Scheme Details :

OBJECTIVE: To improve access of Below Poverty Line (BPL) and Above Poverty Line (APL) families (excluding White Card Holders as defined by Civil Supplies Department) to quality medical care for identified speciality services requiring hospitalization for surgeries and therapies or consultations through an identified Network of health care providers.

SCHEME: Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) has been implemented throughout the state of Maharashtra in a phased manner over a period of 4 years. Government resolution issued on 13th April 2017 regarding the change into the name of Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) to Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) and continuation of the same from 1st April 2017.

The insurance policy/coverage under the MJPJAY can be availed by eligible beneficiary families residing in all the 36 districts of Maharashtra viz. Gadchiroli, Amravati, Nanded, Sholapur, Dhule, Raigad, Mumbai and Mumbai Suburban, Akola, Buldhana, Yavatmal, Washim, Aurangabad, Beed, Hingoli, Jalna, Latur, Osmanabad, Parbhani, Thane, Palghar, Ratnagiri, Sindhudurga, Bhandara, Chandrapur, Gondia, Nagpur, Wardha, Ahmednagar, Jalgaon, Nadurbar, Nashik, Kolhapur, Pune, Sangli, Satara.

BENEFITS: The scheme entails around 971 surgeries/therapies/procedures along with 121 follow up packages in following 30 identified specialized categories:

1 GENERAL SURGERY
2 ENT SURGERY
3 OPHTHALMOLOGY SURGERY
4 GYNAECOLOGY AND OBSTETRICS SURGERY
5 ORTHOPEDIC SURGERY AND PROCEDURES
6 SURGICAL GASTRO ENTEROLOGY
7 CARDIAC AND CARDIOTHORACIC SURGERY
8 PEDIATRIC SURGERY
9 GENITOURINARY SYSTEM
10 NEUROSURGERY
11 SURGICAL ONCOLOGY
12 MEDICAL ONCOLOGY
13 RADIATION ONCOLOGY
14 PLASTIC SURGERY
15 BURNS
16 POLY TRAUMA
17 PROSTHESES
18 CRITICAL CARE
19 GENERAL MEDICINE
20 INFECTIOUS DISEASES
21 PEDIATRICS MEDICAL MANAGEMENT
22 CARDIOLOGY
23 NEPHROLOGY
24 NEUROLOGY
25 PULMONOLOGY
26 DERMATOLOGY
27 RHEUMATOLOGY
28 ENDOCRINOLOGY
29 GASTROENTEROLOGY
30 INTERVENTIONAL RADIOLOGY

The 132 Government reserved Procedures are to be performed only in empanelled Government Hospital / Government Medical College subjects to availability of facility and procedures.

BENEFICIARY FAMILIES: Families belonging to any of the 36 districts of Maharashtra and holding Yellow Ration Card, Antyodaya Anna Yojana Card (AAY), Annapurna Card and Orange Ration Card along with Farmers from 14 agriculturally distressed districts of Maharashtra (Amravati, Akola, Aurangabad, Buldhana, Beed, Hingoli, Jalna, Nanded, Latur, Osmanabad, Parbhani, Wardha, Washim and Yavatmal). The identification for farmers from 14 agriculturally distressed districts of Maharashtra will be based on White Ration Card along with 7/12 extract bearing the name of the beneficiary / head of the family or certificate from the concerned Talathi / Patwari stating that the beneficiary is a farmer or a family member of farmer with valid photo ID proof of the beneficiary.

FAMILY: Family means members as listed on the valid Orange/Yellow Ration Card from 36 districts and White ration card holder with 7/12 from 14 agriculturally distressed districts.

IDENTIFICATION: Valid ration card Orange/Yellow/White Ration Card with

1) Pan Card

2) Aadhar Card

3) Driving License

4) Voter Id

5) Nationalized Bank Passbook with Photo

6) Handicap Certificate

7) School/College Id

8) In rural areas Tahsildar/ along with stamp and signature is there on Photo then it is accepted

9) In Urban areas Tahsildar/Government Local bodies along with stamp and signature is there on Photo then it is accepted.

10) Passport

11) Senior citizen card issued by central and state government Of India

12) Freedom Fighter Id Card

13) Defence ex-service card issued by sainik board

14) Marine Fishers Identity card (Issue by Ministry of Agriculture Government of Maharashtra).

15) Any photo ID proof issued by Govt. of Maharashtra/ Govt. of India

The photo ID proof will act as a tool for beneficiary identification for availing the health insurance facility. Following actions would be undertaken by Network hospitals in case of exceptional situations:

Situation Validations / Check

Children born after issue of card
i.e. name and photo not available
on health card or on valid yellow/Orange ration card

Photograph of child with either parent along with valid Yellow/Orange/White ration card of parent and Birth certificate issued by authorized office.

PRE EXISTING DISEASES: All diseases under the scheme shall be covered from day one. A person suffering from disease prior to the inception of the policy shall also be covered under approved procedures for that disease.

SUM INSURED ON FLOATER BASIS & PERIOD OF INSURANCE: The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary up to Rs. 1, 50,000/- per family per year in any of the Empanelled Hospital subject to Package Rates on cashless basis through valid Ration Card. The benefit shall be available to each and every member of the family on floater basis i.e. the total annual coverage of Rs. 1.5 lakh can be availed by one individual or collectively by all members of the family. In case of renal transplant surgery, the immunosuppressive therapy is required for a period of 1 year. So the upper ceiling for Renal Transplant would be Rs. 2, 50,000 per operation as an exceptional package exclusively for this procedure. The cases are likely to be very few and well controlled by Human Organ Transplant Act 1994. The claims related to this have to be settled by Insurer. The insurance coverage under the scheme for the beneficiary families shall be in force for an initial period of one year from the date of commencement of the policy.

RUN OFF PERIOD: “ Run Off period ” of one month will be allowed after the expiry of the policy period i.e. till one month after the date of policy period. This means that pre-authorizations can be done till the end of policy period and surgeries for such pre-authorizations can be done up to one month after the expiry of policy period and such claim will be honored by the Insurance Company.

PACKAGE: The insurer should ensure that the Network hospitals follow the packages worked out by MJPJAY. The package rates will include bed charges in General ward, Nursing and boarding charges, Surgeons, Anaesthetists, Medical Practitioner, Consultants fees, Anaesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines and Drugs, Cost of Prosthetic Devices, implants, 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). In other words the package should cover the entire cost of treatment of Beneficiary from date of reporting to his discharge from hospital for a period of 10 days after discharge following surgery including complications if any, making the transaction truly cashless to the beneficiary. In the instance of death, the carriage of dead body from network hospital to the village/township would also be part of package. The planned 131 procedures like hernia, vaginal or abdominal hysterectomy, appendicectomy, cholecystectomy, Discectomy, etc. will be performed only in empaneled Government Hospitals/Government Medical Colleges. The rates for each procedure are indicative and represent upper ceiling and the Insurer may negotiate with the given empanelled hospitals to bring them down amicably without compromising quality.

CASHLESS TRANSACTION:  It is envisaged that for each hospitalization the transaction shall be cashless for covered procedures. Enrolled beneficiary will go to hospital and come out without making any payment to the hospital subject to the procedures covered under the scheme. When the beneficiary visits the selected network hospital, services of selected network hospital should be made available (Subject to availability of beds). In instance of non- availability of beds at network hospital, the facility of cross referral to a nearest Network hospital is to be made available and Arogyamitra will also provide the beneficiary with the list of nearby network hospitals.

ONLINE CLAIM SETTLEMENT: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 including the Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The online progress of claim settlement will be scrutinized and reviewed by MJPJAY.

Steps for Treatment in the Network Hospital

STEP 01: Beneficiary families shall approach nearby General, Women/District Hospital/Network Hospital. Arogyamitra placed in the above hospitals shall facilitate the beneficiary. If beneficiary visits Government Health Facility other than the Network Hospital, he/she will be given a referral card to the Network Hospital with preliminary diagnosis by the doctors. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the villages and can get that referral card based on the diagnosis. The information on the outpatient and referred cases in the General, Women/DH and the camps will be collected from all Arogyamitra /Hospitals on regular basis and captured in the dedicated database through a well-established call center.

STEP 02: The Arogyamitra at the Network Hospital examine the referral card and health card or Yellow/Orange Ration Card, Annapurna or Antyodaya card register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. 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 MJPJAY.

STEP 03: The Network Hospital, based on the diagnosis, admits the patient and sends E-preauthorization request to the insurer, same can be reviewed by MJPJAY.

STEP 04: Recognized Medical Specialists of the Insurer and MJPJAY examine the preauthorization request and approve preauthorization, if, all the conditions are satisfied. This will be done within 24working hours and immediately in case of emergency wherein e-preauthorization is marked as “EM”.

STEP 05: The Network Hospital extends cashless treatment and surgery to the beneficiary. The Postoperative notes of the Network Hospitals will be updated on the website by the medical coordinator of the Network Hospital.

STEP 06: Network Hospital after performing the covered surgery/ therapy/ procedure forwards the Originals bills, Diagnostics reports, Case sheet, and Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The Discharge Summary and follow-up details will be part of the MJPJAY portal.

STEP 07: Insurer scrutinizes the bills and gives approval for the sanction of the bill and shall make the payment within agreed period as per agreed package rates. The claim settlement module along with electronic clearance and payment gateway will be part of the workflow in MJPJAY portal and will be operated by the Insurer. The reports will be available for scrutiny on the MJPJAY login.

STEP 08 : The Network Hospital will provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge.

HEALTH CAMPS: Health Camps are to be conducted in Taluka Head Quarters, major village Gram Panchayats and Municipalities. Minimum of two camps per week per empanelled hospital has to be held in the all districts in the policy year at the place suggested by SHAS. Medical Camp Coordinator MCCOs of the hospital shall coordinate the entire activity. Network hospital shall carry necessary screening equipment along with specialists (as suggested by the SHAS) and other Para-medical staff. The Insurer shall put in the minimum requirements as regards the health camp in the MOU with the hospitals. The empanelled hospital shall work in close liaison with District Coordinators of the SHAS, Civil Surgeon/District Health Officer in consultation with District Collector. Hospital shall follow the Camp policy of SHAS.