The State Government of Maharashtra launched its
flagship health insurance scheme, Rajiv Gandhi Jeevandayee Arogya Yojana
(RGJAY) on 2nd July 2012 in 8 districts of Maharashtra (Phase 1) and later on
introduced it to remaining 28 districts of Maharashtra (Phase 2). The scheme is
renamed as Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) from 1st April
2017.
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 specialty services requiring
hospitalizationfor surgeries and therapies or consultations through an
identified Network of health care providers
SCHEME: Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) would be
implementedthroughout the state of Maharashtra in phased manner for a period of
3 years.The insurance policy/coverage under the MJPJAY for the eligible
beneficiaryfamilies in 8 districts: Gadchiroli, Amravati, Nanded, Sholapur
,Dhule, Raigad, Mumbai and Suburbs
BENEFITS: scheme would provide 972 surgeries/therapies/procedures along
with121 follow up packages in following 30 identified specialized categories:
1 |
GENERAL SURGERY |
2 |
ENT SURGERY |
3 |
OPHTHALMOLOGY SURGERY |
4 |
GYNAECOLOGY AND OBSTETRICS SURGERY |
5 |
ORTHOPEDIC SURGERY AND PROCEDURES |
6 |
SURGICAL GASTRO ENTEROLOGY |
7 |
CARDIAC AND CARDIOTHORACIC SURGERY |
8 |
PEDIATRIC SURGERY |
9 |
GENITOURINARY SYSTEM |
10 |
NEUROSURGERY |
11 |
SURGICAL ONCOLOGY |
12 |
MEDICAL ONCOLOGY |
13 |
RADIATION ONCOLOGY |
14 |
PLASTIC SURGERY |
15 |
BURNS |
16 |
POLY TRAUMA |
17 |
PROSTHESES |
18 |
CRITICAL CARE |
19 |
GENERAL MEDICINE |
20 |
INFECTIOUS DISEASES |
21 |
PEDIATRICS MEDICAL MANAGEMENT |
22 |
CARDIOLOGY |
23 |
NEPHROLOGY |
24 |
NEUROLOGY |
25 |
PULMONOLOGY |
26 |
DERMATOLOGY |
27 |
RHEUMATOLOGY |
28 |
ENDOCRINOLOGY |
29 |
GASTROENTEROLOGY |
30 |
INTERVENTIONAL RADIOLOGY |
BENEFICIARY FAMILIES: holding yellow ration card, Antyodaya Anna
Yojana card (AAY), Annapurna card and orange ration card from eight districts
viz. Gadchiroli, Amravati, Nanded, Sholapur, Dhule, Raigad, Mumbai city and
Suburban Mumbai. The families with white ration card holding would not be
covered under the scheme. The beneficiary families would be identified through
the “ Rajiv Gandhi Jeevandayee Health Card ” issued by the Government of
Maharashtra or based on the Yellow and Orange ration card issued by Civil
Supplies Department.
HEALTH CARDS: eligible families in these districts shall be provided with Rajiv
Gandhi Jeevandayee Arogya Yojana Health Cards in due course of time. This
Health Cards will be used for identification of Beneficiary families in the
family under the Scheme. Family Health Cards will be prepared by using data
from valid Yellow or orange ration cards coupled with Aadhaar numbers issued by
UID authorities. As an interim measure till the issuance of health cards, the
valid Orange/Yellow Ration Card with Aadhaar number or in case Aadhaar number
not available, any Photo ID card of beneficiary issued by Govt. agencies
(Driving License, Election ID,) to correlate the patient name and photograph
would be accepted in lieu of health card.
FAMILY: Family means members as listed on the Rajiv Gandhi Jeevandayee
Arogya Yojana Health Cards or holding valid Orange/Yellow Ration Card.
IDENTIFICATION: Health card issued by Govt. of Maharashtra/Rajiv Gandhi
Jeevandayee Arogya Yojana Society or valid Orange/Yellow Ration Card with
Aadhaar number if Health card is not issued would act as a tool for beneficiary
identification for availing the health insurance facility. The following
actions would be undertaken by Network hospitals in case of the possible
exceptional situations:
Situation |
Validations / Check |
No Health Card with beneficiary, |
Aadhaar number and in case Aadhaar |
Children born after issue of card |
Photograph of child
with either parent along with Health card/ valid Yellow or Orange ration card
of parent and Birth certificate issued by authorized office. |
PRE EXISTING DISEASES: All Diseases under the proposed 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
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 Health cards or
valid Orange/Yellow 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. The cases are likely to be very few and well controlled by
Human Organ Transplant Act 1994. The claims related to this have to be settled
by Insurer. The insurance coverage under the scheme for the beneficiary
families shall be in force for an initial period of one year from the date of
commencement of the policy
RUN OFF PERIOD: A “ Run Off period ” of one month will be allowed after the expiry
of the policy period i.e. till one month after the date of policy period for 8
districts Phase-I. This means that pre-authorizations can be done till the end
of policy period and surgeries for such pre-authorizations can be done up to
one month after the expiry of policy period and such claim will be honored by
the Insurance Company
PACKAGE: The insurer should ensure that the Network hospitals follow the
packages worked out by Rajiv Gandhi Jeevandayee Society. The package rates will
include bed charges in General ward, Nursing and boarding charges, Surgeons,
Anesthetists, Medical Practitioner, Consultants fees, Anesthesia, 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) etc. In other words the package should
cover the entire cost of treatment of patient from date of reporting to his
discharge from hospital including complications if any, making the transaction
truly cashless to the patient. In instance of death, the carriage of dead body
from network hospital to the village/township would also be part of package.
The planned procedures like hernia, vaginal or abdominal hysterectomy,
appendicectomy, cholecystectomy, Discectomy, etc. would preferably be performed
in empaneled public hospitals, subject to service availability therein. The
rates for each procedure are indicative and represent upper ceiling and the
Insurer may negotiate with the given empanelled hospitals to bring them down
amicably without compromising quality.
CASHLESS TRANSACTION: It is envisaged that for each hospitalization
the transaction shall be cashless for covered procedures. Enrolled beneficiary
will go to hospital and come out without making payment to the hospital subject
to procedure covered under the scheme. When the beneficiary visits the selected
network hospital and services of selected network hospital should be made
available (Subject to availability of beds). In instance of non- availability
of beds at network hospital, the facility of cross referral to nearest another
Network hospital is to be made available and Arogyamitra will also provide the
beneficiary with the list of nearby network hospitals.
ONLINE CLAIM SETTLEMENT: The Insurance Company shall settle the claims
of the hospitals online within 7 working days of receipt of the Originals
bills, Diagnostics reports, Case sheet, 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 online progress of claim settlement will be scrutinized and
reviewed by Rajiv Gandhi Jeevandayee Arogya Yojana Society.
Steps for Treatment
in the Network Hospital
STEP 01: Beneficiary families shall approach nearby PHC/Rural, Sub
district, General, Women/District Hospital/Network Hospital .Arogyamitra placed
in the above hospitals shall facilitate the beneficiary. If beneficiary visits
Government Health Facility other than the Network Hospital, he/she will be
given a referral card to the Network Hospital with preliminary diagnosis by the
doctors. The Beneficiary may also attend the Health Camps being conducted by
the Network Hospital in the Villages and can get that referral card based on
the diagnosis. The information on the outpatient and referred cases in the
PHC/Rural, Sub district, General, Women/DH and the camps will be collected from
all Arogyamitra /Hospitals on regular basis and captured in the dedicated
database through a well-established call center
STEP 02: The Arogyamitra at the Network Hospital examine the referral card
and health card or Yellow/Orange Ration 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 Rajiv Gandhi
Jeevandayee Arogya Yojana Society.
STEP 03: The Network Hospital, based on the diagnosis, admits the patient
and sends E-preauthorization request to the insurer, same can be reviewed by
Rajiv Gandhi Jeevandayee Arogya Yojana Society.
STEP 04: Recognized Medical Specialists of the Insurer and Rajiv Gandhi
Jeevandayee Arogya Yojana Society examine the preauthorization request and
approve preauthorization, if, all the conditions are satisfied. This will be
done within 12 working hours and immediately in case of emergency wherein
e-preauthorization is marked as “ EM ” . The validity of preauthorization would
be for 7 days.
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,
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 Rajiv Gandhi Jeevandayee Arogya Yojana Society
portal.
STEP 07: Insurer scrutinizes 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 Rajiv Gandhi Jeevandayee Arogya
Yojana Society portal and will be operated by the Insurer. The reports will be
available for scrutiny on the Rajiv Gandhi Jeevandayee Arogya Yojana Society
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.
HEALTH CAMPS: Health Camps are to be conducted in Taluka Head Quarters, Major
Gram Panchayat and Municipalities. Minimum of one camp per week per empanelled
hospital has to be held in the eight districts in the policy year. The insurer
shall ensure that at least one free medical camp is conducted by each network
hospital per week at the place suggested by Rajiv Gandhi Jeevandayee Arogya
Yojana Society. The Rajiv Gandhi Jeevandayee Medical Camp Coordinator MCCOs of
the hospital shall coordinate the entire activity. Network hospital shall carry
necessary screening equipment along with specialists (as suggested by the Rajiv
Gandhi Jeevandayee Arogya Yojana Society) and other Para-medical staff. The
Insurer shall put in the minimum requirements as regards the health camp in the
MOU with the hospitals. The empanelled hospital shall work in close liaison
with district coordinator of the Insurance Company, Civil Surgeon/District
Health Officer in consultation with District Collector. Hospital shall follow
the Camp policy of Rajiv Gandhi Jeevandayee Arogya Yojana Society.
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