Mahatma Jyotirao Phule Jan Arogya Yojana

Mahatma Jyotirao Phule Jan Arogya Yojana is the flagship health insurance scheme of the Government of Maharashtra. The scheme provides end-to-end cashless services for identified diseases through a network of service providers from the Government and Private sector. The scheme earlier was known as Rajiv Gandhi Jeevandayee Arogya Yojana which was started on 2nd July 2012 in eight districts and then was expanded to 28 districts of Maharashtra from 21st November 2013.

OBJECTIVE:

To provide cashless quality medical care to beneficiaries under the scheme for catastrophic illnesses requiring hospitalization for surgeries and therapies under identified specialty services through a network of health care providers.

BENEFITS :

• The scheme provides coverage for meeting all expenses relating to the hospitalization of beneficiaries up to ₹ 1,50,000/- per family per policy year. For Renal Transplants, this limit has been enhanced up to ₹ 2,50,000/- per family per policy year.
• The benefit is available to every member of the family on a floater basis, i.e., the total coverage of ₹ 1,50,000/- or ₹ 2,50,000/- as the case may be, can be availed by one individual or collectively by all members of the family in the policy year.

Benefit Coverage:

This is a package medical insurance scheme to cover hospitalization for Medical and Surgical procedures through cashless treatment concerning the following 34 identified specialties. MJPJAY beneficiary gets a benefit of 996 Medical and Surgical procedures with 121 follow-up procedures. There are 131 government-reserved procedures out of 996 MJPJAY procedures.

Specialized Categories are under follows:-

1. Burns
2. Cardiology
3. Cardiovascular and Thoracic surgery
4. Critical Care
5. Dermatology
6. Endocrinology
7. ENT surgery
8. General Medicine
9. General Surgery
10. Haematology
11. Infectious diseases
12. Interventional Radiology
13. Medical Gastroenterology
14. MEDICAL ONCOLOGY
15. Neonatal and Pediatric Medical Management
16. Nephrology
17. Neurology
18. Neurosurgery
19. Obstretrics and Gynecology
20. Ophthalmology
21. Orthopedics
22. Pediatric Surgery
23. Pediatric Cancer
24. Plastic Surgery
25. Polytrauma
26. Prosthesis and Orthosis
27. Pulmonology
28. Radiation Oncology
29. Rheumatology
30. Surgical Gastroenterology
31. Surgical Oncology
32. Urology (Genitourinary Surgery)
33. Mental disorders
34. Oral and Maxillofacial Surgery

Note : 1209 packages include bed charges in General ward, Nursing and boarding charges, Surgeons and Anesthetists charges, Medical Practitioner and Consultants fees, Oxygen, O.T. & ICU Charges, Cost of Surgical Appliances, Cost of Drugs, disposables, consumables, implants, Cost of Prosthetic Devices, Cost of Blood Transfusion (Blood to be provided as per policy of State Government), X-Ray and Diagnostic Tests, food to inpatient, one time transport cost by State Transport or second class rail fare (from Hospital to residence of patient only). The package covers the entire cost of treatment of patient from date of reporting to his discharge from hospital including complications if any, making the transaction truly cashless to the patient. In instance of death, the carriage of dead body from network hospital to the village/ township would also be part of package.

Eligibility

Beneficiaries under Mahatma Jyotirao Phule Jan Arogya Yojana:

Identification of beneficiaries under Mahatma Jyotirao Phule Jan Arogya Yojana :

List of valid photo ID proofs to be accepted along with document of eligible criteria:

1. Aadhaar Card or Aadhaar Registration Slip with a photo of the beneficiary. An Aadhaar Card would be insisted upon as an identification document and in the absence of an Aadhaar card/number; any document that is accepted for issuance of an Aadhaar card will also be accepted.
2. Pan Card
3. Voter ID
4. Driving License
5. School/College Id
6. Passport
7. Freedom Fighter ID card
8. Health Card of RGJAY / MJPJAY
9. Handicap Certificate
10. Nationalized Bank Passbook with Photo
11. Senior citizen card issued by the Central Government or State Government
12. Defense ex-servicemen card issued by Sainik Board
13. Marine Fishery Identity card (Issued by Ministry of Agriculture / Fisheries Department Government of Maharashtra).
14. Any photo ID proof issued by the Government of Maharashtra/ Government of India

The complete process of treatment of the beneficiary in Maharashtra Network Hospital is given below:

Step 1: Beneficiaries shall approach the nearby Empanelled Network Hospital. Arogyamitras placed in the hospitals shall facilitate the beneficiary. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the vicinity and can get a referral letter based on the diagnosis.

Step 2: The Arogyamitra at the network hospitals examines valid ration cards and Photo IDs and enrolls the patient along with registration. The information like admission notes, and tests done will be captured in the dedicated database by the Medical Coordinator of the Network Hospital as per the requirement of the scheme.

Step 3: If the procedure falls in 996 procedures for the MJPJAY beneficiary and 1209 procedures for the PMJAY beneficiary, the e-preauthorization request is raised by the Hospital by attaching mandatory documents.

Step 4: Medical Specialists of the Insurer shall examine the preauthorization request and approve preauthorization if all the conditions are satisfied. If preauthorization is rejected, it is referred to a technical committee consisting of the CMO of TPA and the CMC of SHAS as the second step. If there is a difference of opinion between the CMO of TPA and the CMC of SHAS, the case is referred to ADHS- SHAS as the third step. The decision of ADHS for approval or rejection of preauthorization is final.

Step 5: After preauthorization is approved, the procedure shall be performed within 30 days by a Private Hospital and within 60 days by a Public Hospital. After that, the preauthorization gets auto-canceled. SHAS shall have the right to re-open auto-cancelled preauthorizations of Government Hospitals. Turnaround time for a decision on preauthorization is 12 hours. In case of emergencies, the medical/surgical preauthorization approval has to be taken by the MCO over telephone Emergency Telephonic Intimation (ETI) which has a voice recording facility.

Step 6: The Network Hospital extends cashless Medical or Surgical treatment to the beneficiary. The Post-operative / daily treatment notes of the Network Hospitals will be updated daily on the portal by the medical coordinator of the Network Hospital.

Step 7: Network Hospital after performing Medical or surgical procedures uploads diagnostics reports and discharge Summary duly signed by the officials appointed by the Hospital, along with acknowledgment of payments of transportation costs and other documents as per operational guidelines. If the procedure falls in the category of follow-up procedures, follow-up details will be informed to the patient at the time of discharge by the Hospital. It will also be the responsibility of Aarogymitra to educate the patient about follow-up procedures (if eligible) and related details.

Step 8: The Network Hospital shall provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge.

Step 9: The Insurer scrutinizes the bills in light of the operational guidelines and mandatory investigations and pays claims as per the agreed package rates and grade of the Hospital. The Insurance Company shall settle the claims of the hospitals online within 15 working days of receipt of the complete claim document from the Network Hospital.

For more information, watch

https://www.jeevandayee.gov.in/