Ayushman Bharat health insurance – Details, Eligibility, Coverage

Ayushman Bharat health insurance – All you wanted to know!

Roboadviso     Consumer Awareness     Posted On, Sun 2nd September, 2018     No comments

What is the Ayushman Bharat health insurance?

During his 2018 Independence Day speech from the Red Fort, Shri Narendra Modi, the Prime Minister of India, declared the commencement of the Ayushman Bharat-National Health Protection Scheme, abbreviated as AB-NHPS. The prime minister stated that this new national health insurance plan will be launched in some states on a pilot basis. The scheme is estimated to be launched on a full scale by the end of September 2018.

Presented below are some details of the AB-NHPS sourced from different government websites.

Who will be the recipients of the Ayushman Bharat-National Health Protection Scheme?

The new health policy is aimed to serve deprived and poor rural families as well as identified occupational group of urban workers and their families. Thus, according to the 2011 SECC (Socio-Economic Caste Census) data, more than 2.30 crore families in urban areas and over 8 crore in rural places will be eligible for the new health insurance scheme. This means that the policy will broadly cover about 50 crore Indians.

The benefit cover defined under the AB-NHPS is around INR 5 lakhs per year per rural/urban family on the basis of a family floater, for tertiary and secondary care hospitalization. The scheme will provide an insurance coverage of INR 5 lakhs per year per family. It is meant to subsume the current RSBY (Rashtriya Swasthya Bima Yojana) established by the UPA government in 2008.

What are the parameters for deciding the eligibility?

The AB-NHPM is designed to be an entitlement based health insurance policy where the coverage will be determined as per the deprivation standards mentioned in the SECC database. The identification of beneficiaries is done on the basis of the deprivation groups, i.e., D7, D5, D4, D3, D2, and D1, elicited for rural areas in the SECC database. In case of urban regions, the entitlement will be decided on the basis of the eleven occupational criteria. Additionally, the beneficiaries of the RSBY/Rashtriya Swasthya Bima Yojna in states where the old scheme is active are also taken into account.

Urban area groups: 11 occupational categories in urban areas have been identified for entitlement under the new health scheme. The primary income source associated to households has been elucidated in urban regions as cobblers/street vendors/hawkers/other types of service providers working on the urban streets; sanitation workers/ sweepers/ malis; rag-pickers; beggars; domestic workers; transport workers/ conductors/ drivers/ helpers to conductors and drivers/ rickshaw pullers /cart pullers; plumbers/ construction workers/ masons/ painters/ labor/ welders/ coolies/ security guards/ and other workers carrying head-load; mechanics/ electricians /repair workers/ assemblers; handicrafts workers/ home-based workers/artisans/ tailors; chowkidars/ washer-men; assistants/ shop workers/ helpers/ peons in small offices or establishments/ delivery assistants/ waiters/ attendants; non-work (rent/pension/interest, etc.); and other work/non-work.

Rural area groups: The various categories entitled in rural regions include families with just 1 room with kucha roof and kucha walls; households headed by a female with no adult male family member aged between 16 and 59 years; families that do not have any adult member aged between 16 and 59 years; ST/SC households; families with not even one able-bodied adult member and/or families with disabled members; and landless workers/households who earn a majority of their income via casual manual labor. There will also be automatic inclusion of families living in rural areas that fall under any of the following categories, i.e., destitute, households without a roof/shelter, living on alms, primitive tribal groups, manual scavenger families, and legally released bonded labor.

Who will be offered coverage under AB-NHPM

In order to make sure that no one gets left out from taking advantage of the scheme, particularly the elderly, women, and kids), no cap is placed on the size of the family and age under the health insurance scheme. The plan will be paperless and cashless at private empanelled hospitals and public hospitals.

What about the inclusions?

The health insurance scheme will pay for hospitalization and medical expenses for nearly all of secondary care and a major section of tertiary care medical procedures.  The ministry of health has put in over 1,350 packages in the policy and such packages include treatments for knee replacements, coronary bypass, and stenting, etc., at a rate that is cheaper by 15 to 20 percent as compared to the CGHS/Central Government Health Scheme rates.

What is the process of hospitalization?

The beneficiaries of AB-NHPM will not need to pay the premium or any charges for expenses related to hospitalization. The benefits also consist of post and pre-hospitalization costs.

Every hospital that is empanelled will consist of an ‘Ayushman Mitra’ to help the entitled patients and will carry out the work of coordination between the hospital and the beneficiaries. They will check the eligibility and verify the documents, operate a help desk, and assist in enrolling for the scheme.

Additionally, all beneficiaries will be provided with letters consisting of QR codes that will be scanned, a demographic validation will be done for purpose of authentication and identification, and to verify the person’s eligibility for availing the coverage provided under the AB-NHPM.

The benefits and coverage of the health policy comes with portability across India. Thus, a person entitled to coverage under the policy will be permitted to avail of cashless treatments from any private empanelled or public hospitals located across the nation.

What are the different eligibility criteria for AB-NHPM?

The AB-NHPM does not come with any kind of enrolment process since its very basis is entitlement driven. Families that the government has identified according to their deprivation levels and occupational criteria on the basis of the data of the SECC, both in urban and rural areas, can avail the benefits of the health scheme. The current SECC database has information gathered during the 2011 census.

A list of families who are eligible has been shared by the central government with the state governments in which those families reside. The list has also been shared with different state departments such as BMO, ANMs, and BDOs of associated areas. Eligible families will be given a dedicated family identification AB-NHPM number and only those families with their name on the list will be eligible to receive health coverage under the new scheme.

Moreover, families with RSBY cards that are active as of Feb 28, 2018, will also be entitled to receive AB-NHPM benefits. There can be no addition of new families into the health scheme. However, families who are already featured in the SECC list have the option of adding the names of more family members.

AB-NHPM’s official website address is www.abnhpm.gov.in. Individuals can open the website to check and download the eligibility list of beneficiaries as well as the list of empanelled hospitals, whenever they are uploaded or updated on the site.

Eligibility for care at hospitals

Different services and benefits provided under the AB-NHPM can be used by eligible beneficiaries at all private empanelled health care centers and public hospitals. Additionally, the basic criteria for empanelment permit the empanelment of a healthcare facility or hospital that has at least 10 beds, and states have been offered sufficient flexibility to relax this requirement even further if they deem so.

Under the new health scheme, the empanelment of different hospitals will be carried out via an online portal run by respective state governments. Data about different empanelled hospitals can be access via varied options such as mobile apps and government portals/websites. The entitled families can also use 14555, the helpline number of AB-NHPM.

It order to make it more cost effective, the payments for hospitalization and other treatments will be carried out as per package rate basis. This rate will be pre-defined by the government. However, different healthcare facilities with NQAS/NABH accreditation may be offered incentives of higher rates, but such rates will be subject to expense and process guidelines.


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