The ambit of coverage under the Union government’s health insurance scheme Ayushman Bharat has been expanded to include all senior citizens aged 70 and above, irrespective of their income. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) is now expected to benefit approximately 4.5 crore families, covering nearly six crore senior citizens. The scheme provides Rs 5 lakh in free health insurance coverage per family.
As part of the expanded benefits, eligible senior citizens will receive a new, distinct card under PMJAY. This also grants them an additional Rs 5 lakh in coverage, separate from the amount allocated to family members below the age of 70. Senior citizens enrolled in other public health insurance schemes, such as CGHS, ECHS, or Ayushman CAPF, may either continue with their existing coverage or opt for PMJAY. Those covered by private health insurance or the Employees’ State Insurance scheme are also eligible to benefit from PMJAY.
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Key features of Ayushman Bharat
Ayushman Bharat provides cashless hospitalisation benefits annually for secondary and tertiary healthcare services at empanelled hospitals. The scheme, originally a key promise in the BJP’s manifesto, has now received an additional financial outlay of Rs 3,437 crore. Like its predecessor schemes, PMJAY primarily focuses on inpatient care, offering comprehensive coverage for hospitalisations related to a wide range of secondary and tertiary needs. This includes treatment costs, procedures, medications, diagnostics, pre- and post-operative care, as well as food and accommodation.
The government claims that Ayushman Bharat is the world’s largest publicly funded health assurance scheme, providing hospitalisation for 55 crore individuals, corresponding to 12.34 crore families. All members of eligible families are covered under the scheme, which has facilitated 7.37 crore hospital admissions, with 49% of the beneficiaries being women. The government has already spent nearly Rs 1 lakh crore on the scheme.
Challenges and reforms needed
While Ayushman Bharat is a commendable welfare initiative, there is a pressing need for reforms to enhance its efficiency and address persisting challenges. Out-of-pocket healthcare expenditures in India have decreased significantly, from 62% in 2015 to approximately 47% in 2020. However, this positive development should not obscure the ongoing implementation gaps in the scheme.
Patients often face substantial medical expenses when admitted to private hospitals under PMJAY. Some private hospitals engage in dual billing, charging patients directly while also claiming reimbursement under the insurance scheme. This practice has contributed to the persistence of high medical expenses for patients covered by PMJAY.
Operational issues and private sector participation
The scheme, despite its benefits, has encountered operational challenges. One major issue raised by private hospitals empanelled in the scheme is delayed reimbursements, leading to cash flow problems and inefficiencies. This has deterred many hospitals from joining the scheme. Private hospitals have frequently voiced their concerns and called for more efficient payment processes.
Although the original PMJAY scheme included a provision to pay 1% interest on delayed payments beyond one month, this clause has not been effectively implemented. Enforcing this provision would ensure timely payments and encourage more hospitals to participate. Expanding the scheme without sufficient hospital participation would limit its effectiveness. Broader participation from private hospitals is crucial to ensuring quality healthcare reaches every corner of India.
Recommendations for improvement
The government must also rationalise the rates paid to hospitals, which should be determined based on scientific studies and linked to inflation with annual revisions. The current rates are generally considered low and require a thorough review with input from private industry representatives. Some experts also suggest that the National Health Authority (NHA) should consider allowing co-payments, enabling beneficiaries to access specialised care at high-quality hospitals for serious illnesses. Additionally, standardising the empanelment process across states and issuing smart cards for interoperability would improve the scheme’s efficiency and accessibility.