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AB-PMJAY is an entitlement-based scheme i.e. the scheme does not mandate any enrolment, but all eligible families are covered based on an identity verification, followed by the issuance of E-cards.

When the scheme was launched, the total number of families to be covered under AB-PMJAY was estimated to be around 10.74 crore, or 50 crore citizens. However, as of December 2022, after addition by states, a total of 14.65 crore families were eligible for the scheme. Of these, 8.94 crore were eligible as per the Socio Economic and Caste Census (SECC) and Rashtriya Swasthya Bima Yojana (RSBY) database, and an additional 5.7 crore families were included by states to expand the coverage of AB-PMJAY (up to Rs. 5 lakh).

The total estimated number of eligible households in a state have been taken from different sources by each state – Andhra Pradesh, and Kerala use data from Civil Supplies Department; Chhattisgarh uses data from Food, Civil Supplies, and Consumer Protection Department; Jharkhand uses data from Public Distribution System (PDS); Himachal Pradesh uses Statistical Outline; while the rest of the 24 states and UTs use data from Census or SECC 2011.

As of March 2022, around 62% of families were covered by AB-PMJAY. However, several states also have their own state insurance schemes. These states run both AB-PMJAY and state schemes and have expanded the coverage by adding a further 2.83 crore families under their state scheme, bringing the total health insurance coverage to 75% of families.

Analysis of coverage by Accountability India

The government enters into a contractual agreement with private and public hospitals--called Empanelled Health Care Providers (EHCP)--which undertake to provide services and treatments at fixed rates. The government forbids these hospitals from charging any additional payment to cover any part of the medical expenses, called 'co-payment'.

The empanelment of hospitals rests with the State Health Agency (SHA). All Community Health Centres (CHCs) and public hospitals are deemed to be EHCPs. Private hospitals are to be empanelled based on defined criteria.

As on 27 January 2023, there were 28,586 EHCPs. Of this amount, 13,085 private EHCPs had been empaneled in India, which amounted to 46% of the total.

A look at the number of eligible families per EHCP (both private and public) under AB-PMJAY gives a sense of the potential patient load on hospitals providing health cover. As on 23 January 2023, there were, on average, 3,128 eligible families per EHCP.

Accountability India found that there was a 42% decrease in the number of eligible families per EHCP since Nov 2020. (source)

Among the bigger states, Assam has the lowest utilisation of PM-JAY with 5,292 hospitalisations for every 100,000 beneficiaries. The state also has only 2 hospitals per 100,000 people. Read more about the performance of AB-PMJAY - IndiaSpend Story: Three Charts on Ayushman Bharat's Achievements & Shortfalls

As indicated in the Claims Adjudication Manual of NHA for AB-PMJAY, all claim payments (for both public and private EHCPs) should have a uniform Turnaround Time (TAT) of 15 days for intra-state claims and 30 days for inter-state claims (portability).

However, as on 19 January 2023, 40% of claim payments took more than 45 days, while 16% of these claim payments took between 30 and 45 days.

Read more about why out of pocket expenses on healthcare continues to remain high in India: IndiaSpend Explainer: Why India's Public Health Insurance Doesn't Work As Well As It Should

Till FY 2021-22, Revised Estimates for the scheme had been around half the Budget Estimates. Yet actual fund utilisation overall remains lower than Revised Estimates.

PM-JAY does not cover the cost of out-patient consultations. Therefore, beneficiaries have to get referrals from government or private doctors for procedures.

Reducing out-of-pocket expenditure (OOPE) on health is one of the objectives of the scheme. Yet, studies from different states reveal that OOPE is still high.

About 87.9% of people dipped into their savings for health expenses, 11.3% borrowed from friends and relatives, while 0.3% utilised health insurance, found a 2023 study by the National Council of Applied Economic Research which surveyed four states, Odisha, Maharashtra, Punjab and Uttar Pradesh.