Ayushman Bharat Health Insurance: Entitlement and Eligibility (Important) (Download PDF)

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Prime Minister, in his Independence Day speech of 2018, announced launch of Ayushman Bharat-National Health Protection Scheme (AB-NHPS). National health insurance scheme will be rolled out on pilot basis in some states.

Image of National Health Protection Scheme (AB-NHPS)

Image of National Health Protection Scheme (AB-NHPS)

Image of National Health Protection Scheme (AB-NHPS)

Full-scale roll-out of project is expected to be in September end.

Who is AB-NHPS aimed at?

  • Scheme is targeted at poor, deprived rural families & identified occupational category of urban workers’ families.

  • According to Socio-Economic Caste Census (SECC) 2011 data, 8.03 crore families in rural & 2.33 crore in urban areas will be entitled to be covered under these scheme, i. e. , it will cover around 50 crore people.

  • AB-NHPS will have defined benefit cover of Rs. 5 lakh per family (on family floater basis) per year for secondary & tertiary care hospitalization.

  • It will offer benefit cover of Rs. 5 lakh per family per year.

  • It will subsume existing Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008 by UPA govt.

Who all are covered?

  • To ensure that nobody is left out (especially women, children & elderly) there will be no cap on family size & age under AB-NHPS.

  • Scheme will be cashless & paperless at public hospitals & empanelled private hospitals.

Image of Ayushman Bharat National Health Protection Misssion

Image of Ayushman Bharat National Health Protection Misssion

Image of Ayushman Bharat National Health Protection Misssion

How Will the Entitlement Be Decided?

  • AB-NHPM will be entitlement based scheme where it will be decided on basis of deprivation criteria in SECC database.

  • Beneficiaries are identified based on deprivation categories (D1, D2, D3, D4, D5, & D7) identified under SECC database for rural areas.

  • For urban areas, 11 occupational criteria will determine entitlement.

  • Rashtriya Swasthya Bima Yojna (RSBY) beneficiaries in states where it is active are included.

Rural Area Categories:

  • Different categories in rural areas include families having only one room w/kucha walls & kucha roof;

  • Families having no adult member b/w ages of 16 & 59 years;

  • Female-headed households w/no adult male member b/w ages of 16 & 59 years;

  • Disabled members & no able-bodied adult member in family;

  • SC/ST households;

  • Landless households deriving major part of their income from manual casual labour.

  • These families in rural areas having any one of following will be automatically included: households w/o shelter, destitute, living on alms, manual scavenger families, primitive tribal groups, & legally released bonded labour.

Urban Area Categories:

  • For urban areas, 11 defined occupational categories are entitled under scheme.

  • Main source of income related to household has been clarified in urban areas as beggars; rag-pickers; domestic workers; street vendors/cobblers/hawkers/other service providers working on the streets;

  • Construction workers/plumbers/masons/labor/painters/welders/security guards/coolies and other head-load workers;

  • Sweepers/sanitation workers/malis;

  • Home-based workers/artisans/handicrafts workers/tailors;

  • Transport workers/drivers/conductors/helpers to drivers & conductors/cart pullers/rickshaw pullers;

  • Shop workers/assistants/peons in small establishments/helpers/delivery assistants/attendants/waiters;

  • Electricians/mechanics/assemblers/repair workers; washer-men/chowkidars;

  • Other work/Non-work;

  • Non-work (Pension/Rent/Interest, etc. )

Hospitalisation Process under Ayushman Bharat

  • Beneficiaries will not be required to pay any charges & premium for hospitalization expenses.

  • Benefit include pre- & post-hospitalization expenses.

  • Each empanelled hospital will have ‘Ayushman Mitra’ to assist patients & will coordinate w/beneficiaries & hospital. They will run help desk, check documents to verify eligibility, & enrolment to scheme.

  • All beneficiaries will be given letters having QR codes which will be scanned & demographic authentication will be conducted for identification & to verify his or her eligibility to avail benefits of scheme.

  • Benefits of scheme are portable across country & beneficiary covered under scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across country.

Inclusions

  • AB-NHPM will cover medical & hospitalization expenses for almost all secondary care & most of tertiary care procedures.

  • Health ministry has included 1,354 packages in scheme under which treatment for coronary bypass, knee replacements & stenting among others would be provided at 15 - 20 % cheaper rates than Central Govt. Health Scheme (CGHS).

Eligibility Criteria for Beneficiary

  • There is no enrolment process in AB-NHPM as it is entitlement-based mission.

  • Families who are identified by govt. on basis of deprivation & occupational criteria using SECC database, both in rural & urban areas, are entitled for AB-NHPM.

  • Database is based on census for year 2011.

  • List of eligible families is shared w/respective state govt. as well as state level departments like ANMs, BMO, & BDOs of relevant areas.

  • Dedicated AB-NHPM family identification number will be allotted to eligible families.

  • Only families whose name is on list are entitled for benefits of AB-NHPM.

  • Families w/active RSBY cards as of 28 February 2018 will covered. No additional new families can be added under AB-NHPM.

  • Names of additional family members can be added for those families whose names are already on SECC list.

  • Official website of AB-NHPM is www.abnhpm.gov.in. One may visit site to view & download beneficiary eligibility & empanelled hospitals list as & when it gets updated.

Hospital Eligibility

  • Services under scheme can be availed at all public hospitals & empaneled private health care facilities.

  • Basic empanelment criteria allows empanelment of hospital w/min. of 10 beds, w/flexibility provided to states to further relax this if required.

  • Empanelment of hospitals under AB-NHPM will be conducted thru online portal by state govt.

  • Information about empaneled hospitals will be made available thru diff. means such as govt. websites & mobile apps.

  • Beneficiaries can call helpline number at 14555.

  • To control costs, payments for treatment will be done on package rate (to be defined by Govt. in advance) basis.

  • Hospitals w/NABH/NQAS accreditation can be incentivized for higher package rates subject to procedure & costing guidelines.

- Published/Last Modified on: September 26, 2018

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