Pradhan Mantri Jan Arogya: India’s baby step to UHC

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Jan Arogya
National Health Mission

The insurance/assurance scheme for 50 crore people, the largest Govt programme in the world, could be a game changer

In less than a month the most ambitious health scheme India – and perhaps the world – has ever seen, will be rolled out.

The world is looking on eagerly because Pradhan Mantri Jan Arogya Yojana (PMJAY) is widely touted as India’s first tentative step towards Universal Health Coverage. UHC for one of the largest populations in the world could change the very trajectory of human development indices for entire human kind.

On a day when health minister J P Nadda unveiled the final contours of the Pradhan Mantri Jan Arogya Yojana, Medibulletin takes your through the nuts and bolts of the scheme that will be launched on September 25, the birthday of RSS ideologue Deen Dayal Upadhyay.

What is PMJAY?

PMJAY is a health assurance cum insurance scheme for 10.74 crore families . Each family will get an annual health cover of Rs 5 lakh for a list of specified diseases at fixed rates. Treatment can be availed at government hospitals and all empaneled private hospitals. It will be cashless at the point of care and beneficiaries can use the PMJAY card to get the benefits.

Who are eligible?

Eligibility will be decided on the basis of data from the Socio Economic Caste Census of 2011. In a letter to states some time back outlining the implementation plan for the scheme, Union health secretary Preeti Sudan wrote: “The number of poor and vulnerable beneficiary families eligible for the scheme is proposed to be based on deprivation and occupational criteria as per Socio Economic and Cast Census(SECC) data. The scheme will be open to all States/UTs. The proposed target population is (a) families that belong to any of the 7 deprivation criteria (b) automatically included families as per SECC database for rural areas and (c) defined occupational criteria for urban areas.”

Beneficiary verification has already been completed. There is no provision for enrolment for the scheme.

What will be covered?

All life saving procedures will be covered. This includes some of the more expensive cancer care options like chemotherapy and radiotherapy. Organ transplants, though will not be covered.

Many procedures will be reimbursed only if they happen in government hospitals. Some would require pre-authorisation. These safeguards are to ensure that the scheme does not exceed budgets without any real tangible health benefits to the beneficiaries.

How will the implementation work?
Health is a state subject. So implementation will happen through the states. So far 29 states have signed MoUs with the National Health Agency for the scheme. In the 19 states where there is already a state health cover plan running, PMJAY will be in alliance with the state scheme.

The cost sharing will be between Centre and states in 60:40 ratio. However in special category states and in Jammu and Kashmir it will be 90:10. The state can decide whether to form a trust for the implementation of the scheme or whether to go through an insurance company.

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