MUMBAI: In a major step towards ushering in universal healthcare, irrespective of the age of the insured, the government last week extended the free health cover under the Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)—the world’s largest health insurance scheme--to those 70 and above, and has allocated an initial budget of Rs 3,437 crore to fund the additional requirements.
The scheme, which offers Rs 5 lakh free health cover per family per annum, will go a long way in reducing the out-of-pocket expenses, which constitute around 70% of the health expenses for a person/family.
According to the 2011 Census, 8.6% or 103 million of the then 1.23 billion were above 60 and this number is seen more than doubling to 19.5% or 319 million by 2050. Though there is no official data available for the number of citizens above 70, according to private estimates, they number around 55 million or around 45 million families. While close to 58% of these elderly are women and 54% of them are widows too, according to NITI Aayog.
According to government data, about 20 million families and 30 million individuals will be added to the scheme because of this extension. More than 60 million have already availed of the benefits of the scheme, which has reduced their out-of-pocket expenditure by around R1 lakh crore at the national level.
According to an ORF (Observer Research Foundation) paper, the expansion of the scheme into non-poor households is a first step of many to follow, offering financial protection to the middle-class during health emergencies requiring hospitalisation and the biggest step towards universal health cover.
And there are 400 million non-poor citizens in the country. The cabinet said enrolment for the coverage will start within a week in phases in select locations before the nationwide rollout. According to the government calculation, the expansion of the scheme will benefit around 45 million families.
Who will be covered?
Everyone above 70, including those already covered under the AB-PMJAY, are eligible and all they need to do is just apply to join the scheme through either the Ayushman mobile app or the PMJAY portal. All those who enroll will get R5 lakh cover per annum. But the sum insured is for a family, and therefore if there are two or more members in a family over 70, the sum insured will be split among them. An Aadhaar card will be required for age verification and other details.
Those having private insurance and ESIC beneficiaries can also apply for the scheme. However, those families already covered under the scheme will be getting a top-up cover of R5 lakh to be used only for those above 70.
The coverage universe
Around 53 million of the total population of 1.44 billion are estimated to be above 70, or around 45 million families. Of these 17.8 million families are already covered. There will be no waiting or cooling-off periods; eligible beneficiaries can immediately access the benefits of the scheme after registration and eKYC.
About 20 million families and 30 million individuals will be added to the scheme because of this announcement and the scheme is also expected to help women further as 58% of the 70 plus age group are women, of which 54% are widows.
Currently, the AB-PMJAY covers around 25 health packages for the elderly.
Is it fully free?
The interested person will have to pay a premium and so it is not as fully free as is being spoken about. The annual premium for the scheme is R1,102/beneficiary, which includes R50 for administrative charges. Of this, the Centre funds 60% and the rest 40% by the respective state. According to the ORF paper, the number of the 70 and above population has grown from 2.8% of the national population in 2011 to 4.3% in 2021, and is expected to double by 2031. NITI Aayog estimates that almost 70% of the elderly are dependent for everyday maintenance on family and relatives, putting economic pressure on the households.
Currently, the 60-plus already comprises 14% of the over 350 million Ayushman card holders who have accessed the scheme. At the same time, almost one-fourth of all authorised hospital admissions, amounting to 69 million, under the scheme from its inception in 2018, are of patients 60 or above and most of them are from the poor and vulnerable households. Already 8 million are covered under various government schemes including Central government health scheme, or ex-servicemen’s contributory health scheme or the employees state insurance corporations schemes.
While those covered under the former can choose to join and discontinue the existing coverage, the former can join this also and retain the ESI cover as well as the premium is paid by the insured and his/her employer.