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Everything You Need to Know About the Ayushman Bharat Health Insurance Scheme

Find out everything you need to know about Ayushman Bharat Health Insurance Scheme by Government of india here on this article.VIsit Kotak Life to know more health insurance

  • 4,575 Views | Updated on: Dec 27, 2023

Healthcare has always been a point of concern for most people. With astronomical costs of medical care in the country and around the world, paying hospital bills is hard, irrespective of the income group the patient falls into. But things are even more challenging for people who belong to low-income groups. The Ayush Bharat Health Insurance Scheme was launched to ease this and bring some monetary relief.

This article talks about the Ayush Bharat Health Insurance Scheme, its eligibility criteria, and how people can benefit from it.

What is the Ayush Bharat Health Insurance Scheme?

The Ayush Bharat Health Insurance Scheme, which is now known as the Pradhan Mantri Jan Arogya Yojana or the National Health Protection Scheme, is a healthcare scheme designed for the economically backward citizens of India. The scheme was launched by Prime Minister Narendra Modi on September 23, 2018, with an aim to cover approximately 50 crore economically vulnerable people in the country. The scheme has been the largest government health care scheme in the country.

The Ayush Bharat Health Insurance Scheme broadly covers up to 40% of people in India. These are economically vulnerable classes that have been referred to as ‘poor and vulnerable’ in the Rural Development Ministry’s Socio-Economic Caste Census, published in 2011 and 2015. This includes about 10.74 crore families and 50 crore people in total.

What are the eligibility criteria for the Ayush Bharat Health Insurance Scheme?

The eligibility criteria for the Ayush Bharat Health Insurance Scheme are different for rural and urban populations.

Eligibility for rural India: The Socio-Economic Caste Census mentions 6 deprivation categories in rural areas that are eligible to avail this scheme. These are:

  • D1
  • D2
  • D3
  • D4
  • D5
  • D7

These categories include the following families:

  • Families living in scheduled caste and scheduled tribe households.
  • Families living in houses with only one room and Kucha (makeshift) walls and roof.
  • Families with no earning adult or male member between the ages of 16 and 59.
  • Families with only females with no adult member between the ages of 16 and 59.
  • Families with disabled or physically challenged people and no able-bodied adult.
  • Families without land ownership deriving their income from casual manual labour.
  • Families earning their income from manual scavenging.
  • Families with released bonded labourers.
  • Families surviving on begging.

Eligibility for urban India: The eligibility criterion in urban areas has been fixed based on the person’s occupation. These include:

  • Domestic helps
  • Sanitation workers
  • Washer men
  • Chowkidars (security guards)
  • Ragpickers
  • Waiters
  • Electricians
  • Repair workers
  • Mechanics
  • Tailors
  • Cobblers
  • Gardeners
  • Sweepers
  • Painters
  • Home-based artisans
  • Handicraft workers
  • Hawkers and others working on streets or pavements
  • Plumbers
  • Masons
  • Construction workers
  • Porters and welders
  • Transport workers: drivers, conductors, helpers, rickshaw pullers
  • Peons
  • Delivery executives
  • Shopkeepers

The following people are not eligible for the scheme:

  • People who own a two-wheeler, three-wheeler, four-wheeler, or a motorized fishing boat.
  • People with a Kisan card with a credit limit of ₹50,000.
  • People in government jobs or those employed by the government.
  • People with a monthly income over ₹10,000.
  • People who own mechanized farming equipment.
  • People who own refrigerators.
  • People living in properly built houses (Pukka houses).
  • People who work in government-managed non-agricultural enterprises.
  • People who own at least 5 acres of agricultural land or more.

What does the Ayush Bharat Health Insurance Scheme cover?

The scheme offers a cover amount of ₹5 lakhs for each family. This includes cashless hospitalization coverage. The scheme is offered to the entire family with no restrictions on the maximum or the minimum number of members. There is also no waiting period for pre-existing illnesses. Critical illnesses covered in the plan include:

  • Prostate cancer
  • Double valve replacement
  • Coronary artery bypass grafting
  • Pulmonary valve replacement
  • Anterior spine fixation
  • Carotid angioplasty with stent
  • Laryngopharyngectomy with gastric pull-up
  • Skull base surgery
  • Tissue expander for disfigurement following burns

In addition to this, the scheme covers the following kinds of expenses:

  • Up to 3 days of Pre-hospitalization expenses
  • Up to 15 days of post-hospitalization expenses
  • Medical examination, doctor’s consultation and treatment of disease
  • Medicines
  • COVID-19 treatment
  • Food
  • Accommodation
  • Medical implant services
  • Non-intensive and intensive care procedures
  • Diagnostic and laboratory expenses,

The scheme does not include the following:

  • OPD expenses
  • Cosmetic treatments
  • Fertility procedures
  • Organ transplants
  • Drug rehabilitation programmes
  • Individual diagnostics for evaluation

How to enrol in the Ayush Bharat Health Insurance Scheme?

There is no separate application process to enrol for the scheme. People who are eligible are enrolled in the scheme automatically. However, individuals who wish to avail the scheme need to check their eligibility. There are two ways to do this:

- They can visit the official government website: https://www.pmjay.gov.in/

- They can call the helpline number: 14555 or 1800-111-565

In either of the methods, a One-Time Password (OTP) will be sent to the person’s mobile number for verification, after which the person can enter their name, mobile number, ration card number, or the Rashtriya Swasthya Bima Yojna number to confirm their eligibility.

How can people use the Ayush Bharat Health Insurance Scheme in their hour of need?

Individuals can directly go to an empanelled hospital. There are people known as Arogya Mitras who help with the admission process. Arogya Mitras are stationed at every empanelled hospital. Hospitals use the patient’s Aadhar card to confirm their identification and eligibility. Eligible families have been given a letter that contains a QR code. The patient needs to carry this letter with them. The Arogya Mitras or the hospital will scan the QR code. After the verification is complete, the hospitals admit the person or provide them with the necessary medical aid. The treatment is provided as per the coverage of ₹5 lakhs, and there is no requirement of any cash payments. The entire process is cashless.

The money for the treatment is paid to the hospital by the state and central government in a 40:60 ratio.

What are the benefits of the Ayush Bharat Health Insurance Scheme?

There are many benefits of the Ayush Bharat Health Insurance Scheme, such as:

1.It offers cashless treatment:The patient can be treated at an empanelled hospital without having to pay any cash. The treatment is entirely cashless. This removes the hassles of applying for a claim later.

2.It has empanelled hospitals all over India: Patients can use the scheme anywhere in the country at their nearest empanelled hospital.

3.It offers a health cover of up to Rs. 5 lakhs: The cover of ₹5 lakhs can help low-income groups cover health care expenses without having to worry about the costs. There are no premiums charged, so these families stay protected without incurring any expenses.

4.It covers a wide variety of treatments: Medical issues such as cardiac problems, kidney problems, Covid-19 treatment, cancer, etc. can all be treated under the scheme.

5.It covers any pre-existing diseases: The scheme also covers pre-existing illnesses without a waiting period.

6.It covers a large number of people: The scheme covers up to 50 crore people and 10 crore families. This makes up 40% of the population of the country.

7.It covers the entire family: The entire family can be covered under the same scheme. There is no restriction on the number of members.

8.It covers senior citizens, children, and women: There is no need for a separate cover for women, senior citizens, or children. The Ayush Bharat Health Insurance Scheme covers all family members.

9.It offers monetary relief to economically vulnerable groups: Lower-income groups can get the right medical attention at no costs. This improves their health and standard of living.

Why is health insurance important?

Health insurance is vital to cover the costs of medical expenses. While the government offers the Ayush Bharat Health Insurance Scheme for the poor, other income groups also require health insurance. Thankfully, there are many affordable and comprehensive health plans available in the market.

Kotak Life offers the Kotak Health Shield plan that provides:

  • Cancer Shield
  • Cardiac Shield
  • Livo Shield
  • Neuro Shield

The plan also offers:

  • Daily hospitalization cash benefit
  • Waiver of premium on the diagnoses of a minor condition
  • Income benefit on the diagnoses of a major condition

To sum it up

The Ayush Bharat Health Insurance Scheme is a noteworthy step by the government to extend the privilege of health insurance to those who cannot afford it. The scheme has helped many families so far and is expected to aid many others in the future. This is bound to contribute to the growth and development of the country too.

- A Consumer Education Initiative series by Kotak Life

Amit Raje
Written By :
Amit Raje

Amit Raje is an experienced marketer who has worked in various Fintechs and leading Financial companies in India. With focused experience in Digital, Amit has pioneered multiple digital commerce in India. Now, close to two decades later, he is the vice president and head of the D2C business department. He masters the skill of strategic management, also being certified in it from IIMA. He has challenged his challenges and contributed his efforts in this journey of digital transformation.

Amit Raje
Reviewed By :
Prasad Pimple

Prasad Pimple has a decade-long experience in the Life insurance sector and as EVP, Kotak Life heads Digital Business. He is responsible for developing user friendly product journeys, creating consumer awareness and helping consumers in identifying need for life insurance solutions. He has 20+ years of experience in creating and building business verticals across Insurance, Telecom and Banking sectors

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