What is Ayushman Bharat Health Insurance?

India has a population of 138 billion and is the world’s second most populous nation. While the nation is striding towards advanced medical technologies and cutting-edge healthcare equipment, the simultaneous escalation of healthcare expenses is alarming. Additionally, the country is looking at an estimated 30% of the population far behind on any health insurance provisions.

The problem is that rising expenses and hiked insurance expenses suggest individuals facing health scares with no financial backup to help them get premium treatments. Subsequently, in an endeavor to grant widely accessible affordable healthcare services, multiple government health initiatives were launched.

Among these initiatives, Ayushman Bharat Yojana Scheme remains the most popular. Over time, this flagship scheme has fetched more & more policyholders considering the significant and unique financial and medical perks it offers to rural and urban sections of the population below the poverty line.

However, you need to know all its nitty-gritty details before you avail of the scheme that, despite being affordable, will be a financial decision to take. This includes the eligibility criteria to apply for the scheme, its pros and cons, features, exclusions, and its edge over standard health insurance policies (if any).

What is Ayushman Bharat Yojana Scheme?

A flagship scheme from the Government of India, the Ayushman Bharat Yojana Scheme, was crafted to offer a comprehensive healthcare service to a wider range of the population that involves the financially challenged across both the rural and the urban sections.

With the vision of Universal Health Coverage (UHC) and meeting Sustainable Development Goals (SDGs) across short and long-term the Ayushman Bharat is a scheme that single-handedly handles the healthcare system from cover to cover.

To ensure an efficient & holistic approach to healthcare services, this Yojana comprises 2 components:

Health and Wellness Centres (HWCs)

The Government of India launched the Ayushman Bharat Yojana Scheme in 2018. Simultaneously, it announced building 1.5 lakhs Health and Wellness Centres (HWCs). To reach this extensive number of HWCs, the Government planned to transform the current Primary Health Centres and Sub Centres. Such HWCs would offer free diagnostics and medicines, healthcare services for non-communicable ailments, and child & maternal medical care services.

The aim of constructing these HWCs was to ensure the delivery of primary healthcare services to the entire population around the Centres, thereby expanding access to quality primary healthcare initiatives. This would also empower communities by helping them become aware of healthy lifestyle habits that can prevent the risks of chronic ailments.

Pradhan Mantri Jan Arogya Yojana (PM-JAY)

The Pradhan Mantri Jan Arogya Yojana, or PM-JAY, is the second half or element of the Ayushman Bharat Yojana Scheme. PM-JAY was crafted as a health insurance drive for the financially challenged sections of society. As of January 2023, this remains the largest insurance penetration tool globally, and an estimated 21.9 crores of beneficiaries have been verified under this drive.

Under the Ayushman Bharat PM-JAY drive, health insurance coverage of INR 5 lakhs is provided to each benefactor family per year, whose premium is paid off by the State and the Central Government in a pre-decided ratio. This coverage kicks in when a policyholder requires secondary and tertiary care hospitalization funding. This financial aid is specifically targeted at the bottom 40% of the population (10.74 crores) who have been recognized by the Socio-Economic Caste Census 2011 (SECC 2011) based on their occupational standards and financial status.

The entire Yojana, termed the Ayushman Bharat Digital Mission (ADHM), aims to boost the integration of technologies into the healthcare services front to maximize efficiency and guarantee the quality of care.

Policyholders can access and exchange their health records over their consent to avail of various advanced medical perks, like - issuing health IDs, registry of healthcare professionals, health facility registry, and health records. Subsequently,

• Over 31 crores of Ayushman Health accounts have been created
• Close to 2 lakh health facilities have been registered
• More than 7 crores of health records have been linked

(as of January 2024).

The aforementioned pointers will clarify the two-pronged holistic approach of the Ayushman Bharat Yojana Scheme towards guaranteeing a quality healthcare service for the financially challenged. However, the scheme has a few pros that will throw some light on the itching question: “how and why is the scheme so popular and nationally acclaimed?”

You will also get a glance at some of the drawbacks of the scheme. This will help you weigh out the advantages and disadvantages & then make an informed choice about whether the scheme caters to your financial and medical requirements.

What are the benefits & drawbacks of the Ayushman Bharat Health Insurance Scheme?

Pros of the Ayushman Bharat Health Insurance Scheme

• The premium for the Ayushman Bharat Yojana Scheme is paid off by the State and the Central Government in a 60-40 ratio. Thus, policyholders don’t need to pay off their premiums. This suggests mitigated financial strains involved in paying yearly premiums.
• Provides cashless access to premium healthcare services at approved hospitals.
• There is no restriction on the family size, age of the policyholder, or gender.
• There is no waiting period for pre-existing ailments. Treatments for such diseases are covered from Day 1.
• As many as 1393 procedures are covered under this scheme. The funding for these procedures includes - treatment-related costs, doctor’s fees, OT and ICU charges, Medicines, Room rent, medical consumables, and more.
• Considering that this scheme is an initiative from the Government of India, financial aid can be accessed throughout the country. With this portable health insurance coverage, beneficiaries can visit any enlisted/network hospital (public or private) in India and enjoy the cashless treatment.
• A substantial reduction in the out-of-pocket expenses for the deprived section of society while meeting their medical requirements.
• Daycare treatment expenses are also covered under this Government-rolled insurance plan.

Cons of the Ayushman Bharat Health Insurance Scheme

• The coverage amount might fall short when it comes to major treatment procedures or for those with chronic ailments requiring multiple hospitalizations across a year.
• Only 3 days of pre-hospitalization and 15 days of post-hospitalization costs are covered under the Ayushman Bharat Yojana Scheme.
• The scheme is ONLY available as a family floater health insurance policy.
• OPD expenses are not covered under the Ayushman Bharat policy.
• No tax benefits are available under Section 80D.

When a Government’s pilot healthcare project turns out to be as successful as Ayushman Bharat Yojana, it is implied that its pros weigh out its cons. A free healthcare service for the financially backward segment of the population that offers premium services for the entire family - summarizes the concept of the scheme. However, since the perks offered are multiple and advanced, along with considerable financial aid, the Government had to place a few eligibility criteria that would help determine who can avail of this policy and who can’t. These eligibility criteria vary based on whether the potential beneficiary is in a rural or urban section.

Here is a quick look at the listed eligibility criteria for the Yojana -

What are the eligibility criteria for availing of Ayushman Bharat Yojana Scheme?

RURAL

• Families with only 1 room with a kucha roof and walls
• Families with no adult members between the ages of 16 to 59.
• Households with no adult male members between the ages of 16 and 59.
• Families with disabled members and/or no able-bodied adult members.
• Scheduled Caste and/or Scheduled Tribes households.
• Households with no land, deriving a major share of their earnings from casual manual labor jobs.

URBAN

With the urban section of the population, the eligibility criteria are solely related to the occupations of the beneficiaries. Here are the 11 occupational categories of workers who are eligible for the Ayushman Bharat Yojana Scheme -

• Assembler/ Repair worker/ Electrician/ Mechanic
• Washer-man/ Chowkidar
• Ragpicker
• Beggar
• Sweeper/ Sanitation worker/ Mali
• Home-based worker/ Artisan/ Handicrafts worker/ Tailor
• Domestic worker
• Street vendor/ Cobbler/hawker / other service provider working on streets
• Helper to drivers and conductors/ Cart puller/ Rickshaw pullerTransport worker/ Driver/ Conductor
• Plumber/ Mason/ Labour/ Painter/Construction worker/ Welder/ Security guard/ Coolie and other head-load workers
• Delivery Assistant / Attendant/ WaiterShop worker/ Assistant/ Peon in small establishment/ Helper

In addition to these eligibility criteria, there is yet another inclusion in the list of potential beneficiaries under this scheme: Employee’s State Insurance Corporation or ESIC beneficiaries. As National Health Authority (NHA) enters into a partnership with ESIC, the synergy between PM-JAY and ESIC will enable ESIC beneficiaries to access the perks of Ayushman Bharat at the network hospitals. ESIC will also return that favor as a vice-versa PM-JAY and ESIC ecosystem. This plan is now being implemented as a pilot plan in some districts nationwide.

What are the Exclusions under Ayushman Bharat Yojana Scheme?

While Ayushman Bharat has successfully offered financial coverage for medical purposes for a major section of the financially deprived section, there are some exclusions under the scheme. These include individuals who cannot avail of this scheme -

1. Individuals with properly build houses.
2. Government employees.
3. Those with a Kisan card
4. People who own vehicles - 2-wheelers, 3-wheelers, or cars.
5. Individuals with a monthly income greater than INR 10,000.
6. Those with agricultural land of more than 5 acres.
7. Households that have refrigerators and landline phones.
8. Those owning a motorized fishing boat.
9. Employees of Government-run non-agricultural enterprises.

What is the difference between standard health insurance policies and  Ayushman Bharat Yojana Scheme?

The government-launched Ayushman Bharat Yojana Scheme is an affordable effort at improving the quality of life for the lion’s share of the population. However, what is undeniable is the numerous missing perks that are normally available with standard health insurance plans. The differences are clear and reflect why, in some cases, the best health insurance plans from premium insurers might be a better pick.

However, on the other hand, the Ayushman Bharat Yojana Scheme, despite missing out on the substantial perks offered by standard health insurance companies, is still a Godsend for the financially challenged sections of society. While the coverage might be just adequate, the mere presence of that financial security net is a relief for those struggling to obtain even the most fundamental medical attention.

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