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Mahatma Jyotiba Phule Jan Arogya Yojana  

Formerly known as Rajeev Gandhi Jeevandayee Yojana.

OBJECTIVE: To improve access of Below Poverty Line (BPL) and Above Poverty Line (APL) families (excluding White Card Holders as defined by Civil Supplies Department) to quality medical care for identified speciality services requiring hospitalization for surgeries and therapies or consultations through an identified Network of health care providers.

BENEFITS:    The scheme entails around 971 surgeries/therapies/procedures.

FAMILY: Family means members as listed on the valid Orange/Yellow Ration Card from 36 districts and White ration card holder with 7/12 from 14 agriculturally distressed districts.

IDENTIFICATION: Valid ration card Orange/Yellow/White Ration Card with

  • Pan Card
  • Aadhar Card
  • Driving License
  • Voter Id
  • Nationalised Bank Passbook with Photo
  • Handicap Certificate
  • School/College Id
  • In rural areas Tahsildar/ along with stamp and signature is there on Photo then it is accepted
  • In Urban areas Tahsildar/Government Local bodies along with stamp and signature is there on Photo then it is accepted.
  • Passport
  • Senior citizen card issued by central and state government Of India
  • Freedom Fighter Id Card
  • Defence ex-service card issued by sainik board
  • Marine Fishers Identity card (Issue by Ministry of Agriculture Government of Maharashtra).
  • Any photo ID proof issued by Govt. of Maharashtra/ Govt. of India
  • The photo ID proof will act as a tool for beneficiary identification for availing the health insurance facility.

SUM INSURED ON FLOATER BASIS & PERIOD OF INSURANCE:

The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary up to Rs. 1, 50,000/- per family per year in any of the Empanelled Hospital subject to Package Rates on cashless basis through valid Ration Card. The benefit shall be available to each and every member of the family on floater basis i.e. the total annual coverage of Rs. 1.5 lakh can be availed by one individual or collectively by all members of the family. In case of renal transplant surgery, the immunosuppressive therapy is required for a period of 1 year. So the upper ceiling for Renal Transplant would be Rs. 2, 50,000 per operation as an exceptional package exclusively for this procedure.

PACKAGE :

The package should cover the entire cost of treatment of Beneficiary from date of reporting to his discharge from hospital for a period of 10 days after discharge following surgery including complications if any, making the transaction truly cashless to the beneficiary.

The package rates will include bed charges in General ward, Nursing and boarding charges, Surgeons, Anaesthetists, Medical Practitioner, Consultants fees, Anaesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines and Drugs, Cost of Prosthetic Devices, implants, 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).

PRE EXISTING DISEASES: All diseases under the scheme shall be covered from day one. A person suffering from disease prior to the inception of the policy shall also be covered under approved procedures for that disease.

Steps for Treatment in the Network Hospital

STEP 01: Beneficiary families shall approach nearby General, Women/District Hospital/Network Hospital. Arogyamitra placed in the above hospitals shall facilitate the beneficiary.

STEP 02: The Arogyamitra at the Network Hospital examine the referral card and health card or Yellow/Orange Ration Card, Annapurna or Antyodaya card register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. The information like admission notes, test done will be captured in the dedicated database by the Medical Coordinator of the Network Hospital as per the requirement of the MJPJAY.

STEP 03: The Network Hospital, based on the diagnosis, admits the patient and sends E-preauthorisation request to the insurer, same can be reviewed by MJPJAY.

STEP 04: Recognised Medical Specialists of the Insurer and MJPJAY examine the preauthorisation request and approve pre authorisation, if, all the conditions are satisfied. This will be done within 24 working hours and immediately in case of emergency wherein e-preauthorisation is marked as “EM”.

STEP 05: The Network Hospital extends cashless treatment and surgery to the beneficiary. The Postoperative notes of the Network Hospitals will be updated on the website by the medical coordinator of the Network Hospital.

STEP 06: Network Hospital after performing the covered surgery/ therapy/ procedure forwards the Originals bills, Diagnostics reports, Case sheet, and Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The Discharge Summary and follow-up details will be part of the MJPJAY portal.

STEP 07: Insurer scrutinises the bills and gives approval for the sanction of the bill and shall make the payment within agreed period as per agreed package rates. The claim settlement module along with electronic clearance and payment gateway will be part of the workflow in MJPJAY portal and will be operated by the Insurer. The reports will be available for scrutiny on the MJPJAY login.

STEP 08 : The Network Hospital will provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge.

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