The Pradhan Mantri Jan Aarogya Yojana (Ayushman Bharat), the government-sponsored health insurance scheme for low-income groups, has been extended to all senior citizens over the age of 70 years, irrespective of their income levels. Under this extension, all senior citizens in this age group will receive a new distinct card under AB PMJAY to access the scheme’s benefits. Even senior citizens who already have private cover are eligible.
The policy covers a wide range of medical treatments, including hospitalisation, surgeries, and diagnostic procedures. The key highlight of the scheme is pre-existing diseases will be covered from the very first day of policy inception unlike traditional health insurance policies. There are also no co-payment clauses which are typically present in health covers of senior citizens. This implies that the senior citizens do not have to bear a percentage of the treatment out of pocket. While the scheme primarily appears as a boon for senior citizens, it is not the ultimate silver bullet which will take care of all the healthcare needs of the elderly.
The limitations of PMJAY include:
- Limited coverage: Considering the healthcare inflation in India, the Rs.5 lakh coverage per family for a senior citizen couple will not be adequate for critical illnesses like cancer, major surgeries and prolonged hospital stays.
- Restricted hospital network: This could be a major issue for senior citizens seeking quality healthcare treatment. Ayushman Bharat is primarily designed for economically weaker sections. So, its network of empanelled hospitals is often limited to government and certain private hospitals and the coverage primarily includes general wards, which may not suit the comfort preferences of senior patients. Furthermore, the treatment rate structure agreed upon with hospitals may restrict the range and quality of available treatments for seniors, if the preferred hospitals or doctors are not part of this network.
- No reimbursement option: The PMJAY scheme does not offer reimbursement for hospitalisation expenses incurred at non-network hospitals. This restriction may pose a significant challenge for individuals who prefer specific healthcare providers or require immediate medical attention and do not have an empanelled hospital in their vicinity.
- Lack of outpatient care: While PMJAY covers in-patient hospitalisations expenses, it does not cover out-patient expenses incurred. With passing age, senior citizens could require regular annual health checks, doctor consultations, diagnostic tests like X-Ray, MRI, etc. or minor surgeries that do not require hospitalisation. Non-coverage of such essential services under PMJAY means senior citizens would have to bear these from their own pocket.
Private health insurers in contrast offer higher coverage and comprehensive health care. Senior citizens also have the flexibility to choose from a wide range of health care providers which suit their preferences and pocket. For such elderly lot, PMJAY can at best act as a supplement to their primary individual health cover.