Maharashtra
Mahatma Jyotirao Phule Jan Arogya Yojana
Main benefit
The scheme provides coverage for meeting all expenses relating to the hospitalization of beneficiaries up to ₹ 1,50,000/- per family per policy year.
Can you get this scheme?
Conditions at a glance
- Family income up to ₹1 lakh a year
About
Mahatma Jyotirao Pule Jan Arogya Yojana is the flagship health insurance scheme of the Government of Maharashtra. The scheme provides end-to-end cashless services for identified diseases through a network of service providers from the Government and Private sector. The scheme earlier was known as Rajiv Gandhi Jeevandayee Arogya Yojana which was started on 2nd July 2012 in eight districts and then was expanded to 28 districts of Maharashtra from 21st November 20
3.
OBJECTIVE:
To provide cashless quality medical care to beneficiaries under the scheme for catastrophic illnesses requiring hospitalization for surgeries and therapies under identified specialty services through a network of health care providers.
Note: The Integrated Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) and Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) were launched in the state on 1st April, 20
0. United India Insurance Company Limited (a Public sector Undertaking Company) provides health insurance coverage to beneficiaries under the insurance mode and the State Health Assurance Society provides coverage in assurance mode. State Health Assurance Society is paying an insurance premium of ₹ 797/- per family per year to the Insurance Company in quarterly installments on behalf of eligible beneficiary families.
Benefits
- The scheme provides coverage for meeting all expenses relating to the hospitalization of beneficiaries up to ₹ 1,50,000/- per family per policy year. For Renal Transplants, this limit has been enhanced up to ₹ 2,50,000/- per family per policy year.
- The benefit is available to every member of the family on a floater basis, i.e., the total coverage of ₹ 1,50,000/- or ₹ 2,50,000/- as the case may be, can be availed by one individual or collectively by all members of the family in the policy year.
- Benefit Coverage:
- This is a package medical insurance scheme to cover hospitalization for Medical and Surgical procedures through cashless treatment concerning the following 34 identified specialties. MJPJAY beneficiary gets a benefit of 996 Medical and Surgical procedures with 121 follow-up procedures. There are 131 government-reserved procedures out of 996 MJPJAY procedures.
- Specialized Categories are under follows:-Burns
- CardiologyCardiovascular and Thoracic surgery
- Critical Care
- DermatologyEndocrinologyENT surgery
- General Medicine
- General Surgery
- HaematologyInfectious diseases
- Interventional Radiology
- Medical GastroenterologyMEDICAL ONCOLOGYNeonatal and Pediatric Medical Management
- NephrologyNeurology
- NeurosurgeryObstretrics and Gynecology
- OphthalmologyOrthopedics
- Pediatric Surgery
- Pediatric Cancer
- Plastic Surgery
- PolytraumaProsthesis and Orthosis
- PulmonologyRadiation Oncology
- RheumatologySurgical Gastroenterology
- Surgical Oncology
- Urology (Genitourinary Surgery)Mental disorders
- Oral and Maxillofacial Surgery
- Note: 1209 packages include bed charges in General ward, Nursing and boarding charges, Surgeons and Anesthetists charges, Medical Practitioner and Consultants fees, Oxygen, O.
- T. & ICU Charges, Cost of Surgical Appliances, Cost of Drugs, disposables, consumables, implants, Cost of Prosthetic Devices, Cost of Blood Transfusion (Blood to be provided as per policy of State Government), 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). The package covers 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.
Who can apply
- Beneficiaries under Mahatma Jyotirao Phule Jan Arogya Yojana:
- Category
- Description of Beneficiaries
- Category AFamilies holding Yellow ration card, Antyodaya Anna Yojana ration card (AAY), Annapurna ration card, Orange ration card (annual income up to ₹ 1,00,000) issued by Civil Supplies Department, Government of Maharashtra for 36 districts of Maharashtra.
- Category BWhite ration card holder farmer families from 14 agriculturally distressed districts of Maharashtra (Aurangabad, Jalna, Beed, Parbhani, Hingoli, Latur, Nanded, Osmanabad, Amravati, Akola, Buldhana, Washim, Yavatmal, and Wardha).
- Category C
- 1. Children of Government Orphanages, Students of Government Ashram Shala, Female Inmates of Government Mahila Ashram, and Senior Citizens of Government Old Age Homes.
- 2. Journalists & their dependent family members approved by DGIPR
- 3. Construction workers and their families have live registration with the Maharashtra Building & Other Construction Worker Welfare Board.
- Identification of beneficiaries under Mahatma Jyotirao Phule Jan Arogya Yojana :
- Category Description of Beneficiaries
- Category AAll eligible families shall be identified with valid Yellow, Orange, Antyodaya, and Annapurna ration cards (irrespective of the date of issue of the Ration Card or the inclusion of the beneficiary's name therein) coupled with any Photo ID proof (as finalized by the Society).
- Category BEligibility for farmers from 14 agriculturally distressed districts of Maharashtra will be decided based on a white ration card with 7/12 extract bearing the name of the beneficiary/head of the family or certificate from the nearest Revenue Officer stating that the beneficiary is a farmer or a family member of a farmer with valid photo ID proof of the beneficiary.
- Category CThe eligibility of beneficiaries shall be decided based on any identity card/health card or any other identification mechanism as decided by the State Health Assurance Society (SHAS).
Documents needed
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How to apply
Online
The complete process of treatment of the beneficiary in Maharashtra Network Hospital is given below:
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Beneficiaries shall approach the nearby Empanelled Network Hospital. Arogyamitras placed in the hospitals shall facilitate the beneficiary. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the vicinity and can get a referral letter based on the diagnosis.
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The Arogyamitra at the network hospitals examines valid ration cards and Photo IDs and enrolls the patient along with registration. The information like admission notes, and tests done will be captured in the dedicated database by the Medical Coordinator of the Network Hospital as per the requirement of the scheme.
- 3
If the procedure falls in 996 procedures for the MJPJAY beneficiary and 1209 procedures for the PMJAY beneficiary, the e-preauthorization request is raised by the Hospital by attaching mandatory documents.
- 4
Medical Specialists of the Insurer shall examine the preauthorization request and approve preauthorization if all the conditions are satisfied. If preauthorization is rejected, it is referred to a technical committee consisting of the CMO of TPA and the CMC of SHAS as the second step. If there is a difference of opinion between the CMO of TPA and the CMC of SHAS, the case is referred to ADHS- SHAS as the third step. The decision of ADHS for approval or rejection of preauthorization is final.
- 5
After preauthorization is approved, the procedure shall be performed within 30 days by a Private Hospital and within 60 days by a Public Hospital. After that, the preauthorization gets auto-canceled. SHAS shall have the right to re-open auto-cancelled preauthorizations of Government Hospitals. Turnaround time for a decision on preauthorization is 12 hours. In case of emergencies, the medical/surgical preauthorization approval has to be taken by the MCO over telephone Emergency Telephonic Intimation (ETI) which has a voice recording facility.
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The Network Hospital extends cashless Medical or Surgical treatment to the beneficiary. The Post-operative / daily treatment notes of the Network Hospitals will be updated daily on the portal by the medical coordinator of the Network Hospital.
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Network Hospital after performing Medical or surgical procedures uploads diagnostics reports and discharge Summary duly signed by the officials appointed by the Hospital, along with acknowledgment of payments of transportation costs and other documents as per operational guidelines. If the procedure falls in the category of follow-up procedures, follow-up details will be informed to the patient at the time of discharge by the Hospital. It will also be the responsibility of Aarogymitra to educate the patient about follow-up procedures (if eligible) and related details.
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The Network Hospital shall provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge.
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The Insurer scrutinizes the bills in light of the operational guidelines and mandatory investigations and pays claims as per the agreed package rates and grade of the Hospital. The Insurance Company shall settle the claims of the hospitals online within 15 working days of receipt of the complete claim document from the Network Hospital. Note 1: The claim settlement module along with electronic clearance and the payment gateway will be part of the workflow in the State Health Assurance Society (SHAS) portal and will be operated by the Insurer. Note 2: The reports will be available for scrutiny on the State Health Assurance Society (SHAS) login.
Common questions
What is the full form of MJPJAY?
MJPJAY's full form is Mahatma Jyotiba Phule Jan Arogya Yojana.
When was MJPJAY started?
MJPJAY was launched in 28 districts of Maharashtra on April 1st, 2020.
What is the objective of MJPJAY?
MJPJAY aims to provide cashless, quality medical care to the beneficiaries under the scheme for catastrophic illnesses requiring hospitalization for surgery and treatment under identified specialized services through a network of health care providers.
How much assistance is available under MJPJAY Yojana?
MJPJAY Yojana 2024 provides coverage up to ₹ 1,50,000/- per policy year per family to meet all expenses related to hospitalization of the beneficiary. For renal transplants, this limit has been increased to ₹ 2,50,000/- per family per policy year.
Who is eligible for receiving Maintenance Haemodialysis treatment under MJPJAY?
A patient suffering from chronic kidney disease requiring maintenance HD and who has a health card is eligible. If the patient does not have a health card, he or she should have an orange or yellow ration card or an Antyodaya or Annapurna card along with valid ID proof.
Which services are provided under package of Maintenance Haemodialysis under MJPJAY for the patient?
The package includes pre- and post-treatment diagnostics,consultation, hospital charges, consumables, and medicines. The detailed package is as follows: >> Investigations Creatinine tests (Monthly) Complete blood count (CBC, Monthly) HIV/Hep.A/Hep.C tests (once every three months) Serum electrolytes (as per advise) Blood glucose, if required >> Consultion Clinical examination by Nephrologist/Medical Cordinator. >> Consumable -Dialyser (It will be used upto optimal capacity and replaced if needed free of charge under scheme), - Tubing (It will be used upto optimal capacity and replaced if needed free of charge under scheme), - Fistula Needle (It will be used upto optimal capacity and replaced if needed free of charge under scheme). - IV fluids, - Haemodialysis Part A/B and o Heparin. >> Medicines Inj.
Erythropoetin, as per the advice of Nephrologist What should be frequency of dialysis cycles under MJPJAY for each approved preauth?
The frequency of dialysis should be a minimum of 8 cycles and a maximum of 12 cycles, as recommended by the nephrologist or medical coordinator based on his or her serum creatinine level.
Does patient have to pay any extra money for treatment?
No. The patient should not pay any extra money to the hospital or center for services that are covered under the approved package.
Will Balance Sum Insured used for dialysis patient limit other household members to avail services under MJPJAY?
The maximum sum assured under MJPJAY is ₹ 1,50,000/- per family, on a family-floater basis. If the dialysis patient has utilized a particular amount from the sum assured, other family members can still avail services under MJPJAY till the total amount of ₹ 1,50,000/- gets exhausted. This amount of
Sum Insured cannot get extended under any circumstances (except if patient requires a renal transplant, where BSI will be considered as ₹ 2,50,000/-)Can HIV or HCV positive cases avail Maintenance Haemodialysis service under MJPJAY ?
Yes. If a patient is a beneficiary of MJPJAY and is HIV or HCV positive, then he or she can still avail services under MJPJAY. Empanelled hospitals and stand-alone dialysis centers must have dedicated machines for HIV or HCV-positive patients. Under no circumstances shall these units be used for other patients.
If patient requires blood transfusion, is cost of blood transfusion covered under package?
No. Maintenance Haemodialysis package does not cover the cost of a blood transfusion.
In case of a query or to register a complaint what should I do ?
In case of a query, you can contact Arogyamitra or call the toll-free number. Arogyamitra is available round the clock in the hospital or center and will facilitate and guide you if any problem arises. But if you are not satisfied, then call our toll-free numbers, 155388 or 18002332200, to register a complaint.