1 January

Ayushmaan Bharat Health Insurance: Entitlement and Eligibility

Category: Moter insurance

The Ayushman Bharat national health protection scheme (NHPS), often referred to as ‘ModiCare’ as was announced by PM Modi from the Red Fort on August 15th, will roll out in 12 states in the first phase, beginning August 15th and completed by October 2nd.

Modicare aims to cover nearly 50 crore beneficiaries from over 10.74 crore deprived families as per socio-economic and caste census (SECC) data with an annual health cover of Rs. 5 lakh per family. The full scare roll out is expected around September end.

The scheme will be launched in the states of Chhattisgarh, Assam, MP, West Bengal, Nagaland, Andhra Pradesh, Gujarat and most Union territories in the 1st phase, this will cover about 3 crore families with about 15 crore individuals. 26 states have already signed the MoU with center, while 4 more states/UT, Delhi, Goa, Punjab and Rajasthan are soon expected to be onboard. Those of the families who have migrated since 2011 census might come back and claim their benefits as well, dry runs are being conducted before the final launch. Gram Swaraj Abhiyaans and Ayushmaan Bharat diwas and ASHA workers have been used to carry out the verification process. While 65 lakh families are yet to be identified under the beneficiary identification scheme, UP has the most of 23.61 lakh (36%) missing families, followed by Bihar with 21.79 lakh (34%), all other states have a total of about 19 lakh families missing.

Who are the target beneficiaries?

The aim is to empower the poor, rural and deprived, so going by the socio-economic and caste census, the numbers come around 8.03 crore families in rural and 2.33 crore families in urban areas in total, covering around 50 crore people.

Subsuming the Rashtriya Swasthya Bima Yojna launched by UPA in 2008, AB-NHPS will have a defined benefit cover of Rs. 5 lakh per family (on a family floater basis) per year for secondary and tertiary health care./hospitalization. 

Who will be covered?

It will be ensured that nobody is left out especially the women, children and elderly with no cap on family size or age. It will be cashless and paperless at all public hospitals and empanelled private hospitals. 

Criteria for entitlement:

SECC database on deprivation will be the guiding criterion. The beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC database for rural areas. For the urban areas, the 11 occupational criteria will determine entitlement. In addition, Rashtriya Swasthya Bima Yojna (RSBY) beneficiaries in states where it is active are also included. 

Rural Area Categories:

Families having only one room with kucha walls and kucha roof; families having no adult member between the ages of 16 years and 59 years; female-headed households with no adult male member between the ages of 16 years and 59 years; disabled members and no able-bodied adult member in the family; SC/ST households; and landless households deriving major part of their income from manual casual labour. 

Also, these families in rural areas having any one of the following will be automatically included: households without shelter, destitute, living on alms, manual scavenger families, primitive tribal groups, and legally released bonded labor. 

Urban Area Categories:

11 defined occupational categories will be included in urban areas, Beggars, Rag Pickers, Domestic Help, Street Vendors/Cobblers/Hawkers/Other service providers working on the streets; Construction Workers/masons/Labor/painters/Welders/Security Guards/Coolies/Other Head Load workers; Sweepers/Sanitation Workers/Mali’s; Home based Workers/Artisans/Handicrafts workers/Tailors; Transport Workers/Drivers/Conductors/Helpers/Cart Pullers/Rickshaw pullers; Shop Workers/Assistants/Peons/Helpers/Delivery Assistants/Attendants/Waiters; Electricians/Mechanics/Assemblers/Repair Workers; Washer-Men/Chowkidaars; Other Work/Non-Work; Non-Work (Pension/Rent/Interest etc.)

Process of Hospitalization:

No charges/Premiums for hospitalization expenses, pre and post-hospitalization expenses will also be covered. An Ayushmaan Mitra will be stationed at each empanelled hospital to co-ordinate and assist the patients along with document verification and verification of eligibility. Letters with QR codes will be given to be scanned and a demographic authentication will be conducted to identify and verify eligibilities. The scheme will be completely portable and can be availed by all eligible people anywhere in the country.


Medical and hospitalization expenses for almost all secondary care and most of tertiary care procedures will be covered. The health ministry has included 1,354 packages in the scheme under which treatment for coronary bypass, knee replacements and stenting among others would be provided at 15-20 per cent cheaper rates than the Central Government Health Scheme (CGHS). 

Eligibility Criterion for Beneficiary:

There is no enrollment process, it’s an entitlement based mission, SECC data according to 2011 census will be the guiding criterion. A list of eligible families has been shared with the respective state governments as well as state level departments like the ANMs, BMO, and BDOs of relevant areas. A dedicated AB-NHPM family identification number will be allotted to eligible families. Only families whose name is on the list are entitled for the benefits of AB-NHPM. 

Additionally, families with an active RSBY cards as of 28 February 2018 will covered. No additional new families can be added under AB-NHPM. However, names of additional family members can be added for those families whose names are already on the SECC list. 

The official website www.abnhpm.gov.in can be visited to view and download the beneficiary eligibility and empanelled hospitals list as and when it gets updated. 

Hospital Eligibility:

All public hospitals and empaneled private health care facilities will be eligible. Also, the basic empanelment criteria allows empanelment of a hospital with a minimum of 10 beds, with the flexibility provided to states to further relax this if required. Empanelment of hospitals will be done through an online portal by the state government. 14555 will be the new helpline number along with websites and apps to assist the beneficiaries.

To control costs, the payments for treatment will be done on package rate (to be defined by the Government in advance) basis. However, hospitals with NABH/NQAS accreditation can be incentivised for higher package rates subject to procedure and costing guidelines. 


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