Pradhan Mantri Jan Arogya Yojana (PM-JAY) is a pioneering initiative to ensure that poor and vulnerable population is provided health cover. This initiative is part of the Government’s vision to ensure that its citizens – especially the poor and vulnerable groups have universal access to good quality hospital services without anyone having to face financial hardship as a consequence of using health services.

The health services covered under the programme include hospitalization expenses, day care surgeries, follow-up care, pre and post hospitalization expense benefits and new born child/children services. The comprehensive list of services is available on the website.

PM-JAY covers more than poor and vulnerable families across the country, identified as deprived rural families and occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data. A list of eligible families has been shared with the respective state government as well as ANMs/BMO/BDOs of relevant area. Only families whose name is on the list are entitled for the benefits of PM-JAY. Additionally, any family that has an active RSBY card as of 28 February 2018 is covered. There is no capping on family size and age of members, which will ensure that all family members specifically girl child and senior citizens will get coverage.

Services under the scheme can be availed at all public hospitals and empaneled private health care facilities.

PM-JAY is an entitlement based mission. There is no enrolment process. Families who are identified by the government on the basis of deprivation and occupational criteria using the SECC database both in rural and urban areas are entitled for PM-JAY.

The beneficiaries are identified based on the deprivation categories identified under the SECC (Socio-Economic Caste Census) database for rural areas and 11 occupational criteria for urban areas. In addition, RSBY beneficiaries in states where RSBY is active are also included.

A dedicated PM-JAY family identification number will be allotted to eligible families. Additionally, an e-card will also be given to beneficiary at the time of hospitalization.

At the time of admission to the hospital, beneficiaries should carry ration card or any other government recognized photo identity document like Aadhaar etc.

The scheme will have portability of benefits across the country. Beneficiary can avail services all across the implementing States/UTs.

The scheme will subsume the functional RSBY schemes – Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).

The hospital must develop a mechanism to identify PMJAY beneficiaries at the time of registration itself. However, a provision is made in the transaction management system (TMS) to register the patient, back dated, up to 5 days maximum. Hence, treatment can be facilitated to patients who have produced the card before discharge and hospital should ensure no extra money is collected from the beneficiary.

Medical and Surgical packages cannot be booked together. All surgical packages include expenditure related to pre and post-operative care. Hence, the hospital shall cancel the pre-auth and generate a new pre-auth request for required surgery. Surgical package under the scheme covers 3 days pre and 15 days post hospitalization expenses.

Minimum of 24 hours stay is required and the rationale for hospitalization should be provided by the hospital through clinical documents. The diagnosis needs to match the listed packages under PMJAY.

The hospital must develop a mechanism to identify PMJAY beneficiaries at the time of registration itself.

• • For Packages requiring pre-auth, mandatory pre-Authorization need to be sought before initiating treatment.
• • In case of emergency, telephonic pre-Authorization can be sought, and treatment can be initiated. However, all the required documentation needs to be uploaded within 24 hours.

This is the expenditure incurred by the beneficiary of the scheme up to 3 days before getting admitted in the hospital (Applicable only to the expenses made in same hospital where treatment under PMJAY is initiated). The expenditure may be related to diagnostics, consultation and medications etc. and inclusive in the package.

The hospital can register the beneficiary in the TMS when he visits hospital for the treatment. If the beneficiary needs admission, pre-auth can be raised and expenses incurred by the beneficiary till then (up to 3 days) shall be considered inclusive in the package. Incase if he does not need hospitalization or daycare procedure as under PMJAY scheme, then pre-hospitalization expenses will be borne by the patient.

It is expenses incurred by the patient from the date of discharge up to 15 days for consultation, medicines & diagnostics and post-operative care. It is covered under the package and patient should not be charged additionally. Also in case of surgery, any post-operative complication and re-admission, linked to the treatment, is to be covered under the earlier package cost.

Hospital must procure required medications and provide to the beneficiary. In case, if diagnostic evaluation and follow-up visits are needed within 15 days post discharge, it should be done free of cost by the hospital.

Yes. There is no limit of family size. The neonate will be provided care provided the benefit limit is not exhausted and the neonate is added to a family with at least one PMJAY verified beneficiary

All eligible beneficiaries can avail free services for secondary and tertiary hospital care for identified packages under PM-JAY at public hospitals and empaneled private hospitals. Beneficiaries will have cashless and paperless access to health services under PM-JAY. VLEs can charge Rs. 30 from a customer for laminated card out of which Rs 8.28 will be wallet deduction.