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Pradhan Mantri Jan Arogya Yojana (PMJAY) UPSC NOTE

 Pradhan Mantri Jan Arogya Yojana (PMJAY)

  • PM-JAY is the world’s largest health insurance scheme fully financed by the government.

  • Launched in 2018, it offers a sum insured of Rs.5 lakh per family for secondary care and tertiary care.

  • Health Benefit Packages covers surgery, medical and day care treatments, cost of medicines and diagnostics.


Beneficiaries:

  • It is an entitlement-based scheme that targets the beneficiaries as identified by latest Socio-Economic Caste Census (SECC) data.

  • The National Health Authority (NHA) has provided flexibility to States/UTs to use non- Socio-Economic Caste Census (SECC) beneficiary family databases with similar socio-economic profiles for tagging against the leftover (unauthenticated) SECC families.

Funding:

  • The funding for the scheme is shared – 60:40 for all states and UTs with their own legislature, 90:10 in Northeast states and Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs without legislature.

Nodal Agency:

  • The National Health Authority (NHA) has been constituted as an autonomous entity under the Society Registration Act, 1860 for effective implementation of PM-JAY in alliance with state governments.

  • The State Health Agency (SHA) is the apex body of the State Government responsible for the implementation of AB PM-JAY in the State.

Challenges

  • The largest component of healthcare expenditures are government expenditures through the State and Centre and they are multiples higher than what the schemes are doing. 

  • if schemes are layered on top of a hospital-centric design, it exacerbates misallocation of government resources. 

  • In fact, there are distortions now: even a government hospital that is supposed to give you free care is now checking whether you’re authorised to receive PMJAY

  • Many hospitals perceived the PMJAY to be poorer as compared to private health insurance with reasons being poor grievance reprisal, poor claim processing and settlement, denial of reimbursement of health packages, poor rates of health packages and little information about the scheme

  • The scheme faces a low awareness level among the potential beneficiaries, especially in rural areas.

  • The scheme faces a supply-side constraint due to the uneven distribution and availability of healthcare infrastructure and human resources in the country.

  • Many states have a shortage of empanelled hospitals, especially in remote and tribal areas

  • The scheme faces a challenge of ensuring timely and adequate reimbursement of claims to the empanelled hospitals, especially private ones.

  • Many hospitals have complained of delayed payments, low package rates, high denial rates, and cumbersome processes.

  • The scheme faces a challenge of preventing and detecting fraud and abuse by some unscrupulous elements who try to exploit the scheme for personal gain.


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Learnerz IAS | Concept oriented UPSC Classes in Malayalam: Pradhan Mantri Jan Arogya Yojana (PMJAY) UPSC NOTE
Pradhan Mantri Jan Arogya Yojana (PMJAY) UPSC NOTE
Learnerz IAS | Concept oriented UPSC Classes in Malayalam
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