Pradhan Mantri Jan Arogya Yojana (PMJAY)

#### Facts for Prelims (FFP)

Source: TOI

Context: A study in Chhattisgarh revealed that despite the Pradhan Mantri Jan Arogya Yojana (PMJAY), out-of-pocket spending (OOPE) on health remains high, particularly in private hospitals, due to the widespread practice of dual billing

PMJAY Overview:

• Ministry: Ministry of Health and Family Welfare

• Genesis: Launched in 2018 as part of Ayushman Bharat scheme

• Benefit: Offers Rs. 5 lakhs/year/family for secondary and tertiary care in public and private hospitals, without restrictions on family size, age, or gender.

• Coverage: Includes pre and post-hospitalization expenses, covering all pre-existing medical conditions.

Challenges with PMJAY Implementation:

• High Out-of-Pocket Spending: Despite PMJAY, significant out-of-pocket expenditure persists, particularly in private hospitals.

• Dual Billing: Private hospitals engage in dual billing, charging patients and claiming reimbursement from the government, leading to fraudulent practices.

• Disparities in Cost: Medical expenditure in private hospitals is substantially higher compared to public hospitals, exacerbating financial burdens on patients.

• Catastrophic Health Expenditure: Utilization of private hospitals under PMJAY often results in catastrophic health expenditure for vulnerable groups.

• Poor Regulation: Lack of effective regulation allows private hospitals to overcharge patients, undermining the affordability goal of PMJAY.

• Limited Access for Vulnerable Groups: Vulnerable sections like scheduled tribes and women predominantly rely on public hospitals, limiting their access to private sector benefits promised by PMJAY.

• Capacity Deficit: Some states face capacity issues with a high number of people per empanelled healthcare provider.

• Delayed Claim Settlements: Despite clear guidelines, there are delays in settling claims.

• Validation Control Issues: Lack of essential validation controls in beneficiary registration, with instances of linking multiple beneficiaries to a single mobile number.

• Grievance Disposal: The delayed resolution of grievances, with only around 10% addressed within the 15-day turnaround time, as per the CAG report.

• Whistleblower Policy Non-Adoption: Several states, including Bihar, Chhattisgarh, and Rajasthan, have not adopted a whistleblower policy.