Under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), 10.74 crore eligible households were identified initially from the Socio Economic and Caste Census (SECC) 2011, based on certain deprivation and occupational criteria in rural and urban areas respectively. Further, in January 2022, the Government of India revised the beneficiary base to 12 crore families, considering the decadal population growth rate of 11.7% and gave the flexibility to States/UTs to use other databases of schemes meant for similar socio-economic profile which are aadhaar verified. In March 2024, 37 lakh families of Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHs) were also included in the scheme. Further, on 29.10.2024, the government expanded AB-PMJAY to provide free treatment benefits of up to ₹5 lakh per year to all senior citizens aged 70 years and above along with their families, irrespective of their socio-economic status. In addition, many States/UTs implementing AB-PMJAY have expanded the beneficiary base under the scheme, at their own cost.

To eliminate ineligible beneficiaries from the scheme, AB-PMJAY beneficiaries are verified through Aadhaar e-KYC at the time of creation of the card. Further, beneficiaries have to undergo Aadhaar authentication at the time of availing services. Aadhaar-authentication helps establish the identity of the eligible beneficiary.

National Health Authority (NHA) has adopted a zero-tolerance policy towards misuse and abuse and has been taking steps for prevention, detection, and deterrence of different kinds of irregularities that could occur in AB-PMJAY at different stages of its implementation.

NHA uses artificial intelligence technologies to detect potential cases of misuse in AB-PMJAY. Technologies deployed include rule-based triggers and Machine Learning algorithms, fuzzy logic, image classification and de-duplication, etc.

Such cases are checked through desk audits, field investigation subsequent to which appropriate action is taken including disabling of the Ayushman Cards, penalty, recovery or legal action is taken against the errant entity. This prevents any leakage or wastage of public funds.

NHA has well-established audit mechanism and guidelines. NHA and State Health Agencies (SHAs) conduct regular desk medical audits as well as field audits at the premises of the Empanelled Health Care Providers (EHCPs). Any malpractices observed during these audits are taken up seriously with Empanelled Health Care Providers (EHCPs) and State Health Agencies (SHAs) are asked to ensure that monies are deducted from and/or penalties are levied against such EHCPs. These may include recovery, de-empanelment and/or initiating criminal case. All these act as deterrence mechanisms. As a result of the stringent measures undertaken, disciplinary actions have been taken against various entities. A total of 1,114 hospitals have been de-empanelled, and 549 hospitals have been suspended under AB-PMJAY and penalties amounting to ₹122 crore have been levied on over 1,504 hospitals.

The Union Minister of State for Health and Family Welfare, Shri Prataprao Jadhav stated this in a written reply in the Rajya Sabha today.

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