Ministry against allowing Ayushman Bharat beneficiaries to avail high-cost treatment

The health ministry has rejected a proposal for allowing Ayushman Bharat beneficiaries to avail high-cost treatment for life-threatening diseases under the Rashtriya Arogya Nidhi, and suggested that the health insurance scheme could be modified and the Rs 5-lakh ceiling enhanced to accommodate such patients.

The AIIMS and the National Health Authority (NHA) made the request to the ministry and cited cases wherein Ayushman Bharat beneficiaries could not avail treatment for blood cancer and chronic liver diseases as these are not covered under the health insurance scheme. In a letter to the CEO of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna (AB-PMJAY), Indu Bhushan, the health ministry said the suggestions of NHA and AIIMS cannot be agreed to as the eligibility criteria for both the schemes are different.

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The eligibility criteria for financial assistance under Rashtriya Arogya Nidhi (RAN) is based on state-wise threshold poverty line decided from time to time, whereas PMJAY is an entitlement-based scheme with entitlement decided on the basis of deprivation criteria in the SECC database 2011, the ministry said.

"As such the eligibility criteria for both the schemes are different. Further AB-PMJAY is an entitlement based scheme whereas assistance under RAN scheme is provided to eligible patients within the available budgetary allocation," the ministry said.

The All India Institute of Medical Sciences and the NHA, the apex body implementing the Ayushman Bharat health insurance scheme, had written to the Health Ministry suggesting if the patients deprived treatment under AB-PMJAY could be covered in the RAN umbrella scheme. They drew the ministry's attention to the cases of patients who were refused under PMJAY as they suffered from ailments such as blood cancer and chronic liver disease which do not figure among the 1,350 medical packages mentioned under the scheme.

These patients were also not able to avail treatment under the umbrella scheme of RAN since they are AB-PMJAY card holders. In its response, the health ministry further elaborating the grounds of rejection said that the funding pattern of PMJAY is 60:40 between the Centre and states whereas the RAN scheme is 100 per cent funded by the central government.

"The RAN scheme is not a general health scheme to provide treatment to all patients whose treatment cost is beyond Rs 5 lakh. It cannot be a substitution of health system of the government."It is a scheme for providing treatment to patients suffering from life threatening diseases at government hospitals having super-speciality facilities and who are eligible for financial assistance as per the state-wise threshold poverty," the letter stated.

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The health ministry also expressed concern about misuse of the provisions of financial assistance by beneficiaries of PM-JAY saying one family member may avail financial assistance for transplantation of organs beyond Rs 5 lakh under RAN scheme and other family members may also avail benefits under PM-JAY at a different hospital/state. Patients having treatment in government hospitals are eligible for financial assistance under RAN whereas enlisted private hospitals are also providing treatment to patients under PM-JAY.

"The NHA may consider for inclusion of transplantation of organs under the procedures covered under PM-JAY," the minister said in its letter. It also suggested the NHA to consider enhancing the ceiling of Rs 5 lakh per annum so that patients eligible under PM-JAY may avail facilities under the programme only. According to Dr Vijay Gurjar, a faculty at AIIMS, several poor patients requiring kidney transplant, bone marrow or liver transplant are facing problem in getting treatment as they are PMJAY card holders.

Their treatments would cost more than Rs 5 lakh and still they are not able to avail benefits under the RAN scheme. AIIMS Medical Superintendent Dr D K Sharma in his letter to NHA had mentioned that patients failing to avail financial assistance due to the lacunae between RAN umbrella scheme and AB-PMJAY schemes were approaching the hospital administration after their RAN application was being rejected and they having left with no option for financial assistance.

"Both schemes must complement each other to help patients suffering from life-threatening diseases. On the contrary, certain poor patients are deprived of healthcare benefits, against the situation before 2019, when all BPL patients suffering from life-threatening diseases were able to avail financial assistance from RAN," the letter read. 

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