CAG Reports AB-PMJAY Beneficiaries Required to Pay Despite Cashless Service Promise

In its recent performance audit report regarding the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the Comptroller and Auditor General of India (CAG) has recorded instances where beneficiaries were required to make payments for medical treatment, despite the program's primary aim of offering cashless medical services.

The AB-PMJAY is designed to furnish annual health coverage of up to Rs 5 lakh per family for secondary and tertiary care hospitalizations. It assures beneficiaries seamless access to medical services without needing physical documents or payments at the point of care which is typically a hospital.

The CAG's audit analysis of AB-PMJAY, recently presented in Parliament, highlighted the discrepancy between the scheme's intended framework and the actual practice. According to the CAG, the agreement established between the State Health Agency (SHA) and private Empanelled Health Care Providers (EHCPS) emphasizes the necessity for complete cashless treatment for PMJAY beneficiaries. The agreement explicitly mandates that once a patient is admitted to the hospital, expenses for diagnostic tests, medications, implants, and related services are to be covered by the hospital, as these costs are incorporated within the comprehensive package amount.

Nonetheless, the audit discovered instances in which patients were required to make payments as part of their treatment under PMJAY. For example, in Himachal Pradesh, 50 beneficiaries across five EHCPs were compelled to cover the costs of their diagnostic tests at other medical facilities, with the expenses incurred by the beneficiaries. However, the report did not mention the exact amount paid by the beneficiaries in these cases in view of the data being unavailable with the State Health Agency (SHA).

The audit further revealed that in Jammu and Kashmir, 459 patients at 10 public EHCPs had initially paid Rs 43.27 lakh directly from their own funds for medical treatment, and they were later reimbursed after the verification of bills. There are still 75 patients awaiting reimbursement, which totals to Rs 6.70 lakh.

Similarly, in Jharkhand, the report noted that the insurance company identified that 36 patients at Life Care Hospital in Godda had paid different amounts for medicines, injections, and blood. The SHA is not in possession of the detailed expense records. Upon the insurance company's findings, the SHA sought an explanation from the concerned hospital within five days or face penalties. However, the hospital failed to provide the explanation, and SHA has not initiated the required punitive action.

In Meghalaya a similar scenario was played out, where out of the 19,459 beneficiaries who received treatment from five private EHCPs between February 2019 and March 2021, 13,418 individuals (approximately 69%) had to make the additional payments totaling Rs 12.34 crore during the discharge process.

In response to these findings, the National Health Authority (NHA) stated in August 2022 that the out-of-pocket expenses might be due to a lack of available health facilities. The audit, however, suggests that hospitals should collaborate with various interconnected service providers to ensure that beneficiaries receive free services.