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The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) will now extend health insurance coverage of up to Rs 5 lakh annually to all senior citizens aged 70 and above, irrespective of their income status. This initiative raises a crucial question for the elderly: should you continue paying for private health insurance or rely solely on this government-provided coverage?
What PM-JAY Offers Senior Citizens
The PM-JAY initiative is designed to provide essential health services to vulnerable populations.Under this initiative, senior citizens will now be eligible to receive health insurance coverage of up to Rs 5 lakh annually for secondary and tertiary hospital treatments. Senior citizens who are part of a family already enrolled in PM-JAY will receive an additional top-up of Rs 5 lakh, exclusive to them. The scheme offers coverage at over 29,000 empanelled hospitals.
Moreover, senior citizens already covered under public health insurance schemes like the Central Government Health Scheme (CGHS), Ex-Servicemen Contributory Health Scheme (ECHS), or Ayushman CAPF will have the option to either continue with their existing scheme or opt for AB PM-JAY. Additionally, those under private health insurance policies or the Employees’ State Insurance scheme will also be eligible to avail of the benefits of AB PM-JAY.
Key features include:
No Premiums: Unlike private health insurance, which can become increasingly expensive with age, PM-JAY requires no premium payments.
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Universal Eligibility: All senior citizens qualify for this coverage, creating a vital safety net for those without existing insurance.
Immediate Coverage for Pre-existing Conditions: Unlike many private plans that impose waiting periods, PM-JAY covers pre-existing diseases from day one.
No Co-payment: Seniors won’t face out-of-pocket expenses, a common requirement in private insurance policies. Beneficiaries enjoy cashless healthcare services at the point of care, eliminating the need for out-of-pocket payments during treatment.
Pre- and Post-Hospitalization Coverage: The scheme covers up to 3 days of pre-hospitalization and 15 days of post-hospitalization expenses, including diagnostics and medications.
Pre- and Post-Hospitalization Coverage: The scheme covers up to 3 days of pre-hospitalization and 15 days of post-hospitalization expenses, including diagnostics and medications.
For many seniors, the benefits of PM-JAY are compelling. For example, Mrs. Sharma, a 72-year-old retiree, was relieved when she learnt she did not have to pay monthly premiums. "This scheme will make healthcare accessible for people like me who live on fixed income," she said.
Nationwide Portability: Beneficiaries can access cashless treatment at any empanelled public or private hospital across India, ensuring flexibility and ease of care.
Comprehensive Service Package: AB PM-JAY offers comprehensive coverage across 1,949 medical procedures spanning 27 medical specialties, including General Medicine, Surgery, Oncology, and Cardiology. Beneficiaries receive hospital services such as free drugs (including 15 days of post-discharge medication), diagnostics (up to 3 days before admission), food, and lodging at no cost.
Despite the benefits, relying solely on PM-JAY has certain limitations, particularly when it comes to the quality and accessibility of healthcare. Pranit Mathur of Value Research explains these limitations:
Lack of reimbursement clause: PM-JAY does not have a reimbursement clause, which means that treatment is restricted to its empanelled hospitals only. If your preferred hospital or a facility close to your home is not part of the PM-JAY network, you won't be able to access care there. This limitation can be a significant drawback, especially for those who are accustomed to receiving treatment at a specific facility. In contrast, most private health insurance policies include reimbursement clauses, allowing you to seek treatment at non-network hospitals and providing greater flexibility in choosing where you receive care.
Room limits: Under PM-JAY, admissions are limited to general wards. Private health insurance, on the other hand, often gives the option of private rooms, which can be an important consideration for senior citizens who prefer privacy and greater comfort during hospitalisation.
Priority treatment: PM-JAY patients may suffer reduced priority in hospitals due to lower tariffs set by the government, which are aligned with CGHS rates in Tier-1 cities. Additionally, delayed payments can further exacerbate this issue, leading hospitals to prioritise patients covered by private insurance over those enrolled in PM-JAY.
"For senior citizens, PM-JAY offers an invaluable layer of health security without the financial burden of premiums, making it a compelling option. However, for those who can afford private health insurance, we suggest you don't ditch it completely. Rather than replacing private health insurance, PM-JAY can supplement your existing health plan. This way, you have a larger insurance coverage, allowing you to access the best care without financial strain," said Mathur.
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