Even as Odisha, Delhi and West Bengal are the only three states that have put 'No Entry' sign for the Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), otherwise known as Modicare, the biggest health insurance scheme in the world will soon don the pan Indian hues.
Either later this year or early next year, Modicare will make its debut in Odisha. This will become possible as the Employment State Insurance Corporation (ESIC), under the Union Ministry of Labour, has recently entered into an agreement with the National Health Authority - the implementing agency of Modicare.
As per the MoU, nearly 14 crore ESIC beneficiaries may avail of cashless medical services under the Pradhan Mantri Jan Arogya Yojana (PMJAY). The benefit is currently (as of Jan 31, 2022) available in 157 districts of the country. The Ministry will extend the facility to the whole of 735 districts in phases.
Significantly, ESIC insured persons in 12 states namely Assam, Chhattisgarh, J&K, Ladakh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Manipur, Nagaland, Rajasthan and Tripura have been integrated with AB-PMJAY.
Since the integration of ESIC with Modicare depends upon the availability of ESI medical facilities and Insured Persons (IP) coverage in that area, in the next expansion phase, around 4-6 districts, including a couple in western Odisha, will be brought under the AB-PMJAY scheme, said ESIC sources here.
ESIC Beneficiaries In Odisha
As per the data available with ESIC regional office in Bhubaneswar, there are over 28.7 lakh beneficiaries in Odisha. The beneficiaries in Jharkhand and Chhattisgarh have been lower at 17.3 lakh and 19.5 lakh, respectively.
The latest data shows that the total ESIC subscribers nationally stands at over 19 crore. The agency has added 5.42 crore new subscribers between September 2017 and July 2021.
What Is ESIC?
Employee State Insurance scheme is conceptualised to cover workers from certain health-related contingencies such as permanent or temporary disablement, sickness, death due to employment injury or occupational disease, which impacts the earning capacity of the worker or leads to loss of income. In sum, the legislation has been enacted by the Union government to provide social security to organised sector workers.
The Employees’ State Insurance Act, 1948 is applicable to non-seasonal, manufacturing establishments employing 10 or more workers. For health and medical institutions, the threshold limit is 20 or more workers. The wage ceiling is Rs 21,000 per month.
In contrast, the AB-PMJAY or Modicare is a universal health assurance scheme. This is not applicable to organised sector workers alone. The scheme provides cashless secondary and tertiary health care services to even destitute, primitive tribal groups and bonded labour.
The Key Takeaway
As the Odisha government has red-flagged the Modicare, the PMJAY cannot become universal in the State, though the scheme will cover around 28 lakh beneficiaries in Odisha via the ESIC route before the 2024 General Elections.
However, the Centre is planning to extend Modicare to employees of all Central government employees under the CGHS (Central Government Health Scheme) and Railways route before the 2024 elections.
Odisha has red signalled Modicare and has rolled out Naveencare. Here is a comparison between the two rival schemes.
- As per Union Health Ministry, AB-PMJAY is the world’s largest Government funded health assurance scheme.
- PMJAY provides health assurance up to Rs.5 Lakh per family per year for secondary
and tertiary healthcare hospitalizations.
- It is a completely cashless and paperless scheme.
- The benefits under the scheme are portable across the country.
- There is no cap on family size, age or gender.
- The automatically enrolled beneficiary families are households without shelter, people living on alms, manual scavenger families, primitive tribal groups, landless labourers and bonded labourers.
- The scheme can also be availed by a household dwelling in one room with kutcha walls and roof, construction workers, street vendors, coolies and all those households identified under the deprivation criteria by the SECC 2011.
- The total hospitalisations since launch has reached 2 crore.
- Over 16 crore Ayushman cards distributed across 33 states/UTs
- This is also a health assurance scheme funded by the Government of Odisha.
- Provides health assurance up to Rs.5 Lakh per family per year and Rs 10 lakh for women members per annum for secondary and tertiary healthcare hospitalizations.
- The auto-enrolment facility is available for cardholders of Biju Krishak Kalyan Yojana, RSBY, BPL and AAY.
- However, all those low-income households, who don't have any such card, have to acquire an annual income (below Rs 50,000 in rural and Rs 60,000 in urban areas) certificate from district-level officials.
- The number of Naveencare cards distributed is not available. But the target is 3.5 cr.
- The State government has not placed the hospitalisation data in the State Assembly.
- It has only provided the data on free medical services availed by people at all levels in the State.