Identifying ways to increase efficiency and improve service delivery of the world’s largest health insurance scheme

• Oct 26, 2021
• 1 min

The Pradhan Mantri Jan Arogya Yojna or PM-JAY is the largest health insurance scheme in the world. PM-JAY intends to provide a health cover of USD 6,723 (INR 500,000) per family per year for secondary and tertiary care hospitalization. The program expects to reach more than 107.4 million poor and vulnerable families or approximately 500 […]

The Pradhan Mantri Jan Arogya Yojna or PM-JAY is the largest health insurance scheme in the world. PM-JAY intends to provide a health cover of USD 6,723 (INR 500,000) per family per year for secondary and tertiary care hospitalization. The program expects to reach more than 107.4 million poor and vulnerable families or approximately 500 million beneficiaries who form the bottom 40% of the Indian population.

The program empanels government and private hospitals to perform medical procedures and surgeries to treat diseases and medical conditions on those covered by PM-JAY. Delays in settling claims by the State Health Authority (SHA) may lead to disenchantment among Empaneled Health Care Providers (EHCPs), leading them to lose confidence in the program. MSC conducted a study in Bihar, Haryana, and Madhya Pradesh to assess the challenges that healthcare providers empaneled with the government faced in delivering health services.

The study found that delay in settling claims of these healthcare providers is a significant factor in the slow uptake of the PM-JAY scheme. MSC made some key recommendations, including a pilot for real-time claim adjudication (RTCA) to address delays in payments to impaneled health care providers.