Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) is the flagship health insurance scheme launched by the State Government of Maharashtra. The scheme was launched on July 2, 2012. It was renamed as Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) from 1st April 2017. In Phase I, the scheme was launched in 8 districts of Maharashtra. It was applied to the remaining 28 districts in Phase II in November 2013. The universal healthcare program targets to reach the poor people who hold one of the four cards (Antyodaya card, Annapurna card, yellow ration card or orange ration card) issued by Government of Maharashtra.
Benefits of MJPJAY
The beneficiaries of MJPJAY will get access to 488 hospitals across the State. The scheme covers 971 types of diseases, surgeries and therapies. The coverage for each family is up to Rs. 1, 50,000. In case of renal failure, the coverage will be up to Rs. 2, 50, 000.
As of January 2016, 7.27 surgeries and therapies were performed and 7.13 lakh beneficiaries. 11.81 lakh procedures were performed to the tune of Rs. 1827 crores.
The scheme caters to the health needs of families under the poverty line (BPL) and marginally above poverty line (APL).
Health camps will be conducted by empanelled hospitals at various levels including Taluka Head Quarters, major village Gram Panchayats and Municipalities. Specialists will be present at health camps and necessary screening equipment will be used to assess the beneficiary for a referral.
The packages worked out by the MJPJAY should be followed by the network hospital. As per the package, the charges include nursing & boarding charges, surgeons, anesthetists, consultation fee, O.T. Charges, X-ray, diagnostic tests and medicines & drugs. The package will cover the entire cost of the treatment.
The transaction will be cashless for each covered procedure. The beneficiary will visit the network hospital and will come out without paying any amount. If the beds are not available in the nearest hospital, the cross-referral to the nearest hospital will be made available to the beneficiary.
After the expiry of the policy, a ‘run off period’ of one month will be allowed. The pre-authorization can be done until the end of the policy period. Hence, the surgeries can be done up to one month after the policy expiry date. The insurance claim should honor those claims and there will be a great benefit to the beneficiary through the unique and successful health program.
Steps for treatment
Obtaining the referral card - The beneficiary can approach the nearby general, women, district or network hospital. The Arogyamitra present at the hospital will facilitate the beneficiary. If the beneficiary approaches the government hospital, the required diagnosis will be performed by doctors and the beneficiary will be referred to the network hospital. The referral card can be obtained from the health camp organized at villages. The up-to-date information about the outpatient as well as referral cases can be obtained from the central database maintained by the call center.
Examination of the referral card – The referral card and health card will be examined by the Arogyamitra at the network hospital. After registration, the patient will be able to undergo specialist treatment or consultation. The preliminary diagnosis and admission process will be completed. The relevant information (admission, consultation, surgery) will be updated in the central database.
Request to the insurer – The network hospital admits the patient and sends e-preauthorization request to the insurer and it will be reviewed by MJPJAY.
Approval of pre authorization – The medical specialists of the insurer will examine the MJPJAY request and they will approve the treatment (based on the fulfillment of all conditions). The approval will take place in 24 hours. In case of emergency, the e-preauthorization is termed as EM.
Cashless treatment – The network treatment will provide cashless treatment or surgery as per the case. The medical coordinator at the network hospital will update the postoperative notes.
Bill submission by network hospital – The procedure or surgery bills and medical reports and discharge summary will be prepared by the network hospital and they will be sent to the insurer. MJPJAY portal contains discharge summary and follow-up details.
Claim settlement by the insurer – The bills are scrutinized by the insurer and gives approval for payment as per the terms and conditions mentioned in the package. The claim settlement will be done online.
Free follow up – there will be free follow up a consultation, diagnosis and medical check-up at the network hospital up to 10 days from the day of discharge.
Conclusion
The purpose of MJPJAY is the provision of free health insurance thereby free quality critical care will be provided for low-income families. The scheme excludes white card holders as defined by the Civil Supplies Department of Maharashtra. The website, https://www.jeevandayee.gov.in/ provides complete information about the MJPJAY health scheme.
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