new heights with the recently announced scheme by Prime Minister of India -Narendra Modi Ayushman Bharat Health Insurance Scheme. PM during his independence speech at Red Fort has announced Pradhan Mantri Jan Arogya Abhiyaan, alternately Ayushman Bharat Scheme to be launched on September 25, 2018 in India. This government-sponsored insurance scheme will provide health coverage up to Rs. 5 lakh per family. The health facilities can be availed from any of the government or even at empanelled private hospitals across India.

This brings a ray of hope among the underprivileged section of the society as this scheme is designed to financially empower the poor in terms of healthcare. This will be the first-ever-largest health plan to cover 10cr families in India.

Since the scheme is designed only for the economically deprived families, not everyone will be eligible to avail the policy benefits. Under this scheme, the healthcare facilities will be provided around 10.74 crore beneficiary families and about 50 crore Indian citizens.

Some Facts of Ayushman Bharat Health Insurance

Some of the facts of this newly launched health scheme are as follows:

  • The scheme will target around 50 cr people.
  • 03 crore rural and 2.33 crore urban areas are covered.
  • It is the world’s largest healthcare scheme.
  • Around 1,354 healthcare packages are included under the scheme.
  • Treatment for knee replacement, coronary bypass, stinting, etc. will be offered in up to 15-20 percent cheaper price as compared to Central Government Health Scheme (CGHS).
  • Hospitals under Employee State Insurance Corporation (ESIC) may also be empanelled based on their occupancy of bed.
  • Private hospitals can be empanelled online based as per the defined criteria, which will be updated later.

Salient Features of Ayushman Bharat Health Scheme

Some of the outstanding features of Ayushman Bharat Scheme are as follows:

  • After launching across the country, the scheme will offer secondary and tertiary medical care facilities with a cover of Rs. 5 lakh.
  • Those who are eligible can avail automatic coverage. The eligibility will be measured based on the data of the Socio-Economic Caste Census (SECC).
  • In case of an emergency where the insured needs to be hospitalized, the family members don’t need to pay the medical expenses incurred in the treatment. This facility can be availed from any of the government or network private hospitals.
  • Unlike the other health insurance plans, Ayushman Bharat Scheme covers pre-existing illnesses form the day one. On the other hand, every health insurance policy comes with a definite waiting period to cover pre-existing Moreover, the scheme also offers pre and post hospitalization expense.
  • To avail, the cashless treatment at the authorized health centres, the insured or the beneficiaries need to carry a prescribed ID along with the Aadhaar Card.

What is the Eligibility Criterion for Modi Healthcare Scheme:

To avail the benefits under this scheme, the following conditions need to be met:

For Rural Areas:

  • Families with only one-room or live in ‘kuccha roof and kuccha walls’.
  • Families with no adult member aged between 16-56 years.
  • If the breadwinner of the family is a woman with no adult male member aged between 19-59 years.
  • Families with at least one differently-abled member and no abled adult member
  • Legally-released bonded labourer
  • SC/ST families
  • Manual scavenger families
  • Landless families earning the major part of their income from daily manual labour
  • Primitive tribal groups

For Urban Ares:

The government of India has prepared the below list of occupational categories of workers that are automatically eligible to avail the benefits:

  • Beggar
  • Domestic worker
  • Ragpicker
  • Hawker/street vendor/cobbler or the persons working on streets
  • Construction worker
  • Sweeper/ gardener/ sanitation worker
  • Artisan/home-based worker/ handicrafts worker / tailor
  • Mason
  • Plumber /labour/ welder/ painter/ coolie/ security guard and other head-load workers
  • Transport worker/vehicle driver/ helper to drivers and conductors/ conductor/ cart puller/ rickshaw puller
  • Washer-man/ Gate-keeper
  • Electrician/ assembler/ mechanic/ repair worker
  • Shop worker/ peon in small organization/ assistant/helper/ attendant/ delivery assistant /waiter

The eligibility criteria under this scheme can also be checked online by following the below mention steps:

  • Log on to the official website of Ayushman Bharat Scheme
  • Click on the ‘Download Beneficiary List’ tab
  • Select from the given options ‘Rural’ or ‘Urban’ as per the type of your residence
  • Provide a mobile number to receive OTP(one-time password)
  • Download the list by entering the OTP

Do Policyholders Have to Pay for Healthcare?

This scheme is fully sponsored by the government of India. The expenses incurred in the premium payment will be borne by the Central and State Governments in a particular ratio.  The total expenditure will be decided based on the current market-defined premium paid in States and Union Territories where the scheme will be introduced by various insurance service providers. Where the scheme is implemented in Trust or Society mode, the Central share of funds will be offered based on the actual expenses or premium ceiling in the predefined ratio.

Hospitalisation Process under Modi Health Insurance Scheme

As you already know that the insured or beneficiary will not be required to pay the hospitalization expenses, the government will take care of the premium expenses. The pradhan mantri health insurance offers pre and post- hospitalization expenses cover where the treatment can be availed before and after the hospitalization free of cost. The network hospitals will set up a helps desk called ‘Ayushman Mitra’ to assist the patients and will coordinate with the beneficiaries. They will check the documents and verify the eligibility at the time of enrolment.

The beneficiaries will be given a letter with a QR code to scan and demographic authentication. Furthermore, this QR code will be used to identify and verify the eligibility of the beneficiary to avail the scheme benefits.

The benefits of the AB scheme can be availed across the country and the person covered under the scheme is allowed to avail cashless facilities from any of the govt./public listed hospitals.

Which Parts of India are Covered under?

As per the government notice, 22 Indian states are selected to run the scheme on the ‘trust model’. While Delhi, Karnataka, Punjab, Kerala, and Maharashtra are yet to be included in the list. Odisha govt. has declined to be a part of this scheme.

It is Going to be the First Time for India

As India has never opted for a huge free nation-wide health insurance scheme, this will be the first time experience.  The Ayushman Bharat Health Insurance will be clubbed into two on-going centrally sponsored health schemes, namely- the RSBY (Rashtriya Swasthya Bima Yojana) and the SCHIS (Senior Citizen Health Insurance Scheme).

Ministry of Labour and Employment introduced RSBY in the year 2008 which offers cashless healthcare services with a coverage of Rs. 30,000 annually. This plan can be availed as family floater basis, where the benefits are extended to five members. It is especially of the families under below poverty line (BPL) and other categories of unorganized workers.

How will the Modicare Scheme be Implemented?

At the central level, New Delhi will act as an AB-NHPMA or Ayushman Bharat National Health Protection Mission Agency. States and Union territories will choose a dedicated State Health Agency (SHA) for the NHPM. They can use an existing society, trust, state nodal agency or not-for-profit company to implement the scheme. The scheme can also be implemented through insurance companies. The funds will be sent directly by the central government to SHA through an escrow account.

Predictable Challenges

Introducing something new always comes with lots of challenges. Ayushman Bharat Scheme also may face challenges post-implementation, which include:

  • Treatment of an illness which a hospital does not offer
  • If doctors performing unnecessary procedures
  • Authorised hospitals charging a fee for a particular treatment even if it is cashless
  • Enrolment or addition of ghost beneficiaries
  • Conversion of patients from OPD to IPD
  • Blocking of higher priced package

In a Nutshell!

A big relief comes for the poor with a Modicare scheme that has a great potential to rescue the poor from devastating health conditions. When healthcare related expenses are catastrophic for them, the scheme will surely reduce the out-of-pocket expenses. Sadly, a major part of Indians is not aware of various types of health insurance plans in India. Given that, when the healthcare expenses are equally rising with the increasing incidents of diseases, this kind of support would go a long way to enabling the underprivileged class to avail quality healthcare services.

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