Lok Sabha Question No. 4151 (UNSTARRED), answered on 2024-12-20
Subject: Claims Settlement under AB-PMJAY
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Shri Mohite Patil Dhairyasheel Rajsinh, Dr. Amol Ramsing Kolhe, Smt. Supriya Sule, Shri Sanjay Dina Patil, Prof. Varsha Eknath Gaikwad, Shri Amar Sharadrao Kale, Shri Nilesh Dnyandev Lanke, Shri Bajrang Manohar Sonwane, Shri Bhaskar Murlidhar Bhagare

## GOVERNMENTOFINDIA MINISTRYOF HEALTH AND FAMILYWELFARE DEPARTMENTOFHEALTH AND FAMILYWELFARE

## LOK SABHA UNSTARRED QUESTION NO. 4151 TO BE ANSWERED ON 20 TH DECEMBER, 2024

## CLAIMS SETTLEMENT UNDER AB-PMJAY

## 4151. SHRI BHASKAR MURLIDHAR BHAGARE:

DR. AMOLRAMSING KOLHE:

PROF. VARSHA EKNATH GAIKWAD:

SHRI BAJRANG MANOHAR SONWANE:

SHRI NILESH DNYANDEV LANKE:

SMT. SUPRIYASULE:

SHRI MOHITE PATILDHAIRYASHEEL RAJSINH:

SHRI SANJAY DINA PATIL:

SHRI AMAR SHARADRAO KALE:

Will the Minister of HEALTHAND FAMILYWELFARE be pleased to state:

- (a) the average time taken for settlement of claims under Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY);
- (b) the percentage of claims settled within the stipulated timeline during the last one year;
- (c) the number of Ayushman cards that have been created during the last three years in the State of Maharashtra, year-wise/district-wise;
- (d) the details of expenditure incurred on Out Patient Department (OPD) treatment and hospital admitted cases of the beneficiaries;
- (e) the details of the eligibility criteria and procedure prescribed to provide medical facility related benefits to the patients under the said Yojana; and
- (f) whether many SC/ST/OBC households from rural and remote areas have not been enrolled under AB-PMJAY thereby depriving them of the benefits therein and if so, the details thereof, along with the corrective steps taken/proposed to be taken in the regard?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI PRATAPRAO JADHAV)

- (a) and (b): Under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), claims are settled by respective State Health Agencies (SHAs). Funds are released to the State for implementation of the scheme after State government contributes their share. As per the

established process, the State Health Agencies then settle the claims within the stipulated time, subject to availability of funds and resolution of any queries for the cases.

Timely settlement of claims is one of the key parameters against which the scheme performance is measured. Therefore, the status of claim settlement under the scheme is constantly monitored to ensure that claims are settled within defined turnaround time. Additionally, the issue of overdue claims is also taken up regularly during State review meetings. Further, capacity building activities are organised for efficient claims settlement.

(c): District-wise details of number of Ayushman cards created during the last three years in the State of Maharashtra are at Annexure .

(d): AB-PMJAY provides free in-patient care only i.e. hospitalization. OPD services are not covered under the scheme. As on 30.11.2024, an expenditure of Rs.1.16 lakh crore has been incurred for the treatment of beneficiaries under the scheme.

(e): AB-PMJAY is a flagship scheme of the Government which provides health cover of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization to approximately 55 crore beneficiaries corresponding to 12.37 crore families constituting economically vulnerable bottom 40% of India ' s population. In the latest national master of the Health Benefit Package (HBP), the scheme provides cashless healthcare services related to 1961 procedures across 27 medical specialties.

The beneficiary families under AB-PMJAY were identified from the Socio-Economic Caste Census (SECC) of 2011 on the basis of 6 deprivation and 11 occupational criteria across rural and urban areas respectively. Further, in January 2022, on the basis of decadal growth rate of 11.7%, Government of India revised the beneficiary base to 12 crore families and provided the flexibility to States/UTs to use other databases for verification of beneficiaries against such SECC beneficiaries who could not be identified and verified. Many of the 33 States and Union Territories (UTs) implementing AB-PMJAY have further expanded the beneficiary base at their own cost using non-SECC data sources (including National Food Security Act, State specific datasets).

In March 2024, 37 lakh families of ASHA, Anganwadi Worker and Anganwadi Helpers were also included in the scheme. Further, on 29.10.2024, the Government of India expanded ABPMJAY to provide free treatment benefits of up to Rs. 5 lakh per year on a family basis to all senior citizens aged 70 years and above, irrespective of their socio-economic status.

(f): As on 05.11.2024, a total of 1.97 crore and 0.97 crore Ayushman cards have been issued to SC and ST beneficiaries respectively under AB-PMJAY. Further, States/UTs have adopted various beneficiary databases along with SECC database.

## District-wise details of number of Ayushman cards created during the last three years in the State of Maharashtra

| District                  | FY 2021-2022   | FY2022-2023   | FY2023-2024   |
|---------------------------|----------------|---------------|---------------|
| Ahmednagar                | 14,906         | 45,680        | 12,44,481     |
| Akola                     | 3,194          | 21,793        | 3,02,202      |
| Amravati                  | 18,213         | 51,058        | 4,93,344      |
| Beed                      | 4,869          | 23,480        | 4,61,926      |
| Bhandara                  | 2,101          | 25,067        | 2,96,360      |
| Buldhana                  | 8,730          | 23,706        | 3,87,987      |
| Chandrapur                | 4,265          | 1,45,062      | 3,34,018      |
| Chhatrapati Sambhajinagar | 2,627          | 19,407        | 6,05,017      |
| Dharashiv                 | 7,883          | 92,920        | 3,63,569      |
| Dhule                     | 6,624          | 23,766        | 4,37,940      |
| Gadchiroli                | 20,157         | 25,659        | 2,76,249      |
| Gondia                    | 4,548          | 35,561        | 2,51,961      |
| Hingoli                   | 10,196         | 27,782        | 2,61,487      |
| Jalgaon                   | 33,078         | 63,207        | 5,28,283      |
| Jalna                     | 11,190         | 1,03,860      | 4,32,353      |
| Kolhapur                  | 9,167          | 57,554        | 11,52,872     |
| Latur                     | 3,456          | 49,043        | 3,31,003      |
| Mumbai                    | 25,079         | 15,388        | 1,54,135      |
| Mumbai Suburban           | 48             | 13            | 6,22,380      |
| Nagpur                    | 12,101         | 42,550        | 10,37,254     |
| Nanded                    | 15,605         | 44,669        | 7,29,835      |
| Nandurbar                 | 6,323          | 22,701        | 2,94,305      |
| Nashik                    | 15,488         | 2,42,038      | 9,77,828      |
| Palghar                   | 1,228          | 13,344        | 3,19,662      |
| Parbhani                  | 3,504          | 26,901        | 3,48,330      |
| Pune                      | 76,852         | 53,079        | 8,84,642      |
| Raigad                    | 1,118          | 12,737        | 3,33,180      |
| Ratnagiri                 | 822            | 26,033        | 3,64,652      |
| Sangli                    | 10,647         | 61,964        | 7,70,520      |
| Satara                    | 2,910          | 67,776        | 6,79,748      |
| Sindhudurg                | 1,476          | 12,234        | 3,15,054      |
| Solapur                   | 11,038         | 52,952        | 6,37,982      |
| Thane                     | 10,702         | 58,592        | 5,29,288      |
| Wardha                    | 608            | 50,711        | 2,25,840      |
| Washim                    | 3,084          | 29,398        | 3,37,351      |
| Yavatmal                  | 7,034          | 99,408        | 2,65,648      |

Note Data as on 16.12.2024

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