ABOUT PM-JAY. A cover of Rs. 5 lakh per family per year for secondary and tertiary care

Transcription

1 ABOUT PM-JAY A cover of Rs. 5 lakh per family per year for secondary and tertiary care crore poor & vulnerable families in India and lakh families of Gujarat entitled as per SECC No cap on family size, age or gender All pre existing conditions are covered. The benefit cover will include pre & post hospitalization expenses Cashless and paperless treatment in case of hospitalization Benefits will be portable across the country in all public or empaneled private hospitals PM-JAY was launched by Hon ble Prime Minister on 23 rd September 2018 from Ranchi, Jharkhand 1

2 Target Group for Rural Total deprived Households targeted, who belong to one of the six deprivation criteria amongst D1, D2, D3, D4, D5 and D7: D1: Only one room with kucha walls and kucha roof D2: No adult member between age 16 to 59 D3: Female headed households with no adult male member between age 16 to 59 D4: Disabled member and no able-bodied adult member (D4) D5: SC/ST households (D5) D7: Landless households deriving major part of their income from manual casual labour Automatically included- Households without shelter Destitute/ living on alms Manual scavenger families Primitive tribal groups 2 Legally released bonded labour

3 Target Group for Urban Occupational Categories of Workers 1. Rag picker 2. Beggar 3. Domestic worker 4. Street vendor/ Cobbler/hawker / Other service provider working on streets 5. Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and another head-load worker 6. Sweeper/ Sanitation worker / Mali 7. Home-based worker/ Artisan/ Handicrafts worker / Tailor 8. Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller 9. Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter 10. Electrician/ Mechanic/ Assembler/ Repair worker 11. Washer-man/ Chowkidar 3

4 IMPLIMENTATION of AB-PMJAY Target Beneficiaries: Around lakh families (Rural lakh and Urban lakh) as per SECC database. Collection & capturing of Aadhar no., RSBY, MA/ MAV number and mobile number. Hospitalization Cover: Cashless health cover of Rs.5 lakh per family per year. Up to Rs.50,000/- --- Insurance base From Rs.50,001/- to Rs. 5,00,000/- ---Assurance base The Oriental Insurance Company is selected in Gujarat with the premium rate of Rs /family/year.

5 OBTAINING CARE UNDER PRADHAN MANTRI JAN AROGYA YOJANA Patient Hospitalization Beneficiary Identification &Registration Pre-Authorization Request & Approval Treatment Discharge Claim Request & Settlement Confirm person is an eligible Beneficiary under PMJAY using software Confirm identity preferably through Aadhaar Hospital selects package, checks balance Submits supporting evidence required for treatment Discharge summary and post treatment evidence submitted Electronic payments Beneficiary feedback 5 5 7

6 Empanel Hospitals AB-PMJAY Empanel Hospitals as on 12/03/19 Sr.No District Private Public Grand Total 1 AHMADABAD AMRELI ANAND ARVALLI BANAS KANTHA BHARUCH BHAVNAGAR BOTAD CHHOTAUDEPUR DANG DEVBHUMI 11 DWARKA DOHAD GANDHINAGAR GIR SOMNATH JAMNAGAR JUNAGADH AB-PMJAY Empanel Hospitals as on 12/03/19 Sr.No District Private Public Grand Total 17 KACHCHH KHEDA MAHESANA Mahisagar MORBI NARMADA NAVSARI PANCH MAHALS PATAN PORBANDAR RAJKOT SABAR KANTHA SURAT SURENDRANAGAR TAPI VADODARA VALSAD Grand Total

7 Gujarat s performance Ranking as on 12 th March, nd rank- (2,03,235) Claim Amount- 1 st rank (Rs Cr.) Pre Authorization No.- 3rd rank (2,63,560) Pre authorization Amount- 1 st rank- (Rs Cr.) Golden Card generated - 2 nd Rank (40,43,541) Hospital empanelled 3,081 7

8 Gujarat s initiatives Multiple surgical treatments- 100%, 50% 25% of the package rate. 10% extra package rates to NABH Accrediated Hospitals. Rs Transportation charge to beneficiaries. Rs. 100 per visit - all ASHAs for claiming in Public hospital. Rs. 5 - ASHA & Rs Operators of Village Computer for card generation. Rs. 5 - ASHA & Rs Operators of Common Service Centres (CSCs) for card generation. 25% of claim amount - incentive for public hospital staff. 8

9 Commissionerate of Health, Family Welfare, Medical Services & Medical Education, Gandhinagar, Govt. of Gujarat Toll free

10 Objective of the scheme:- To improve access of beneficiaries to quality tertiary medical and surgical care. To provide the treatment of identified lifethreatening diseases. To provide an opportunity to the beneficiaries to select hospitals of his/her choice from both Private and Government hospitals for cashless hospitalization and treatment. 10

11 Beneficiaries:- MA Yojana:- BPL (As per the list of Rural and Urban development department). MA Vatsalya Yojana:- Families having an annual income up to Rs lakh, All Urban & Rural ASHA, Reporters Fix pay employees of class-3 & 4 appointed by state government U-Win card holders. 11 Senior citizens of those families with annual income up to Rs. 6 lakh

12 Milestone of the Scheme 04/09/2012 Mukhyamantri Amrutam MA Yojana was launched for BPL of the state. Initially, 472 procedures had been prescribed for the treatment of catastrophic illness. 01/06/ procedures such as plastic surgery procedures in burns, fistula repair in kidneys, dialysis procedures, and fractures in Polytrauma were included. So total 544 procedures had been decided for catastrophic illness. 15/08/2014 Based on feedback from various stakeholders, the Scheme was extended to all the females and their children (below the age of 21 years) belonging to the families having an annual income less than Rs lakh per annum names as Mukhyamantri Amrutam MA Vatsalya by the State Government 12

13 Conti 26/03/2015 limit of 21 year for male has been removed and now onwards, all the family members (male and female) whose annual income is less than Rs.1.20 lakh per annum are included under MA Vatsalya Yojana. 1/12/ % package rates were increased of existing MA procedures. 01/04/2017 The limit of income is been increased from Rs lakh to Rs lakh per annum for MA Vatsalya beneficiaries.. 13

14 Conti 23/05/ procedures were increased, Modification in 6 procedures, Deletion of 11 procedures and increased package rates of 139 procedures. So, total 628 procedures were decided. 18/10/2017 The limit of income is been increased from Rs lakh to Rs lakh per annum for MA Vatsalya beneficiaries. Financial Year All urban & rural ASHAs (Accredited Social Health Activist) (GR dated 04/10/2017), Reporters (GR dated 31/07/2017) and fix pay employees of class-3 & 4 appointed by state government (GR dated- 22/12/2016) are included under MA Vatsalya Yojana. 14

15 Conti 01/04/2018 The limit of income is been again increased from Rs lakh to Rs lakh per annum for MA Vatsalya beneficiaries. Senior citizens of those families with annual income up to Rs. 6 lakh are included under MA Vatsalya scheme. 01/04/2018 The Sum assured is up to Rs. 3,00,000/- per family per annum on a family floater basis. 01/04/2018 Kidney Transplant, Liver Transplant, Kidney + Pancrease Transplant procedures are covered with benefit up to Rs. 5,00,000/- under scheme. Knee and Hip replacement procedures are covered with cap of Rs. 40,000/ - per one replacement. Additional cost will be borne by the beneficiary. 15

16 Card Code of Category Under MA Yojana Sr. No. Category Card Code 1 BPL Families having an annual income up to Rs.3.00 lakh U Win Card Holder Reporters ASHA (Accredited Social Health Activist) Karma Yogi Senior Citizens

17 Features of the Scheme % State funded scheme. Health Assurance and not health Insurance scheme. Cashless, protecting beneficiaries from high, unexpected catastrophic health expenditure and from falling into debt. Each enrolled family is given a QR Coded MA card. It ensures the genuineness of beneficiaries and avoids duplications and frauds. Taluka kiosks and Civic Centre kiosks have been established for enrollments. Mobile kiosks are also provided at each district for growingly enrollment. Total 255 Hospitals (162 Private Hospitals + 24 Government Hospitals + 69 Standalone dialysis Centers) are empanelled under the scheme.

18 Features of the Scheme Zero direct costs incurred by the beneficiaries as all costs of treatment, medicines, follow-up and transportation etc are borne by the State. Payment against approved claims is released directly through RTGS by the State Government. Hospitals accreditation by NABH / JCI/ ACHS or by any other accreditation body approved by International Society for Quality in Healthcare (ISQua) are given Quality Incentives of 10% extra over and above the package rates. Rs. 300/- is paid to the beneficiary as transportation charges for every instance of availing treatment from the empanelled hospital. 18

19 Scheme Administration IT Solutions Provider, (n)code Solutions Card Printing, Distribution and modifications Development of software Implementation Support Agency (ISA), MD India Healthcare NetworX Pvt. Ltd. Claim processing Deployment of ArogyaMitras IEC activities 19 Enrolment Kiosk Enrolment of beneficiaries Setting up of Service Delivery Points (Kiosks) Network Hospital Empanelment of hospitals Call Centre Facility MA Kiosk at hospital

20 MA Card Quick Response (QR) Coded MA Card contains: A Unique Registration Number (URN) Photograph of the head of the family (HoF) / spouse. 20 Biometric thumb impressions of all enrolled family members along with basic details. The details are also stored at Central server which can be fetched online on real time basis with a click.

21 Beneficiary Enrolment Process Flow Beneficiary approaches MA Kiosk for enrolment Head of Family is verified against existing BPL list through Photo ID Proof or Income certificate Photo Capturing of beneficiary Finger Print Capturing of beneficiary MA / MA Vatsalya Card Generated Verification of beneficiary by Taluka Verifying Authority 21

22 Treatment and Processing Beneficiary approaches network hospital for treatment Aarogya Mitra coordinates at MA Help Desk Swiping of MA Card and fingerprint verification Claim Processing and Payment Preauthorization taken by network hospital from ISA Claim scrutiny done by ISA Rs. 300/- transportation charges paid to beneficiary Claim verification and payment done by SNC Preauthorization 22 Treatment Consultation Online Payment made directly by SNC to network hospital through RTGS

23 Summary Report (MA & MA Vatsalya Yojana) Start to till Details of the Scheme Year Year Year Year Cumulative Since 2012 to Enrolled Families 22,34,860 22,59,427 22,66,052 22,72,540 22,72,540 MA Yojana No. 35,406 51,847 61,847 79,564 2,74,676 Amount (Rs.in Cr.) MA Vatsalya Yojana Enrolled Families 8,40,103 31,92,397 38,95,385 46,82,159 46,82,159 No. 84,716 2,40,466 4,05,202 6,14,259 13,48,729 Amount (Rs.in Cr.) , Enrolled Families 30,74,963 54,51,824 61,61,437 69,54,699 69,54,699 Total No. 1,20,122 2,92,313 4,67,049 6,93,823 16,23,405 Amount (Rs.in Cr.) ,390.21

24 Sr.No. District No. of District Wise Data Year Year Year Year ( ) Amount (In Rs.) No. of Amount (In Rs.) No. of Amount (In Rs.) No. of Amount (In Rs.) 1 Ahmedabad 11,172 22,96,78,086 27,225 50,82,74,667 48,760 86,74,09,175 87, ,43,05,837 2 Amreli 3,943 6,97,84,414 9,341 13,97,03,658 12,789 20,77,06,603 19,117 28,86,45,632 3 Anand 7,412 10,48,01,966 14,763 18,33,12,080 21,856 28,90,85,134 32,621 39,53,08,111 4 Aravalli 1,824 3,36,87,299 3,783 6,42,20,041 7,675 10,46,85,142 10,977 14,59,39,951 5 Banaskantha 6,826 7,36,64,128 14,868 15,56,19,595 23,088 24,58,17,865 34,443 36,32,40,008 6 Bharuch 1,797 4,98,14,080 5,830 10,78,57,303 9,779 18,92,15,352 14,963 25,94,89,837 7 Bhavnagar 6,832 10,00,83,746 16,424 20,74,11,785 20,787 32,56,97,148 27,157 40,99,31,243 8 Botad 1,274 2,55,12,113 3,549 5,68,26,667 4,566 9,00,56,551 5,912 10,38,91,212 9 Chhotaudepur 875 2,28,95,231 2,447 4,67,71,219 3,805 7,51,69,665 4,359 9,19,44, Dahod 1,482 3,74,02,488 2,447 5,39,36,931 4,352 8,93,01,717 5,775 11,65,97, Dangs 88 26,77, ,48, ,42, ,28, Devbhoomi Dwarka 1,088 2,01,19,572 3,534 4,28,73,686 7,259 7,71,96,145 8,170 10,49,08, Gandhinagar 2,447 4,06,27,830 5,956 8,86,28,478 10,669 16,69,16,231 15,793 23,68,92, Gir Somnath 3,043 5,61,62,191 5,992 9,76,72,894 9,456 14,11,55,835 12,934 19,14,51, Jamnagar 3,311 4,96,23,380 10,987 10,14,68,581 12,681 15,57,28,273 15,758 20,98,92, Junagadh 5,113 8,68,55,542 12,284 15,76,00,392 15,987 22,54,56,350 19,442 31,28,75,280

25 District Wise Data Year Year Year Year ( ) Sr.No. District No. of Amount (In Rs.) No. of Amount (In Rs.) No. of Amount (In Rs.) No. of Amount (In Rs.) 17 Kheda 3,202 7,55,02,185 8,354 13,05,67,345 10,677 20,43,02,183 17,312 28,67,48, Kutch 4,998 7,20,26,953 17,037 15,65,89,383 26,181 29,85,64,933 33,261 39,42,31, Mahisagar 1,045 2,59,04,435 1,863 4,59,06,881 3,893 7,71,83,243 6,096 10,97,81, Mehsana 6,531 7,00,64,765 15,831 14,94,73,684 21,229 26,32,79,761 29,790 40,96,89, Morbi 2,640 3,33,88,358 6,401 5,62,64,386 9,906 10,23,97,699 12,360 15,31,96, Narmada 568 1,57,87,445 1,092 3,05,04,201 1,596 4,52,20,481 2,810 6,08,14, Navsari 1,902 5,59,96,197 4,647 10,56,02,907 7,878 15,56,90,732 13,979 22,46,26, Panchmahal 1,645 4,36,45,299 3,687 7,97,58,312 9,142 14,12,32,203 14,452 17,70,98, Patan 6,126 5,40,74,061 10,536 9,48,75,086 16,190 16,81,58,051 20,402 22,71,39, Porbandar 1,686 2,61,67,435 3,672 4,58,18,308 5,291 6,84,84,249 5,905 9,66,79, Rajkot 15,210 15,86,71,507 33,654 30,79,80,001 43,962 46,01,67,563 52,575 62,92,90, Sabarkantha 2,752 4,98,70,437 7,193 10,30,08,813 10,718 15,98,92,729 14,947 24,48,71, Surat 3,330 11,32,44,316 9,836 34,26,43,018 32,364 62,11,64,005 68,549 93,81,56, Surendranagar 3,175 5,72,65,207 8,078 11,81,57,941 12,320 19,02,47,309 17,844 26,88,43, Tapi 652 1,87,07,006 1,683 3,41,47,996 4,643 6,10,02,475 7,475 8,78,31, Vadodara 4,899 12,47,82,589 16,620 28,31,67,117 29,563 50,59,40,356 48,005 67,33,61, Valsad 1,234 3,25,74,034 2,552 6,92,60,245 7,746 12,65,75,847 12,386 18,01,10,066 Total 1,20, ,10,62,266 2,92, ,23,52,459 4,67, ,50,43,123 6,93, ,57,12,689

26 Achievements of the MA Scheme SKOCH Awards on 20 th September, 2014 CSI-Nihilent e-governance Awards on 13 th December, 2014 ELETS for Best Accessible Healthcare Initiative on 26th March, 2018 GEMS of Digital India Awards on 7 th June, 2017 Best Affordable Healthcare Initiative in Healthcare Summit 2016 at Jaipur.

27 Smiles All The Way MA-Toll free no