The Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) is a health insurance scheme introduced by the Government of Maharashtra. This plan offers cashless services for specific illnesses and functions by enabling linkage between the government and private sectors. Earlier called Rajiv Gandhi Jeevandayee Arogya Yojana, the scheme had been started on July 2, 2012, spanning eight districts. It later expanded to 28 districts of Maharashtra on November 21, 2013.
When and where was Mahatma Jyotirao Phule Jan Arogya Yojana launched?
Launched on 1st April 2020 and integrated with Ayushman Bharat scheme, the Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) was rolled out in the state of Maharashtra. Being a public sector undertaking, the United India Insurance Company Limited is enabling health insurance to beneficiaries of the scheme through insurance mode. The State Health Assurance Society provides health coverage to people through an assurance mode and pays ₹797 per family per year to the Insurance Company in quarterly payments for eligible families.
Who is eligible for benefits from Mahatma Jyotirao Phule Jan Arogya Yojana?
Those who are in Maharashtra and eligible for benefits from the Mahatma Jyotirao Phule Jan Arogya Yojana are mentioned below:
The government of Maharashtra issues different types of ration cards through the Civil Supplies Department for all the districts in Maharashtra. Notably, ‘Category A’ families have a special Yellow card. There are also different cards like the Antyodaya Anna Yojana card (AAY), the Annapurna card, and the Orange card. The Orange card is for those who earn less than INR 1 lakh every year.
Additionally, farmer families in Maharashtra are ‘Category B’, as they have a White ration card (Category B) and reside in 14 districts, and face challenges in the agriculture sector. The areas are Aurangabad, Jalna, Beed, Parbhani, Hingoli, Latur, Nanded, Osmanabad, Amravati, Akola, Buldhana, Washim, Yavatmal, and Wardha.
Category C – to make it simpler "Level C - 1" pertains to children who do not have parents and live in homes provided by the government. This also includes students who attend schools provided by the government, women who live in settlement homes provided by the government for women, and older people who live in homes provided by the government.
Several journalists & their dependent family members approved by DGIPR and Construction workers and their families are signing up with the Maharashtra Building and other Construction Worker Welfare Board.
What documents are required to enrol for MJPJAY scheme?
Below are the documents which need to be furnished to be part of the scheme:
For Category A, all families must have a valid Yellow, Orange, Antyodaya, or Annapurna ration card, regardless of the card's issue date or the beneficiary's name on it. They must also provide a photo ID.
Farmers from 14 struggling districts in Maharashtra can qualify for Category B if they have a white ration card with a 7/12 extract that shows their name or the head of their family, or if they have a certificate from the nearest Revenue Officer stating that they are a farmer or a family member of a farmer in the areas that are specified for eligibility. They also need to provide a valid photo ID as proof.
Those in Category C will be determined by identification card, health card, or any other method chosen by the State Health Assurance Society (SHAS).
The Maharashtra-centric health plan covers all hospital expenses up to ₹1,50,000 for each family per year. For Renal Transplants, the maximum amount of money covered per family per year has been increased to ₹ 2,50,000. Each member of the family can benefit from this on a sharing basis. In simple words, one person or all family members can get insurance coverage of either ₹1.5 lakh or ₹2.5 lakh for the entire policy year.
How MJPJAY beneficiaries are treated in a network hospital
Step One: The first step is that beneficiaries should go to a network hospital that is close to them. The ‘Arogyamitras’ present at these hospitals will help the people who are eligible for the scheme. The person can also go to health camps that are organised by the hospital nearby and secure a letter saying they need further treatment.
Step Two: The Arogyamitra at the hospital will check their ration card and ID and register them as a patient. The hospital will keep a record of their medical information in a special database. If the treatment they need falls under certain procedures, the hospital will ask for permission from the insurance company. If the insurance company denies the request, it will be reviewed by a committee of doctors and officials. If the CMO of TPA and CMC of SHAS disagree, they ask ADHS-SHAS to decide. The ADHS is authorised to make a final decision to either approve or reject the pre-authorisation.
Step Three: After getting permission, the private hospital must complete the procedure within 30 days, and the Public Hospital must do it within 60 days. Then, the pre-authorisation is automatically cancelled. The SHAS can review and approve pre-authorisations that were previously cancelled by Government Hospitals.
Step Four: A decision on whether to approve or deny a pre-authorisation has to be made within 12 hours. If there is an emergency, the MCO must approve the medical/surgical treatment over the phone using Emergency Telephonic Intimation (ETI), which records the conversation. The Network Hospital provides medical or surgical treatment without the patient having to pay any cash upfront. The medical coordinator from the Network Hospital provides daily updates on the portal through treatment notes. The hospital uploads diagnostics reports, discharge summaries, and other documents as required. If the procedure requires follow-up, the hospital will inform the patient before they leave.
Step Five: The Aarogymitra will teach the patient about post-treatment steps and information. The hospital will offer free follow-up appointments, tests, and medications for up to 10 days after leaving. The Insurer reviews the bills based on guidelines and investigations and pays claims according to agreed rates and hospital ranking. The Insurance Company will pay the hospitals' claims online within 15 working days after they receive the necessary documents. This process is implemented through the State Health Assurance Society portal and managed by the Insurance Company. The reports can be viewed on the State Health Assurance Society login for review.
In addition, free Health Camps are conducted by Network Hospitals in Taluka HeadQuarters, major Gram Panchayats, and Municipalities. At least one free health camp is conducted by each network hospital per month at the place suggested by the District Monitoring Committee/ District Coordinator so that people avail the benefit of the MJPJAY scheme.
It is important to know that empanelled hospitals under the MJPJAY scheme comprise government and private hospitals.
For beneficiaries, it is important to be well aware and stay updated on any changes or updates made by the state government to the MJPJAY scheme. This way, the most accurate and current information can be utilised to secure the benefits of the MPJAY scheme.
Contact
State Health Assurance Society, ESIS Hospital Compound, Ganpat Jadhav Marg, Worli Naka, Worli, Mumbai – 400018.
