PMJAY Fraud and Regulatory Concerns

  • March 14, 2025
  • Posted by: OptimizeIAS Team
  • Category: DPN Topics
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PMJAY Fraud and Regulatory Concerns

Sub : Schemes

Sec: Health

Key Points:

  • Fraudulent Activities in PMJAY:
    • 600 hospitals to be suspended due to fraudulent activities.
    • 1,113 hospitals removed from the panel.
    • Penalties of ₹122 crore to be imposed on 1,504 hospitals.
    • Recommendations were made by the National Health Authority’s anti-fraud unit.
  • Need for Regulation:
    • Stronger regulatory measures are needed to tackle fraud in the Pradhan Mantri Jan Arogya Yojana (AB-PMJAY).
    • The Parliamentary Standing Committee on Health and Family Welfare highlighted the necessity of addressing systemic fraud and unethical practices.
  • Government Response:
    • The National Health Authority (NHA) follows a zero-tolerance policy towards fraud and abuse.
    • Measures are being taken to prevent, detect, and categorize different fraud types.
  • AB-PMJAY Benefits:
    • Provides annual health coverage of ₹5 lakh per family for secondary and tertiary hospital treatment.
    • Benefits 12.37 crore families, covering about 40% of India’s population.
  • Future Recommendations:
    • A proactive, data-driven monitoring system is required to identify fraud early.
    • Adoption of AI-based technologies, digital tools, and analytics to prevent fraud.
    • The NHA should take corrective measures to address regulatory shortcomings.

National Health Agency (NHA)

  • National Health Agency was restructured as the “National Health Authority” for better implementation of Pradhan Mantri – Jan Arogya Yojana (PM-JAY).
  • It is an attached office to Ministry of Health & Family Welfare.
  • It replaced multi-tier decision making structure of National health Agency and has been replaced with the Governing Board chaired by the Minister of Health & Family Welfare, Government of India which will enable the decision making at a faster pace, required for smooth implementation of the scheme.
  • It will have due representations from the Government, domain experts, etc. Besides, the States shall also be represented in the Governing Board on rotational basis.
  • It will have full accountability, authority and mandate to implement PM-JAY through an efficient, effective and transparent decision-making process.

Ayushman Bharat, a flagship scheme of Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to “leave no one behind.”

Ayushman Bharat is an attempt to move from sectoral and segmented approach of health service delivery to a comprehensive need-based health care service. This scheme aims to undertake path breaking interventions to holistically address the healthcare system (covering prevention, promotion and ambulatory care) at the primary, secondary and tertiary level. Ayushman Bharat adopts a continuum of care approach, comprising of two inter-related components, which are –

  • Health and Wellness Centres (HWCs)
  • Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Health and Wellness Centres (HWCs)

  • In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres. These centres are to deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people. They cover both, maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.
  • Health and Wellness Centers are envisaged to deliver an expanded range of services to address the primary health care needs of the entire population in their area, expanding access, universality and equity close to the community. The emphasis of health promotion and prevention is designed to bring focus on keeping people healthy by engaging and empowering individuals and communities to choose healthy behaviours and make changes that reduce the risk of developing chronic diseases and morbidities.

Pradhan Mantri Jan Arogya Yojana (PMJAY)

  • AB-PMJAY was launched by the Prime Minister on 23rd September, 2018.
  • It is the “world’s largest government funded healthcare program” targeting more than 50 crore beneficiaries.
    • Over 10.74 crore vulnerable entitled families (approximately 50 crore beneficiaries) are eligible for these benefits.
  • It provides a cover of up to Rs. 5 lakhs per family per year, for secondary and tertiary care hospitalization.
    • The family cap is of five members.
  • It covers up to 3 days of pre-hospitalization and 15 days of post- hospitalization expenses such as diagnostics and medicines.
  • PMJAY provides cashless and paperless access to services for the beneficiary at the point of service.
  • NHA is the apex implementing agency of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY).
  • PM-JAY offers 1,949 treatment procedures across 27 medical specialties.
  • Eligibility:
    • The households included are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively.
    • The coverage mentioned under PM-JAY, therefore, also includes families that were covered in RSBY but are not present in the SECC 2011 database.
  • Cover Under PM-JAY-includes all expenses incurred on the following components of the treatment.
    • Medical examination, treatment and consultation
    • Pre-hospitalization
    • Medicine and medical consumables
    • Non-intensive and intensive care services
    • Diagnostic and laboratory investigations
    • Medical implantation services (where necessary)
    • Accommodation benefits.
    • Food services
    • Complications arising during treatment
    • Post-hospitalization follow-up care up to 15 days
PMJAY Fraud and Regulatory Concerns Schemes