No expert committee has been set up for extending health benefits to cover citizens aged 70 and above under Ayushman Bharat, Union Minister of State for Health Prataprao Jadhav told the Lok Sabha on Friday. He also informed that there was no proposal to open the scheme beyond the existing beneficiaries based on contribution of premium.

Jadhav was responding to a question on whether the government proposed to cover citizens aged 70 and above by expanding Ayushman Bharat through the launch of a national health claims exchange and if an expert panel had been set up to strengthen the format of the scheme for the planned expansion. The minister, in a written reply, said all members of eligible families, irrespective of age, were covered under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana.

The scheme provides health insurance cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to 55 crore individuals, corresponding to 12.34 crore families, he said.

“No expert committee has been set up for extending the health benefits to cover senior citizens aged 70 and above,” he stated.

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Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana Beneficiaries

Initially, 10.74 crore beneficiary families were identified on the basis of the 2011 socio-economic caste census, using select deprivation and occupational criteria separately for rural and urban areas.

In January 2022, the beneficiary base was expanded to 12.34 crore families and states and Union Territories were given the flexibility to use other digitised databases of similar socio-economic conditions for identification of beneficiaries under the scheme. Accordingly, they were provided Aadhaar-seeded databases of poor and vulnerable families for verification under the scheme.

A beneficiary may directly visit any empanelled public or private hospital around the country to avail themselves of cashless treatment benefits. Based on the diagnosis done by the hospital, eligible beneficiaries are provided treatment free of cost. Post treatment, the beneficiary is discharged and the hospital submits the claim for reimbursement, Jadhav stated.

The scheme is being implemented in 33 states and Union Territories except the NCT of Delhi, West Bengal and Odisha, he said.

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National Health Claims Exchange (NHCX)

Responding to another question, Jadhav said 34 insurers and third-party administrators were live and approximately 300 hospitals ramping up to start sending their claims on the National Health Claims Exchange (NHCX), which aims to streamline and fasten health insurance claim processing, as on July 21.

He said the government built the NHCX gateway under the Ayushman Bharat Digital Mission. It aims to streamline and standardise health insurance claim processing, enhance efficiency in the insurance industry and improve patient experience.

It serves as a gateway for exchanging health claim information among insurers, third party audit, healthcare providers, beneficiaries and other relevant entities and ensures interoperability, machine-readability, auditability and verifiability, making the information exchange accurate and trustworthy, the minister said. This system will enhance efficiency and transparency in the insurance industry, benefiting policyholders and patients, he added.

Supported by the Insurance Regulatory and Development Authority of India and the General Insurance Council, the NHCX will enable standardised and faster health insurance claim processing, Jadhav said.

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Validation Checks To Avoid Invalid Entries Into AB-PMJAY Database

Ineligible beneficiaries received benefits under the Ayushman Bharat, resulting in excess premium payments to insurance companies, a parliamentary committee has said, stressing the need for in-built validation checks to avoid invalid entries. The committee also flagged that patients earlier recorded as having “died” in the Transaction Management System (TMS) (used for claims settlement) continued to avail treatment under the scheme, PTI reported on July 25.

The performance audit of AB-PMJAY by the Public Accounts Committee of the previous 17th Lok Sabha was tabled in Parliament this week. Data analysis of TMS revealed that 88,760 patients were recorded to have died during treatment under the scheme. A total of 2,14,923 claims recorded in the system as “paid” were related to fresh treatment of these patients, the panel report said. The audit noted that the TMS was not only allowing initiation of pre-authorisation requests for beneficiaries already shown as “dead” in the system but was allowing all other entries such as “admission date, surgery date and discharge dates”, the report highlighted.

The committee further noted from the audit findings, the failure of insurance companies to meet the claim ratio specified in comparison with the premium paid which led to a substantial amount of refund of premium being recoverable.

Out of the total refund of Rs 700.10 crore recoverable from insurance companies in six states and UTs, only Rs 241.91 crore has been partially recovered, leaving Rs 458.19 crore outstanding for the period from 2018-19 till June 2022.