The government has revised the rates of around 400 procedures under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) and added a new medical package related to black fungus management.

In the revised Health Benefit Package (HBP 2.2), the National Health Authority (NHA) which implements the AB PM-JAY scheme has raised the rates of packages by 20 per cent to 400 per cent.

The HBP 2.2 is expected to be rolled out from November, 2021.

Key points:

• The Ayushman Bharat PM-JAY aims to achieve the target of universal health coverage and provide access to free and affordable health care services to the citizens residing in the remotest of the areas.

• In 2018, Ayushman Bharat PM-JAY was launched with the HBP 1.0 with a total of 1,393 packages. 

• Currently, Ayushman Bharat PM-JAY covers 1,669 treatment procedures out of which 1,080 are surgical, 588 medical and one unspecified package. 

• The scheme aims to provide free and cashless health care services up to Rs 5 lakh per family per year to over 10.74 crore poor and vulnerable families (over 53 crore beneficiaries) as per Socio-Economic Caste Census (SECC)-2011 database.

• Since the inception of the scheme, more than 2.2 crore eligible AB-PMJAY beneficiary have been provided with health coverage for secondary, tertiary and day care procedures for treatment of diseases and medical conditions through a vast network of 24,000 Empanelled Health Care Providers (EHCP).

• The Health Benefit Package defines the scope of health care services being provided and also determines the extent of financial risk protection to the beneficiaries.

• In the revised version of Health Benefit Package (HBP 2.2), rates of some health packages have been increased by 20 percent to 400 per cent under PM-JAY.

• Under medical management procedures, the rates for ICU with ventilator support has been revised by 100 per cent and without ventilator by 136 per cent, while the rates for HDU (High Dependency Unit) has been revised by 22 per cent and the prices for routine ward has been revised by 17 per cent.

• State Health Agencies (SHAs) currently implementing any of the previous versions of HBP can now accept and implement HBP 2.2.

• The NHA has undertaken rate revision in the categories which include radiation oncology procedures, medical management procedures like those for dengue, acute febrile illness, etc, surgical package treatment for black fungus and other procedures like right/left heart catheterisation, PDA closure, arthrodesis, cholecystectomy, appendicectomy, etc.

National Health Authority 

• National Health Authority (NHA) is the apex body responsible for implementing Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY).

• It has been entrusted with the role of designing strategy, building technological infrastructure and implementation of Ayushman Bharat Digital Mission to create a national digital health ecosystem.

• NHA is governed by a Governing Board chaired by the Union health minister. It is headed by a chief executive officer (CEO), who is in the rank of secretary to the government of India.

Functions of NHA under PM-JAY:

• Formulation of various operational guidelines related to PM-JAY, model documents and contracts to ensure standardization and interoperability.

• Determine the central ceiling for premium (or maximum central contribution for trusts) per family per year to be provided to the states/UTs and review it from time to time, based on field evidence and actuarial analysis.

• Develop and enforce compliance with standards for treatment protocols, quality protocols, minimum documentation protocols, data sharing protocols, data privacy and security protocols, fraud prevention and control including penal provisions etc.

• Develop mechanisms for strategic purchasing of health care services through PM-JAY, so as to get best return on government’s investment. 

• Create conducive conditions for strategic purchasing by preparing a list of packages and their rates and updating them from time to time using a transparent, predictable and evidence-based process.

• Set up effective and efficient mechanisms to pay to the health care providers.

• Set up systems and processes for convergence of PM-JAY with other health insurance/assurance schemes. This will include schemes being implemented by both state and central governments. The National Health Authority will also develop a pathway to converge PM-JAY with schemes targeting workers from both the formal and informal sectors.

• Build a state-of-the-art health information technology ecosystem with requisite foundational components on which PM-JAY and other health systems can be hosted/linked. 

• Explore options including ways to link PM-JAY with the larger health care system, especially primary care, in consultation with the ministry of health and family welfare.

• Work closely with the Insurance Regulatory and Development Authority (IRDA) on development and implementation of Health Insurance Regulations targeting insurance companies, third party administrators, hospitals and other stakeholders.

• Effective implementation of PM-JAY across the country and its regular monitoring including taking course corrections actions, as and when required.

• Coordination with various state governments on a regular basis for implementation of PM-JAY.

• Capacity building of state health agencies and other stakeholders continuously.

• Carrying out awareness activities for informing beneficiaries and other stakeholders about the scheme.

• Prevention, detection and control of fraudulent activities and abuse.

• Grievance redressal for all the stakeholders at various levels.

• Set up an efficient monitoring system for the scheme.

• Stimulate cross learning, sharing of best practices amongst states and documentation of these practices.

• Ensure interoperability, standardisation and convergence amongst schemes of central ministries.

• Conduct and facilitate policy relevant research and evaluation studies including knowledge sharing and information dissemination at the national and international level.

• Develop strategic partnerships and collaboration with central and state governments, other public and private institutions including not-for-profit institutions, banks, insurance companies, academic institutions such as universities, missions, think tanks, and other national and international bodies of repute in areas relevant to the objectives of PM-JAY.

• Generate evidence for the policy makers from schemes’ data and other research/evaluations so as to facilitate evidence-based decision making and policy formulation by the government.

• Act as apex body for state health agencies that have been set up to implement PM-JAY.

• Take any decision related to the implementation of the scheme, recruitment rules and hiring of staff, disbursement of grant-in-aid to the states and issue relevant directions from time to time, as required.

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