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AYUSHMAN BHARAT-NATIONAL HEALTH PROTECTION MISSION (AB-NHPM)

Also named as PM-JAY: Pradhanmantri Jan Arogya Yojana


Under Ministry of Health and Family Welfare, Govt. Of India
Under its ambit AB-PMJAY’s prime focus is to reduce the financial burden on poor and vulnerable groups
arising out of catastrophic hospital episodes and to ensure their access to quality health care. PM-JAY
seeks to accelerate India’s progress towards achievement of Universal Health Coverage (UHC) and
Sustainable Development Goal - 3 (SDG3).

PMJAY will provide financial protection (Swasthya Suraksha) to 10.74 crore poor, deprived rural families
and identified occupational categories of urban workers’ families as per the latest Socio-Economic Caste
Census (SECC) data (approx. 50 crore beneficiaries). It will have offer a benefit cover of Rs. 500,000
per family per year (on a family floater basis).

PM-JAY will cover medical and hospitalization expenses for almost all secondary care and most of
tertiary care procedures. PM-JAY has defined 1,350 medical packages covering surgery, medical and
day care treatments including medicines, diagnostics and transport.

To ensure that nobody is left out (especially girl child, women, children and elderly), there will be no cap
on family size and age in the Mission. The scheme will be cashless & paperless at public hospitals and
empanelled private hospitals. The beneficiaries will not be required to pay any charges for the
hospitalization expenses.

The scheme is an entitlement based, the beneficiary is decided on the basis of family being figured in
SECC database. When fully implemented, the PM-JAY will become the world’s largest government
funded health protection mission.

AB-PMJAY is an ‘Entitlement Based Scheme’ unlike the RSBY which operated as ‘Enrollment Based
Scheme’, thereby taking care of the low enrolment gaps of entitled and identified beneficiaries. Every
family figuring in defined SECC database will be entitled to claim benefit under the scheme.

1. The objective of the scheme is:


a. To reduce catastrophic Health Expenditure
b. To improve access to quality health care. ( Incentivized package rates are given for
aspirational districts to improve access in Tier 2 & 3 cities)
c. To reduce unmet needs
d. To reduce out of pocket expenses. (Primary care including screening and diagnostics for
Non-Communicable diseases (NCD) including cost of medicines will be provided by >
1.50 lacs health and wellness centers AND secondary and tertiary care IPD costs will be
covered in AB-NHPM).
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Rajnish Ranga,AM, Reference: Model Tender Documents Vol: I,II,III 05th Feb 2019
2. Who all are entitled for coverage?
MoHFW has decided to use latest Socio-Economic Caste Census (SECC) data as a
source/base data for validation of beneficiary families under the AB-
NHPM. Based on SECC
data, number of families in each State, that will be eligible for central subsidy under th
e ABNHPM, will be identified. The categories in rural and urban that will be covered u
nder ABNHPM are given as follows:
• For Rural Total deprived Households targeted for ABNHPM
who belong to one of the six
deprivation criteria amongst D1, D2, D3, D4, D5 and D7:
• Only one room with kucha walls and kucha roof (D1)
• No adult member between age 16 to 59 (D2)
• Female headed households with no adult male member between age 16 to
59 (D3)
• Disabled member and no able SC/ST households (D5)
• Landless bodied adult member (D4)
• households deriving major part of their income from manual casual labour (D7)
• Automatically included Households without shelter Destitute/ living on alms
Manual scavenger families Primitive tribal groups Legally released bonded labour
3. For Urban Occupational Categories of Workers • Rag picker • Beggar • Domestic worker •
Street vendor/ Cobbler/hawker / Other service provider working on streets • Construction worker/
Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and another head-load worker
• Sweeper/ Sanitation worker / Mali • Home-based worker/ Artisan/ Handicrafts worker / Tailor
• Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw
puller • Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant /
Attendant/ Waiter • Electrician/ Mechanic/ Assembler/ Repair worker • Washer-man/ Chowkidar
4. To ensure that nobody is left out (especially girl child, women, children and elderly), there will be
no cap on family size and age in the Mission. The scheme will be cashless & paperless at public
hospitals and empanelled private hospitals.
5. The beneficiaries will not be required to pay any charges for the hospitalization expenses. The
benefit also includes pre and post-hospitalization expenses.
6. The States have the option to run the scheme in Insurance Model, Trust Model (Govt assured)
or Hybrid Model (Insurance + Trust).
a. In Insurance Model the price of premium will be discovered by tender process.
b. The scheme will subsume the centrally sponsored schemes (RSBY & Sr Citizen Health
Insurance Scheme). States may have flexibility to add more enrolments and entitlements
on their cost.
7. The scheme has been designed on
a. Cashless basis- where payment will be made to hospitals called as Empaneled Health
Care Providers.
b. Paper less basis- where digital records will be enabled in System/Portal at NHA Portal
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and TMS (Transactional Management System).


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Rajnish Ranga,AM, Reference: Model Tender Documents Vol: I,II,III 05th Feb 2019
c. Presence less basis- through digital identities and remote authentication mechanisms
(BIS-Beneficiary Identification System).
d. Benefits of the scheme are Portable across the country from any empanelled hospital
within or outside State under the Portability Benefits.
8. Insurance Companies will participate in these schemes on the basis of their Board approved
underwriting policy, their risk appetite and considering the adequacy of capital for such
participation.
a. The Scheme is designed to consider only claim cost and marginal 10 to 15% (20% in
case of State category ‘A’) management expenses. If the experience of scheme is
profitable more than these ratios the amount is required to be returned to the State. Thus
profits and adequate margins are not expected from these schemes.
b. The requirements of the scheme are large enough to be covered in these pre-defined
management expenses. (Project office in State, District offices in each district, MBBS
doctor in every state, cost of hardware and software of public hospitals, costs related to
MIS, Ayushman Mitras and hospital training, connectivity with National Stack etc).
c. The Regulation for Solvency requires 50% additional assets for any business growth &
assumed liabilities.
d. The premium recoveries not made good for 365 days are not considered in assets
valuation for determining solvency margins.
e. Additional capital either by equity of by alternate capital is thus must for participating in
this scheme.
9. The scheme does not consider clusters within the State. The unit of insurance remains one State.
However, to prefer the PSUs the state may be divided in 2 Zones and in case the PSU remains
a higher bidder (but lowest amongst all PSUs) and agrees to the rate of L1 one of the zone (not
preferred by L1) will be offered to PSU.
10. Sharing pattern of the Scheme will be in 60:40 for Central and State Government respectively.
However for North Eastern States and 3 Himalayan States ( J&K; HP; UK) this ratio will be 90:10
and for UTs without Legislature Central Government’s share will be 100%.
11. Central Government is developing ‘National Stack’ (IT Platform) for a integrated health
information system as a digital framework usable by Central & State Governments across Public
and Private Sectors to effectively run this scheme on nationally shared digital infrastructure. Its
design considers
a. Both Provider Registry and Beneficiary Registry
b. Policy and Claim Engine for auto adjudication of claims
c. Fraud Management Service to detect frauds
d. Data Analytics
e. Digital Health ID
f. Federated Personal Health Records framework.
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Benefits of PM-JAY
Beneficiary Level

• Government provides health insurance cover of up to Rs. 5,00,000 per family per year.
• More than 10.74 crore poor and vulnerable families (approximately 50 crore beneficiaries)
covered across the country.
• All families listed in the SECC database as per defined criteria will be covered. No cap on family
size and age of members.
• No entry or exit age restrictions will apply to the members
of a Beneficiary Family Unit; and
• No member of a Beneficiary Family Unit will be required to undergo a pre-
insurance health check-up or medical examination before their eligibility as a Beneficiary.
• Unit of coverage under the Scheme shall be a family and each family for this Scheme
shall be called a AB-NHPM Beneficiary Family Unit, which will comprise all members in
that family. Any addition in the family will be allowed only as per the provisions
approved by the Government.
e. The presence of name in the beneficiary list shall be the proof of eligibility of the
Beneficiary Family Unit for the purpose of availing benefits under this Insurance
Contract and a Policy issued pursuant to this Insurance Contract.
• Priority to girl child, women and senior citizens.
• Free treatment available at all public and empaneled private hospitals in times of need.
• For availing select treatment in any empanelled hospitals, preauthorization is required.
• Covers secondary and tertiary care hospitalization.
• 1,350 medical packages covering surgery, medical and day care treatments, cost of medicines
and diagnostics.
• Hospitalisation expenses benefits.
• Day care treatments available.
• Follow-up care benefits.
• All pre-existing diseases covered from the first day of the start of the policy. Hospitals cannot
deny treatment.
• Pre and Post Hospitalisation expenses: Expenses incurred for consultation, diagnostic
tests and medicines before the admission of the patient in the same hospital and cost
of diagnostic tests and medicines and up to 15 days of the discharge from the hospita
l for the same ailment/ surgery.
• New born child/ children benefits.
• Cashless and paperless access to quality health care services.
• Hospitals will not be allowed to charge any additional money from beneficiaries for the
treatment.
• Eligible beneficiaries can avail services across India, offering benefit of national portability. Can
reach out for information, assistance, complaints and grievances to a 24X7 helpline number –
14555
• Beneficiary Identification:
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The beneficiaries will be identified using Aadhaar and/or Ration Card and / or any other
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specified identification document produced by the beneficiary at the point of contact.

Rajnish Ranga,AM, Reference: Model Tender Documents Vol: I,II,III 05th Feb 2019
Once successfully identified, the beneficiary will be provided with a print of AB-NHPM
e-card which can be used as reference while availing benefits.
• Portability of Benefits
a. The benefits of AB-
NHPM will be portable across the country and a beneficiary covered
under the scheme will be able to get benefits under the scheme across the country at
any EHCP.
b. Package rates of the hospital where benefits are being provided will be applicable
while payment will be done by the insurance company that is covering the beneficiary
under its policy.
c. The Insurer is required to honor claims from any empanelled hospital under the
scheme within India and will settle claims within 30 days of receiving them.
d. To ensure true portability of AB-NHPM, State Governments shall enter into
arrangement with ALL other States that are implementing AB-NHPM for allowing
sharing of network hospitals, transfer of claim & transaction data arising in areas
beyond the service area.
Health System

• Help India progressively achieve Universal Health Coverage (UHC) and Sustainable Development
Goals (SDG).
• Ensure improved access and affordability, of quality secondary and tertiary care services through
a combination of public hospitals and well measured strategic purchasing of services in health care
deficit areas, from private care providers, especially the not-for profit providers.
• Significantly reduce out of pocket expenditure for hospitalization. Mitigate financial risk arising out
of catastrophic health episodes and consequent impoverishment for poor and vulnerable families.
• Acting as a steward, align the growth of private sector with public health goals.
• Enhanced used to of evidence based health care and cost control for improved health outcomes.
• Strengthen public health care systems through infusion of insurance revenues.
• Enable creation of new health infrastructure in rural, remote and under-served areas.
• Increase health expenditure by Government as a percentage of GDP.
• Enhanced patient satisfaction.
• Improved health outcomes.
• Improvement in population-level productivity and efficiency
• Improved quality of life for the population

AB-NHPM: In Alliance with the States

• The Scheme is principle based rather than rule based, allowing States enough exhibility in terms of
packages, procedures, scheme design, entitlements as well as other guidelines while ensuring that
key benefits of portability and fraud detection are ensured at a national level.
• States will have the option to use an existing Trust/Society or set up a new Trust/Society to
implement the Scheme as State Health Agency and will be free to choose the modalities for
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implementation. They can implement the Scheme through an insurance company or directly
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through the Trust/Society/Implementation Support Agency or a mixed approach.

Rajnish Ranga,AM, Reference: Model Tender Documents Vol: I,II,III 05th Feb 2019
AB-NHPM: Home grown architecture, state of the art IT

• The Scheme will run on a state of the art IT system with inbuilt intelligence and data processing
capabilities for detection of fraud and misuse as well as providing a well-dened completely online
empanelment, complaint and grievance redressal and tracking mechanism.
• The National Health Agency has signed a MoU with Government of Telangana to customize and
expand the existing State scheme platform in a way amenable for all States and Union Territories.
States continue to have an option with regards to hosting and customizing existing platforms.

AB-NHPM: Aiding the States

• NHA will provide full support and leadership of the program and has issued detailed operational
guidelines as guiding posts for the Scheme to the States. NHA will continue to engage productively
with the States to enhance their capacities. It will also foster co-ordination and convergence
with other similar schemes being implemented by the Government of India and State
Governments.
• The States will have to ensure that cabinet approvals are undertaken as quickly as possible and an
MoU is signed between the NHA and the State Health Department. Budgetary allocations need to
be made suitably as per the Centre - State sharing pattern in vogue.
• A District Implementation Unit (DIU) will also be required to support the implementation in every
District included under the Scheme.
• NHA will continue to update the evolving guidelines and model documents on http://pmrssm.gov.in

Filing Guidelines on Product as per IRDAI:


Approval of Premium and Terms and Conditions of Cover by IRDAI:

a. The Insurer shall, if required by the Health Insurance Regulations, obtain IRDAI's
approval for the Premium and the terms and conditions of the Covers provided under
this Insurance Contract under the File & Use Procedure prescribed in the Health
Insurance Regulations, within 75 days of the date of execution of this Insurance Contract.

b. The Insurer undertakes and agrees that it shall not:


(i) file an application with the IRDA for approval of the revision, modification or
amendment of the Premium for or the terms and conditions of or for the withdrawal of any
or all of the Covers; or
(ii) revise, modify, amend or withdraw any or all of the Covers, whether with or
without the IRDA's approval under the Health Insurance Regulations, at any time
during the Term of this Insurance Contract.
(iii) The Insurer hereby irrevocably waives its right to seek the IRDA's approval for the
revision, modification, amendment or withdrawal of any or all of the Covers under
this Insurance Contract by filing an application under the File & Use Procedure.
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Rajnish Ranga,AM, Reference: Model Tender Documents Vol: I,II,III 05th Feb 2019
Exclusions to the Policy

The Insurer shall not be liable to make any payment under this policy in respect of any
expenses whatsoever incurred by any Beneficiary in connection with or in respect of:
1. Conditions that do not require hospitalization: Condition that do not require
hospitalization and can be treated under Out Patient Care. Out Patient Diagnostic, unless
necessary for treatment of a disease covered under Medical and Surgical procedures or
treatments or day care procedures (as applicable), will not be covered.
2. Except those expenses covered under pre and post hospitalisation expenses, further
expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic
purposes only during the hospitalized period and expenses on vitamins and tonics etc.
unless forming part of treatment for injury or disease as certified by the attending physician.
3. Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure,
filling of cavity, root canal including wear and tear etc. unless arising from disease, illness or
injury and which requires hospitalisation for treatment.
4. Congenital external diseases: Congenital external diseases or defects or anomalies,
Convalescence, general debility, “run down” condition or rest cure.
5. Fertility related procedures: Hormone replacement therapy for Sex change or treatment
which results from or is in any way related to sex change.
6. Drugs and Alcohol Induced illness: Diseases, illness or injury due to or arising from use,
misuse or abuse of drugs or alcohol or use of intoxicating substances, or such abuse or
addiction
7.Vaccination:Vaccination, inoculation or change of life or cosmetic or of aesthetic
treatment of any description, plastic surgery other than as may be necessitated due to an
accident or as a part of any illness. Circumcision (unless necessary for treatment of a
disease not excluded hereunder or as may be necessitated due to any accident),
8. Suicide: Intentional self-injury/suicide
9. Persistent Vegetative State.

Oriental is servicing this Policy under two regions:


1. State of Gujarat: Mix Model: Limit of Liability: Rs. 50,000/-
2. Daman & Diu/Dadar & Nagar Haveli: Insurance Model: Rs. 5,00,000/-
Both the Products are separately filed with the Regulator
For detailed terms and conditions, coverages and other guidelines:
Please refer Model Tender Documents: Volume-I, II, III
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Rajnish Ranga,AM, Reference: Model Tender Documents Vol: I,II,III 05th Feb 2019

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