Strengthening Ayushman Bharat PM-JAY in Response to CAG Audit Findings: MoS Health

New Delhi: The Minister of State for Health, Shri Prataprao Jadhav, shared detailed insights into the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and its operational framework. Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a flagship healthcare scheme launched by the Government of India to provide health coverage to economically vulnerable families.

The scheme offers free secondary and tertiary hospitalization services, up to Rs. 5 lakh per family per year, and is one of the largest health insurance programs globally.

Under AB-PMJAY, healthcare providers, both public and private, submit pre-authorization requests and claims for treatments provided to beneficiaries. These claims are processed by the respective State Health Agencies (SHAs) or insurance companies contracted by the SHAs. The government is currently conducting audits and studies to assess the performance of AB-PMJAY and is committed to making improvements to the scheme based on the findings of these reviews.

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The minister was responding to the question raised by Shri Vivek K Tankha about whether, in light of the Comptroller and Auditor General of India (CAG)'s report on Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), Government is considering to adopt NHS-style monitoring practices, such as requiring a General Practitioner (GP) recommendation before beneficiaries access hospital services, to enhance accountability;

He seeks to know whether AB-PMJAY could adopt a system where the government directly pays healthcare providers, inspired by the NHS model, thereby eliminating financial interactions for beneficiaries and simplifying access to services; and

Furthermore, he inquired, whether the Government will implement regular independent audits and performance reviews, incorporating best practices from the NHS, to improve transparency, resource utilization, and service delivery within the AB-PMJAY.

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Under AB-PMJAY, a network of over 29,929 hospitals has been empaneled to provide healthcare services to the scheme beneficiaries. This includes 13,222 private hospitals.

All eligible beneficiaries are entitled to free healthcare services where they can visit any impaneled hospital to avail of healthcare services across the country.

The Minister further informed that under AB-PMJAY, the empaneled hospitals raise pre-authorization and claim requests to their respective State Health Agencies regarding the treatment given to the scheme beneficiaries. Further, depending on the mode of implementation adopted by the State/UT, the State Health Agencies (SHAs) and/or insurance companies (engaged by respective SHAs) subsequently settle the claims raised by the empaneled hospitals for the treatments availed by the scheme beneficiaries.

The performance audit regarding the implementation of AB PM-JAY for the period September 2018 to March 2021 was conducted by CAG at the request of the National Health Authority (NHA).

A baseline study was commissioned by the Government of India in 2019-2020 to understand the impact of AB-PMJAY across the States of Bihar, Chhattisgarh, Gujarat, Kerala, Meghalaya, Tamil Nadu and Uttar Pradesh covering a sample of 72,636 individuals, added the Minister.