Comptroller and Auditor-General of India’s (CAG) performance audit report flagged irregularities in the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY).
Ayushman Bharat-PMJAY
- PM-JAY is the world’s largest health insurance scheme fully financed by the government.
- Launched in February 2018, it offers a sum insured of Rs.5 lakh per family for secondary care and tertiary care.
- Health Benefit Packages covers surgery, medical and day care treatments, cost of medicines and diagnostics.
- It is an entitlement-based scheme that targets the beneficiaries as identified by latest Socio-Economic Caste Census (SECC) data.
- The National Health Authority (NHA) has provided flexibility to States/UTs to use non- Socio-Economic Caste Census (SECC) beneficiary family databases with similar socio-economic profiles for tagging against the leftover (unauthenticated) SECC families.
Funding
- The funding for the scheme is shared – 60:40 for all states and UTs with their own legislature, 90:10 in Northeast states and Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs without legislature.
Nodal Agency
- The National Health Authority (NHA) has been constituted as an autonomous entity under the Society Registration Act, 1860 for effective implementation of PM-JAY in alliance with state governments.
- The State Health Agency (SHA) is the apex body of the State Government responsible for the implementation of AB PM-JAY in the State.
Issues Highlighted By CAG
Treatment of Dead Patients
- The patients earlier shown as “dead” continued to avail treatment under the scheme.
- The maximum number of such cases were in Chhattisgarh, Haryana, Jharkhand and minimum number of such cases were from Andaman & Nicobar Islands, Assam and Chandigarh.
- 88,760 patients died during treatment specified under the Scheme. A total of 2,14,923 claims shown as paid in the system, related to fresh treatment in respect of these patients.
Unrealistic Household Sizes
- There are instances where the registered household sizes were unrealistically large, ranging from 11 to 201 members.
- Such discrepancies suggest a lack of proper validation controls during the beneficiary registration process.
Pensioners Availing Benefits
- Pensioners in certain states were found to possess PMJAY cards and were availing treatment under the scheme.
- Delayed actions to remove ineligible beneficiaries from the scheme led to ineligible individuals receiving benefits under the PMJAY.
Bogus Mobile Number and Aadhaar
- It revealed that some beneficiaries were registered with a single bogus mobile number, potentially compromising the verification process.
- Similarly, some Aadhaar numbers were linked to multiple beneficiaries, raising questions about proper verification.
Systemic Failures
- CAG’s report unearthed systemic issues, including private hospitals performing public hospital-reserved procedures, infrastructural inadequacies, equipment shortages, and medical malpractice cases.
- Absence of adequate validation controls, invalid names, unrealistic date of birth, duplicate PMJAY IDs.
- In several States and UTs, the available equipment in empanelled hospitals were found to be non-functional.