Ayushman Bharat Yojana – A Complete Guide to National Health Insurance Plan

Updated on: 14 Dec 2021 // 47 min read // Health Insurance
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Ayushman Bharat is a pilot insurance scheme under National Health Protection Mission (AB-NHPM) sponsored by the central government. According to Prime Minister Narendra Modi’s Independence Day speech, AB-NHPM will be launched as a free Insurance Plan on September 25, 2018, across the country.

While in the long run, the Ayushman insurance plan envisages to cover the entire population of the country; in its first phase, the Modicare would target 10.74 crore poor and economically deprived people, basis Socio-Economic Caste Census (SECC) database of 2011.

Currently, the health insurance awareness, as well as penetration, is too low in India. At least 70-80 % of the population has no significant health insurance in the country. A majority of people in India is dependent on out-of-the-pocket expenses for medical contingencies and health issues. For low-income households, medical emergencies take a toll on their lifelong savings and often result in a debt-trap and deteriorated life-conditions.

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The prime focus of Ayushman Bharat is to provide free and paperless medical insurance cover up to 5 Lakh per family per year to 10 crore poor and below poverty line households in India. Any member of the beneficiary family with no age bar can make use of the present scheme. The benefits of insurance plan would thus cater to at least 50 crore people in the country.

Ayushman Bharat Yojana Details: In Quick Points

PM Modi’s Ayushman Bharat Yojana is set to be the world’s largest sponsored insurance scheme for maximum’ number of beneficiaries ever. In its present form, AB-NHPM will subsume and merge all on-going government schemes such as Rashtriya Swasthya Bima Yojana (RSBY) and Senior Citizen Health Insurance Scheme (SCHIS).

Ayushman Bharat

The central and state governments will fund the Scheme in 60:40 ratio. Already 28 States and UTs have signed the Memorandum of Understanding (MoU) with National Health Agency (NHA) for Ayushman Bharat- NHPM. The testing for Software for the pilot project is already started in 14 states under Ayushman Bharat. Other 15 states will soon join the wagon.

The insurance packages will vary state-wise owing to the underlying differences in the cost of medical procedures in different cities. The details on packages are yet to be disclosed before the final rollout of scheme on September 25.

Facts to Know about Ayushman Bharat Scheme

1. Defined Cover of 5 lakh per family per year for beneficiaries.

The existing insurance plans sponsored by governments focus on primary health concerns such as maternity and immunization, while the PM Modi Ayushman Bharat  Scheme aims to cover most of the secondary and tertiary care procedures, including pre and post-hospitalization expenses. For extending the insurance benefits to the whole family, including women, children and the elderly, there is no cap placed on family size, and age, of the beneficiary. Any member in the family in need of medical care can utilise cover up to Rs. 5 lakh per year. The insurance benefit is available on per family basis.

2. Type of claims

For extending real-time health insurance benefits to the needy, there are no exclusions for pre-existing health conditions.  You can avail cashless benefits from empanelled hospitals. The cover would also include the cost of food for hospital-stay, medicines, diagnosis, fees of the medical professional and transport allowance for hospitalization. You do not need to pay for any of the procedures from your pocket.

3. No Waiting Period

There is no waiting period prior making the claims. From the day one of the policy you can claim the cover from all government hospitals and empanelled hospitals.

4. Benefits available pan India

Once you are listed as a beneficiary for Ayushman Bharat Scheme (basis SECC), you can seek the insurance benefits across the country from empanelled hospitals. You can avail comprehensive coverage irrespective of the nature of your job and place of living.

5. Aadhaar Card is not mandatory

Having an Aadhaar Card is not an eligibility criterion to seek benefits under Ayushman Bharat Scheme. However, you need to provide a prescribed identity proof (ID) to avail of the treatment at the empanelled hospital.

6.  Ayushman Bharat Scheme Eligibility

AB-NHPM is an entitlement based scheme that will identify the beneficiaries by deprivation criteria as listed in the SECC database 2011. The insurance beneficiaries would be recognized as D1, D2, D3, D4, D5, and D7 for rural areas; while for urban areas the beneficiary’s occupation will be determinable for entitlement. The 80 % of beneficiaries are based in rural areas, while 20 % are from Urban regions.

According to the National Health Agency, Ayushman Bharat is a no enrolment or no premium scheme. You do not need to enrol, register or pay any premium to avail the benefits under Ayushman Health Insurance Scheme.

Defined Categories for Rural Area:

  • Families living in one room kuchcha house
  • Families without an adult member between the age of 16 to 59
  • Households with only female head and no adult male member between age 16 to 59
  • Disabled member with no abled-bodied adult in the family
  • Landless households deriving income majorly from manual casual labour
  • Destitute households living without shelter, on alms, etc
  • Families involved in manual scavenging work
  • SC/ST households
  • Primitive tribal groups
  • Bonded labour released legally
  • Defined categories for urban areas

Currently, 11 occupational categories are identified for Ayushman Bharat entitlement.

  • Beggars
  • Rag-pickers
  • Domestic workers
  • Street vendors like cobblers, hawkers, etc
  • Construction workers and other head-load workers such as plumbers, masons, daily wage labourers, painters, welders, security guards, coolies, sweepers, sanitation workers and gardeners (Malis).
  • Home-based workers including artisans, handicrafts workers, and tailors
  • Transport workers like drivers, helpers, and conductors; cart pullers; rickshaw pullers
  • Shop workers, assistants, peons in small businesses, helpers, delivery assistants, attendants, waiters
  • Electricians, mechanics, assemblers, repair workers
  • Washer-men, chowkidars

Frequently Asked Questions or FAQs

1. How would I know if I am eligible for Ayushman Bharat Benefits?

Ayushman Bharat Scheme is a paperless scheme wherein an already recorded database has helped authorities identify the beneficiaries. You do not need to register anywhere to avail the benefits. Beware of the unscrupulous websites and agents who promise to help you make a beneficiary, or spreading Ayushman Bharat Registration myths online.

The mechanism of the AB-NHPM is based on the pre-gathered data. According to Indu Bhushan, CEO of Ayushman Bharat, “All the beneficiaries will receive a printed letter from Prime Minister recognizing their eligibility to avail Ayushman Bharat benefits.” The list of eligible beneficiaries will also available be with Asha workers and common service centers. You can contact them to check if your name is listed or not. The list of beneficiaries and empanelled hospitals will also be made public on the website.

2. Is there a call center or central body to contact for queries?

Yes. The call center number for Ayushman Bharat is 14555. You can check the updates on Ayushman Bharat from the official website: https://www.abnhpm.gov.in/

3. Where can I check the list of eligible Hospitals?

The final list of empanelled hospitals is yet to be released for public. The list would be made public on the official website. Besides, it is important to note here that the beneficiaries can avail benefits in both public and private empanelled hospitals. All public hospitals implementing AB-NHPM in states are deemed to be empanelled. Hospitals for Employee State Insurance Corporation (ESIC) may also be included. As for private hospitals, the invitation for joining the national health care system is open currently.

4. Is there any application procedure for Ayushman Bharat Benefits?

The enrolment for Ayushman Bharat is not required. The list of beneficiaries is according to NSES data available with authorities. Beware of fraudulent agents promising the registration for Ayushman benefits. You do not need to send any application for enrolment to the program.

5. Do I need to pay for any premium or the scheme is free?

You do not need to pay any premium to avail the benefits of the PM Ayushman Bharat scheme. The benefits are cashless as well as free from obligation to pay any premium.

6. Can I be denied the benefits if I do not have Aadhaar Card?

Aadhaar is not mandatory to avail the benefits of Ayushman scheme. In the absence of Aadhar Card, you can provide another valid identity proof (as prescribed) to claim when your name is available on the list.

7. What is the process of extending the benefit to listed families?

Basis the list of poor and BPL families, a dedicated AB-NHPM family identification number would be allotted to eligible families. All families that are eligible for RSBY cards (as on 28 February 2018) will also be eligible for Ayushman benefits. No more families would be added to this list now as per the Centre’s directive. However, names of more family members can be added, for listed families in SECC database.

8. What are the inclusions?

AB-NHPM will provide medical cover for almost all secondary care and tertiary care procedures. The health ministry has included a total of 1,354 packages, including treatment for coronary bypass, knee replacements, and stenting. To keep the costs low, the procedures are provided at 15-20 percent lower rates than Central Government Health Scheme (CGHS). Also, the treatments would be offered on a package basis to keep the costs low. It would thus vary from state-to-state.

9. What is the hospitalisation process?

The beneficiaries will not be required to pay any charges or premium for the hospitalisation expenses. Right from pre and post hospitalisation expenses, the free cover would also include, cost of secondary and tertiary procedures, travel cost, diagnosis and food costs.

Steps to avail hospitalisation benefits:

  • Visit the empanelled hospital and ask for Ayushman Mitra (AM). Each empanelled hospital has a dedicated Ayushman Mitra or Insurance friend to assist patients.
  • AM will assist and coordinate with beneficiaries. They are responsible for running Ayushman help desk, checking documents, and verifying eligibility to AB-NHPM.
  • Do carry any of the prescribed IDs to receive treatment at the hospital.
  • After the verification process, the beneficiaries will get letters with unique QR code. It will be scanned to establish demographic authentication.
  • Now you will be verified for the scheme. After the verification, you can avail free diagnosis and treatment.
  • The medical history will be recorded in the software, and you can claim further benefits without any trouble.

10. How to Apply for Ayushman Bharat Yojana if I need claim in the city of my work?

Ayushman Bharat is portable across the country. A beneficiary to the scheme is allowed to take cashless benefits from any of the public/private empanelled hospitals across the country. You only need to visit the empanelled hospitals and follow the steps discussed above.

Watch this space for more updates on Ayushman Bharat.

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