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Govt using AI to check for frauds under Ayushman Bharat health insurance; Features, benefits of Pradhan Mantri Jan Arogya Yojana


PM Modi unveiled the largest publicly sponsored healthcare program PM Jan Arogya Yojana (PMJAY) on September 23, 2018. As of August 1, 2023, a total of 24.33 crore Ayushman cards has been created. To prevent, detect, and deter healthcare fraud and to ensure that eligible beneficiaries receive adequate treatment, the Government of India is using Artificial Intelligence (AI) and Machine Learning (ML), according to a PIB press release issued on August 8, 2023.

 




What is Pradhan Mantri Jan Arogya Yojana (PM-JAY)?

This program is a component of the government's ambition to guarantee that all of its residents, particularly the underprivileged and vulnerable populations, have access to high-quality hospital care without suffering any financial hardship as a result of accessing those services.

 

Key Features of PM-JAY

It provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empanelled hospitals in India.

· PM-JAY provides cashless access to health care services for the beneficiary at the point of service, that is, the hospital.

· It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.

· There is no restriction on the family size, age or gender.

· Beneficiary can visit any empaneled public or private hospital in India to avail cashless treatment.

· Services include approximately 1,929 procedures covering all the costs related to treatment, including but not limited to drugs, supplies, diagnostic services, physician's fees, room charges, surgeon charges, OT and ICU charges etc.

· Public hospitals are reimbursed for the healthcare services at par with the private hospitals.

 

What benefits are available under PM-JAY?

Each qualified household is provided cashless coverage of up to INR 5,00,000 year by PM-JAY for the aforementioned secondary and tertiary care problems. All pre-existing conditions are covered starting on the first day when PM-JAY is implemented in the relevant States/UTs.

The following costs related to the treatment are all covered by the scheme's insurance.

· Medical examination, treatment and consultation

· Pre-hospitalization

· Non-intensive and intensive care services

· Diagnostic and laboratory investigations

· Medical implantation services (where necessary)

· Accommodation benefits

· Food services

· Complications arising during treatment

· Post-hospitalization follow-up care up to 15 days

· The benefits of Rs 5,00,000 are family floater benefits, therefore any one or all family members may use them.

 

Where can beneficiaries avail of services under PM-JAY?

All public hospitals and accredited private healthcare facilities offer the scheme's services. Beneficiaries can also dial 14555 for the helpline. Additionally, regular updates will be sent through ASHAs, ANMs, and other particular touch points.

 

How are the beneficiaries identified?

The beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC (Socio-Economic Caste Census) database for rural areas and 11 occupational criteria for urban areas. In addition, RSBY beneficiaries in states where RSBY is active are also included.

 

What is the hospitalization process?

The beneficiaries won't have to pay any fees or premiums for the costs associated with their hospitalisation. Additionally, pre- and post-hospitalization costs are covered under the program.

 

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