Table 1. Key features of the Pradhan Mantri Jan Arogya Yojana (PMJAY).
| Purchasers | National Health Authority (NHA) through State Health Agencies (SHA) with flexibility for states to implement the scheme and purchase care through one of three modes: a public trust, a third-party Insurance, or a combination (i.e. trust and Insurance) |
| What services are purchased? | a) Health insurance coverage of Rs. 5,00,000 (roughly $ 6,800) per family annually for secondary and tertiary care hospitalization. b) Covering 3 days of pre-hospitalization and post hospitalization charges up to 15 days c) As of 2019, services comprise of nearly 1,393 procedures (1,083 are surgical, 309 medical and 1 unspecified package) covering all the costs incurring for treatment, drugs and consumables diagnostics, and various user fees [14]. However, states are given power to restrict certain treatment packages for public sector only d) There is no restriction on family size, age or gender and beneficiaries can avail cashless treatment from an empanelled healthcare provider |
| Who uses the services? | Enrolled Population falling under the category • Below the Poverty Line (BPL) in the Socio-Economic Caste Census (SECC) • Existing Rashtriya Swasthya Bima Yojana (RSBY) beneficiaries • State notified categories |
| Who provides services? |
Public- All public hospitals (including ESIC [15]) equipped with inpatient facilities (Community Health Centre level and above) are empanelled by default [16]. Private and not for profit hospitals–Hospitals meeting the minimum criteria established by National Health Authority (NHA) which include qualified doctor and nurse presence, in-patient beds with staff, medical and surgical service availability (including human resources around the clock, support systems, ambulance facilities 24x 7 with technically qualified staff) [16]. |
| How are providers paid? | Based on the treatment package, public and private hospitals have the same package rate, which may be specified, like a surgical package for which there is case based bundled payment or unspecified, for which a claimant will negotiate with pre-approval by intermediary/ SHA. |