Good, Replicable Practices and Innovations under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) – (MJPJAY) as a Key Stakeholder

Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) was launched on 02.07.2012. Earlier only 85% population was covered but under the universal scheme: As per GR dated 23.05.2020 now the entire 100%  state population is covered under MJPJAY. The Insurance cover per family per annum is 1.5 lakhs (2.5 lakhs for renal transplant)for MJPJAY & 5 lakhs for PMJAY. 
Network of Hospitals 
  • Total empanelled NWHs: 967 (287 Public & 680 private)
  • Minimum 2 NWHs are being empanelled per taluka
  • A (100%), B (90%) & C (80%) grades for multispecialty and A (100%) & B (90%) grades for single specialty
  • ‘A’ grade with 100% rate allotted to all the Public Hospitals
  • Hospitals in neighboring states are being empanelled
  • One grade higher to the hospitals in tribal, hilly and aspirational districts (Osmanabad, Gadchiroli, Nandurbar & Washim)
  • Number of beds required for empanelment brought down     from 30 to 20 beds for hospitals in tribal, hilly and aspirational districts
Best practices and innovations 
  • 100% packages are preauth based
  • Around 98% Preauths & Claims are processed within stipulated TAT of 12 hours and 15 working days respectively
  • Rs.63.78 crore unspent IEC amount was recovered from insurance company in June 2018
  • Premium rate per family per annum was brought down from Rs.690 to Rs.640 in Feb.2019
  • Appointed Super Specialists  & Specialists to review the cases to prevent the fraud and abuse of the packages
  • Clinical Protocols for evidence based treatment/package selection
  • Evidence based adjudication guidelines and mandatory investigations – for preuth and claims processing
  • Follow-up Medicines to eligible beneficiaries till 1 year
  • 2 Tier monitoring System
  • Arogyamitras deployed by TPAs in each NWH to assist the beneficiaries
  • Health Camps to create awareness about the scheme
  • Chairmanship of Central claims committee, Empanelment Committee & Preauth technical committee is with SHAS
  • Regular visits to NWHs by CEO, SHAS and other officials from SHAS, Insurance Company &  TPAs
  • Biometric attendance System for monitoring  of the field & PO team
  • Periodic rotation of Arogyamitra from hospitals to hospitals
  • Periodic rotations of SHAS field officers
  • Stringent fraud deterrence process.
  • Social Audit Mechanism- Beneficiary Feedback Mechanism
  • Pre-recorded voice message of Hon.Chief Minister
  • SMSes are sent to all beneficiaries in local language at various stages during the hospitals stay
  • Dynamic Grading of the Hospitals- Package rates linked to Grade so as to maintain the quality
  • 24X7 dedicated Call Centre with 32 lines monitored by SHAS & 24X7 Grievance redressal system
  • Hosting web services on Cloud Environment
  • Re-appeal system for claims rejection & deduction
  • Refund of excess premium from Insurance Company, if ICR is blow 85%
  • 3 separate open e tenders were floated: Insurance Company, Call centre & IT Company
Transparency In Processes
  • 24X7 Online Preauthorization & Claims Settlements
  • Emergency Telephonic Intimation Service – For emergency Treatment (Accidental treatment, CVTS,   Cardiology Treatment)
  • Technical Committee to review rejected preauths
  • Repudiation & Central Claim Monitoring System (Amount approved in CCM is around Rs.16 crore)
  • Online Empanelment Process Coordination Empanelment Disciplinary Committee
COVID 19 Care
  • Total 20 packages under Pulmonology, Critical care, Nephrology & Pediatric Medical Management
  • Till date 3378 COVID positive patients have availed benefit under the integrated scheme
  • Charges of private hospitals restricted as per the notification dated 21.05.2020 (80% regulated beds and 20% non-regulated  beds)
  • CEO, SHAS is monitoring authority in the state for the implementation of the notification dated 21.05.2020
  • In response to the notification dated 21.05.2020 till date 65 grievances have been received and resolved. Due to intervention of SHAS till date Rs.13,37,578 waived off from the bill amount/ reimbursed  back to the patient’s family
  • Committee chaired by CEO, SHAS finalized the COVID 19  test cost : Cost brought down to Rs.2200 from Rs.4500
  • Emergency Telephonic Intimation (ETI) provided to maximum cases in the light of lockdown amidst COVID 19 pandemic
  • In ETI cases limit of 5 working days extended up to 70 days for submission of documents
  • Photo copies of ration card & photo ID and https://nexusofgood.org.in/wp-content/uploads/2020/11 received on WhatsApp are also accepted
  • Ration card generated through website of the website of Food &  Civil Supplies department is also considered
  • Around 500 additional hospitals empanelled in the first week of April 2020
  • 210+ COVID hospitals
  • Free COVID test in empanelled hospitals under scheme packages
  • Government  to acquire private ambulances/ vehicles and fix transport charges for such acquired ambulances for citizens
Updates as on 23.05.2020
  • Universal scheme: MJPJAY scheme benefits extended to  the families who don’t have any ration card
  • Families who don’t hold any ration card can avail benefit on the basis of domicile certificate/Tehsildar certificate along with valid photo ID
  • CEO, SHAS has an authority to relax the documents required for availing the scheme benefits
  • 120 Government reserved procedures opened for private hospitals
  • Additional 67 diagnostic, minor & major procedures for private hospitals (includes procedures like Delivery, Caesarian section,  ECG, X ray, 2D Echo, Endoscopy, USG etc.)
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