SCHEME OBJECTIVE:To provide cashless quality medical care to beneficiaries under the scheme for catastrophic illnesses requiring hospitalization for surgeries and therapies under identified specialty services through network of health care providers.

ABOUT SCHEME:

Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY):Mahatma Jyotirao Pule Jan Arogya Yojana is a flagship health insurance scheme of Government of Maharashtra. The scheme provides end to end cashless services for identified diseases through a network of service providers from Government and Private sector. The scheme earlier was known as Rajiv Gandhi Jeevandayee Arogya Yojana which was started from 2nd July,2012 in eight districts and then was expanded to 28 districts of Maharashtra from 21st November, 2013.

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY):Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched by Government of India from 23rd September, 2018. AB-PMJAY was launched in the Maharashtra in integration with Mahatma Jyotirao Phule Jan Arogya Yojna and was implemented on mixed Insurance and Assurance Mode.

The Integrated Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) and Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched in the state on 1st April, 2020. United India Insurance Company Limited (Public sector Undertaking Company) is providing health insurance coverage to beneficiaries under the insurance mode and State Health Assurance Society providing coverage on assurance mode. State Health Assurance Society is paying insurance premium of ₹ 797/- per family per year to Insurance Company in quarterly installment on behalf of eligible beneficiary families.

Mahatma Jyotirao Phule Jan Arogya Yojana is fully funded by Government of Maharashtra. Pradhan Mantri Jan Arogya Yojana is jointly funded by Government of India and Government of Maharashtra in the ratio of 60:40.

Insurer - Scheme was run by insurer National Insurance Company a Public Sector Undertaking Company from 02.07.12 to 31.03.20. From 01.04.20 Integrated Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) and Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is run by insurer United India Insurance Company a Public Sector Undertaking Company.

BENEFICIARIES :

1) Beneficiaries under Mahatma Jyotirao Phule Jan Arogya Yojana:

Categories	Description of Beneficiaries
Category A	Families holding Yellow ration card, Antyodaya Anna Yojana ration card (AAY), Annapurna ration card, Orange ration card (annual income up to INR 1 lakh) issued by Civil Supplies Department, Government of Maharashtra for 36 districts of Maharashtra.
Category B	White ration card holder farmer families from 14 agriculturally distressed districts of Maharashtra (Aurangabad, Jalna, Beed, Parbhani, Hingoli, Latur, Nanded, Osmanabad, Amravati, Akola, Buldhana, Washim, Yavatmal, and Wardha).
Category C	1. Children of Government Orphanages, Students of Government Ashram Shala, female inmates of Government Mahila Ashram & senior citizens of Government old age homes. 2. Journalists & their dependent family members approved by DGIPR 3. Construction workers and their families having live registration with Maharashtra Building & other Construction worker Welfare Board .

2) Beneficiaries under Pradhan Mantri Jan Arogya Yojana: The households included are based on the automatic inclusion, deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. There are 83.72 lakh families in state. This data is frozen hence additional families cannot be added. However new members in existing families can be added.

Area	Description of Beneficiaries
Urban	For Urban area, 11 occupational criteria are identified as Rag pickers, Beggars, Domestic workers, Street vendors, Cobbler, hawkers, Construction workers, Plumbers, Masons, Painters, Welders, Sweepesrs Sanitation workesr, Mali, Home-based workers, Artisans, Handicrafts workers, Tailors, Transport workers, Drivers, Conductors, Helpers, Rickshaw pullers, Shop workers, Assistants, Peons, Attendants, Waiters, Electricians, Mechanics, Assemblers, Repair workers, Washer-men, Chowkidar.
Rural	Rural Criteria for rural area are from D1 to D7 which include families with only one room with kachha wall and kachha roof, No adult member between age 16 to 59, Female headed household s with no adult members between age 16 to 59, Disabled member and no able bodied adult member, SC/ST households, Landless households deriving major part of income from manual casual labour. Automatically Included category includes Households without shelter, Destitute-living on alms, Manual Scavenger Families, Primitive Tribal Groups and Legally released Bonded Labour.

Eligibility and Identification:

1) Beneficiaries under Mahatma Jyotirao Phule Jan Arogya Yojana :

Categories	Description of Beneficiaries
Category A	All eligible families shall be identified with valid Yellow, Orange, Antyodaya, and Annapurna ration card (irrespective of date of issue of Ration Card or the inclusion of the beneficiary’s name therein) coupled with any Photo ID proof (as finalized by the Society).
Category B	Eligibility for farmers from 14 agriculturally distressed districts of Maharashtra will be decided based on white ration card with 7/12 extract bearing the name of the beneficiary / head of the family or certificate from the nearest Revenue Officer stating that the beneficiary is a farmer or a family member of farmer with valid photo ID proof of the beneficiary.
Category C	Eligibility of beneficiaries shall be decided on the basis of any identity card / health card or any other identification mechanism as decided by the State Health Assurance Society (SHAS).

Beneficiaries under Pradhan Mantri Jan Arogya Yojana:

Under PMJAY members from families registered under Social, Economic and Caste Census, 2011 (SECC) are eligible for getting benefits in all empaneled hospitals by showing computerized e-cards and photo identity card. Beneficiary of PMJAY from any state having e-card and photo identity proof can avail treatment at any empaneled hospital of any other state.

List of valid Photo Id proofs to be accepted along with document of eligible criteria :

1. Aadhaar Card / Aadhaar Registration Slip with photo of the beneficiary. Aadhaar Card would be insisted upon as identification document and in absence of Aadhaar card / number; any document which is accepted for issuance of Aadhaar card will also be accepted.
2. Pan Card
3. Voter Id
4. Driving License
5. School/College Id
6. Passport
7. Freedom Fighter ID card
8. Health Card of RGJAY / MJPJAY
9. Handicap Certificate
10. Nationalized Bank Passbook with Photo
11. Senior citizen card issued by Central Government or State Government
12. Defense ex-servicemen card issued by Sainik Board
13. Marine Fishery Identity card (Issued by Ministry of Agriculture / Fisheries Department Government of Maharashtra).
14. Any photo ID proof issued by Government of Maharashtra/ Government of India

Sum Insured on Floater basis:

Mahatma Jyotirao Phule Jan Arogya Yojana:

1. The scheme provides coverage for meeting all expenses relating to hospitalization of beneficiary up to ₹ 1,50,000/- per family per policy year. For Renal Transplant this limit has been enhanced up to ₹ 2,50,000 per family per policy year.
2. The benefit is available to each and every member of the family on floater basis i.e. the total coverage of ₹ 1.5 lakh or ₹ 2.5 lakh as the case may be, can be availed by one individual or collectively by all members of the family in the policy year.

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY):

1. Ayushman Bharat PM-JAY provides a health cover of Rs. 5 lakhs per family per policy year for secondary and tertiary care hospitalization in any of empaneled hospitals across the country. The benefit is available to each and every member of the family on floater basis.

Benefit Coverage:

This is a package medical insurance scheme to cover hospitalization for Medical and Surgical procedures through cashless treatment in respect of the following 34 identified specialties. MJPJAY beneficiary gets benefit of 996 Medical and Surgical procedures with 121 follow up procedures and PMJAY beneficiary gets benefit of 1209 Medical and Surgical procedures (Additional 213 Medical and Surgical procedures) with 183 follow up procedures. There are 131 government reserved procedures out of 996 MJPJAY procedures and additional 37 government reserved procedures for PMJAY 1209 procedures.

Sr.No.	Specialized Category
1	Burns
2	Cardiology
3	Cardiovascular and Thoracic surgery
4	Critical Care
5	Dermatology
6	Endocrinology
7	ENT surgery
8	General Medicine
9	General Surgery
10	Haematology
11	Infectious diseases
12	Interventional Radiology
13	Medical Gastroenterology
14	MEDICAL ONCOLOGY
15	Neonatal and Pediatric Medical Management
16	Nephrology
17	Neurology
18	Neurosurgery
19	Obstretrics and Gynecology
20	Ophthalmology
21	Orthopedics
22	Pediatric Surgery
23	Pediatric Cancer
24	Plastic Surgery
25	Polytrauma
26	Prosthesis and Orthosis
27	Pulmonology
28	Radiation Oncology
29	Rheumatology
30	Surgical Gastroenterology
31	Surgical Oncology
32	Urology (Genitourinary Surgery)
33	Mental disorders
34	Oral and Maxillofacial Surgery

1209 packages include bed charges in General ward, Nursing and boarding charges, Surgeons and Anesthetists charges, Medical Practitioner and Consultants fees, Oxygen, O.T. & ICU Charges, Cost of Surgical Appliances, Cost of Drugs, disposables, consumables, implants, Cost of Prosthetic Devices, Cost of Blood Transfusion (Blood to be provided as per policy of State Government), X-Ray and Diagnostic Tests, food to inpatient, one time transport cost by State Transport or second class rail fare (from Hospital to residence of patient only). The package covers the entire cost of treatment of patient from date of reporting to his discharge from hospital including complications if any, making the transaction truly cashless to the patient. In instance of death, the carriage of dead body from network hospital to the village/ township would also be part of package.

Process flow of the beneficiary treatment in the Network Hospital:

Step 1-
➢ Beneficiaries shall approach nearby Empanelled Network Hospital. Arogyamitras placed in the above hospitals shall facilitate the beneficiary.
➢ The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the vicinity and can get the referral letter based on the diagnosis.

Step 2-
➢ The Arogyamitra at the network hospitals examines valid ration cards and Photo ID and enrolls the patient along with registration.
➢ The information like admission notes, test done will be captured in the dedicated database by the Medical Coordinator of the Network Hospital as per the requirement of the scheme.

Step 3-
➢ If the procedure falls in 996 procedures for MJPJAY beneficiary and 1209 procedures for PMJAY beneficiary, e-preauthorization request is raised by Hospital by attaching mandatory documents.

Step 4-
➢ Medical Specialists of the Insurer shall examine the preauthorization request and approve preauthorization if all the conditions are satisfied.
➢ If preauthorization is rejected, it is referred to technical committee consisting of CMO of TPA and CMC of SHAS as second step. If there is difference of opinion between the CMO of TPA and CMC of SHAS, the case is referred to ADHS- SHAS as third step. The decision of ADHS for approval or rejection of preauthorization is final.
➢ After preauthorization is approved, procedure shall be performed within 30 days by Private Hospital and within 60 days by Public Hospital. After that the preauthorization gets auto cancelled. SHAS shall have right to re-open auto-cancelled preauthorizations of Government Hospitals.
➢ Turn-around time for decision on preauthorization is 12 hours. In case of emergencies, the medical / surgical preauthorization approval has to be taken by MCO over telephone – Emergency Telephonic Intimation (ETI) which has a voice recording facility.

Step 5-
The Network Hospital extends cashless Medical or Surgical treatment to the beneficiary. The Post-operative / daily treatment notes of the Network Hospitals will be updated daily on the portal by the medical coordinator of the Network Hospital.

Step 6-
➢ Network Hospital after performing Medical or surgical procedure uploads diagnostics reports, Discharge Summary duly signed by the officials appointed by the Hospital, along with acknowledgement of payments of transportation cost and other documents as per operational guidelines.
➢ If the procedure falls in the category of follow up procedures, follow-up details will be informed to patient at the time of discharge by Hospital. It will also be the responsibility of Aarogymitra to educate the patient about follow-up procedures (if eligible) and related details.

Step 7-
The Network Hospital shall provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge.

Step 8-
➢ The Insurer scrutinizes the bills in light of the operational guidelines and mandatory investigations pays claims as per agreed package rates and grade of Hospital. The Insurance Company shall settle the claims of the hospitals online within 15 working days on receipt of complete claim document from the Network Hospital.
➢ The claim settlement module along with electronic clearance and payment gateway will be part of the workflow in State Health Assurance Society (SHAS) portal and will be operated by the Insurer.
➢ The reports will be available for scrutiny on the State Health Assurance Society (SHAS) login.

Health Camp:
Free Health Camps shall be conducted by Network hospital in Taluka Head Quarters, major Gram Panchayats and Municipalities. At least one free health camp is conducted by each network hospital per month at the place suggested by District Monitoring Committee/ District Coordinator.

Health care Providers:
1. The empaneled Hospitals under the Scheme include both Government and Private hospitals. Government Hospitals include Hospitals from Public Health Department, Medical Education and research department, Hospitals under Municipal Corporation and Municipality.
2. Maximum number of Government and Private Hospitals will be 1000.
3. Government and Private Hospitals, both multi-specialty and single specialty, can be empanelled as per the requirement and directions of Coordination Empanelment and Disciplinary committee chaired by Chief Executive Officer State Health Assurance Society. For multi-specialty Private hospitals, there is criteria of minimum 30 beds with ICU (with certain relaxations), while for single-specialty specialty hospitals 10 beds and other criteria shall be applicable.