Nagaland has about 62% of families covered under PMJAY, with medical oncology claims making up the majority (43%) of contributions under AB-PMJAY as of March 2022.
The Budget Estimates (BEs) for Financial Year 2023-24 indicate that the government of India has allocated INR 7,200 crore to the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). This represents a 12% increase over the Revised Estimates (REs) of the previous year, which amounted to INR 6,412 crore.
According to a report released by Accountability Initiative under Centre for Policy Research as of March 2022, AB-PMJAY is currently being implemented in 33 states and union territories throughout India, with the exception of West Bengal, Odisha, and the National Capital Territory of Delhi, while Telangana became the most recent state to adopt the programme in May 2021.
As of December 2022, seven states and union territories namely Meghalaya, Nagaland, Punjab, Dadra and Nagar Haveli and Daman and Diu, Jammu and Kashmir, Ladakh, and Puducherry had implemented the scheme under an Insurance mode.
While four states, namely Gujarat, Jharkhand, Maharashtra, and Tamil Nadu had chosen the mixed mode and the remaining states and UTs were implementing AB-PMJAY through a Trust.
As on March 2022, on average, 66% of families in India were covered under PMJAY, while in terms of overall coverage, including AB-PMJAY and state schemes, Kerala, Haryana, Sikkim, Maharashtra, and Punjab were among the states with the lowest coverage under AB-PMJAY, ranging from 27% to 49%.
However, Nagaland had a relatively higher percentage of families covered under PMJAY, at 62%, as per the Socio Economic and Caste Census/ Rashtriya Swasthya Bima Yojana (SECC/RSBY) database.
As of January 18, 2023, cardiology was the leading specialty for which the highest number of claims, totaling INR 4,115 crore, was filed under AB-PMJAY in all Indian states and union territories. Kerala and Gujarat had the highest claims for cardiology, at INR 653 crore and INR 650 crore, respectively.
General medicine was the second most claimed specialty under AB-PMJAY, with claims worth INR 3,985 crore filed across India. Maharashtra and Andhra Pradesh had the highest claims for General Medicine, at INR 797 crore and INR 737 crore, respectively.
While state-wise analysis of the total claim amount indicated that states like Goa 56% and Sikkim 53% had the largest share of general medicine claims made within their state in terms of claim amount.
States such as Mizoram (52%) and Nagaland (43%) had the highest contribution of medical oncology claims in terms of claim amount, within the respective states.
As per the Claims Adjudication Manual, a claim request progresses from the Claims Executive (CEX), to the Claims Processing Doctor (CPD), followed by the Accounts Officer (ACO) and finally the State Health Agency or Insurance Company (SHA/ IC), who is the final authority for the decisions pertaining to claims.
And as on January 19, 2023, across India, 6,10,981 cases were pending with the CEX or CPD, whereas 8,60,622 were pending with the ACO, 6,89,188 with the SHA, and 2,89,669 cases with banks.
The states with the large proportion of claims pending at the CEX level included Chhattisgarh with 76% followed by Haryana 30% and Uttar Pradesh 28% and on the other hand, a majority of claims were pending at the SHA level in Mizoram at 71%, Himachal Pradesh at 67% and Goa at 60%.
While in case of Nagaland, 34% of claims were pending at hospitals, 19% each of claims pending at ACO and banks and 14% each of claims pending at SHA and CEX/CPD.
Assam and Gujarat had the highest number of claims pending for payment with the ACO while Jharkhand and Meghalaya had highest cases pending with banks.