BHUBANESWAR: Even as Odisha government readies for the MoU with the Centre for implementation of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in the state six years after its nation-wide rollout, finalisation of modalities for integration with the state-funded Gopabandhu Jan Arogya Yojana (GJAY) remains the key challenge.
The GJAY was previously known as Biju Swasthya Kalyan Yojana (BSKY). The previous BJD government had introduced BSKY in 2018 by forgoing the central scheme following disagreement over the number of beneficiaries and eligibility criteria. Now, around 1.1 crore families are covered under GJAY that provides annual cashless treatment of Rs 5 lakh per family and additional Rs 5 lakh for women beneficiaries.
As per the eligibility criteria, sources said, around 67.8 lakh families will be covered under AB-PMJAY, which provides health insurance coverage of up to Rs 5 lakh per family per annum, while the state government will cover the remaining beneficiaries under GJAY. The process has already begun for integration of both the schemes and it is likely to be named AB-GJAY.
However, seamless integration is the challenge, especially when it comes to issuing a single health card to beneficiaries of two schemes having different eligibility criteria and coverage limits.
The GJAY is a trust-based health assurance scheme with additional coverage of Rs 5 lakh for women beneficiaries and the other is an insurance model. A major hurdle could be identifying and categorising beneficiaries between PMJAY and GJAY without duplication or omission and finalising healthcare packages.
Sources pointed out that as decided, both the schemes will be integrated into a single card for ease of access. But challenges may crop up in certain surgery packages which are already being availed by GJAY beneficiaries, and not available under PMJAY.
“It remains to be seen how this can be addressed in the one-card system and whether women beneficiaries under PMJAY will get additional coverage of Rs 5 lakh. With differing eligibility criteria and data sets, a significant task will be to ensure unfair inclusion or exclusion,” the sources said.
Health and Family Welfare minister Mukesh Mahaling had recently said individual health cards will be provided to nearly 3.5 crore people in the state after the MoU is signed with the Centre. It will also benefit elderly persons above 70 years irrespective of their income. Beneficiaries will avail treatment in around 27,000 hospitals across the country, he said.
Besides, balancing two funding structures under a unified framework, technicalities of merging data and enabling interoperability for hospitals will need work. Hospitals empanelled under GJAY are still unaware about modalities and how the integrated system will function once rolled out.
“Before the merger, the existing software will have to be upgraded to process two different data sets. Integrating IT systems for real-time monitoring, claim processing, and beneficiary verification will also require significant investments in technology and human resources,” the sources said.
Although PMJAY does not cover OPD expenses, it may not be an issue for its beneficiaries in the state with separate provisioning of funds under different initiatives under GJAY in the budget.
While Rs 5,450 crore was allocated under GJAY in 2024-25 budget and Rs 500 crore for Ayushman Bharat, an additional Rs 644 crore has been provisioned for GJAY in the supplementary budget.
A senior health official said integration will not be an issue once the modalities are finalised. “A central team from the National Digital Health Mission (NDHM) has come to the state. Every issue will be discussed and modalities will be finalised. There are plans to issue new health cards to each family. The back end integration will be done as per eligibility,” the official said.