National Health Entitlement Card

The National Health Entitlement Card is generally a government-issued credential that entitles the card-holder to access certain healthcare benefits under public health schemes. In the Indian context, this often refers to the “Ayushman Bharat / PM-JAY (Pradhan Mantri Jan Arogya Yojana) card”, sometimes loosely called an entitlement or health card.

Purpose and Role

• It acts as proof of eligibility under a health insurance or assurance scheme, allowing beneficiaries to access cashless hospitalisation at empanelled public or private hospitals.
• It reduces financial barriers for low-income and vulnerable citizens by covering costs of secondary and tertiary care.
• It ensures portability of benefits, enabling beneficiaries to use the card across different states and hospitals in the country.
• It helps the implementing authority to track utilisation, prevent fraud, and monitor scheme performance.

Key Features

• Coverage Amount: Under schemes like PM-JAY, the card enables coverage of up to ₹5 lakh per family per year for eligible tertiary and secondary healthcare services.
• No Upfront Payment: Beneficiaries do not need to pay at the time of service; the hospital bills are settled directly by the scheme.
• Pre- and Post-Hospitalisation Benefits: It often covers associated diagnostic, medicine, and treatment costs for a few days before and after hospitalisation.
• No Family Size or Age Restriction: All family members are covered under the card without discrimination by age or gender.
• Inclusion of Pre-Existing Conditions: Treatment for pre-existing conditions is included from day one in many versions of the scheme.
• Nationwide Portability: The card’s benefits are accepted across empanelled hospitals throughout the country, not just within one region.

Eligibility and Issuance

• Eligibility is usually based on socioeconomic criteria (for example, data from census surveys or deprivation indices).
• Households identified as poor or vulnerable are enrolled and issued cards after verification.
• A unique ID is assigned to each beneficiary family or individual, and physical or digital versions of the card are provided.
• The card is often linked with national identity systems (such as Aadhar) for verification and authentication.

Advantages

• Access to Healthcare: Families that could not afford expensive treatments gain access to quality care.
• Financial Protection: Reduces out-of-pocket expenditure and prevents health-related impoverishment.
• Equity: Helps extend universal health coverage to underserved populations.
• Transparency & Monitoring: Makes tracking of services and costs easier for administrators.
• Ease of Use: Simplifies procedures, reducing paperwork and delays for patients.

Challenges and Limitations

• Awareness Gaps: Many eligible persons may not know about the card or how to use it.
• Fraud & Misuse: Instances of hospitals inflating claims or enrolling ineligible beneficiaries can occur.
• Infrastructure Gaps: Rural areas or remote districts might lack sufficient empanelled hospitals or proper facilities.
• Service Quality Variation: The standard of care under the scheme can vary greatly between hospitals.
• Administrative Delays: Delays in card issuance or verification may hamper access to treatment.
• Scheme Limitations: Some services (e.g. outpatient care, certain therapies) may be excluded.