Nagaland acts against 12 hospitals over PM-JAY, CMHIS violations

Twelve hospitals have faced action for alleged violations of norms under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and the Chief Minister's Health Insurance Scheme (CMHIS) in Nagaland, Health and Family Welfare Minister P Paiwang Konyak informed the state Assembly on September 1.

Of the 12 hospitals, six were penalised for violations under AB-PMJAY, while another six faced action for alleged violations under CMHIS.

Replying to supplementary questions from MLA Kuzholuzo Nienu on whether empanelled hospitals could charge beneficiaries beyond the prescribed package rates, Konyak said additional charges could be levied only for services outside the approved package and with the patient's consent.

There are currently 64 hospitals empanelled under AB-PMJAY in Nagaland, the minister said.

AB-PMJAY provides health coverage of up to Rs 5 lakh, while Nagaland has extended the coverage to around 2.88 lakh households, compared with 2.59 lakh households covered under the Centre's 2011 Census-based allocation.

Konyak said beneficiaries could generate Ayushman cards at hospitals using Aadhaar and stressed the need to improve Aadhaar coverage among eligible beneficiaries.

He clarified that PM-JAY generally does not cover outpatient treatment, except for specified day-care procedures such as dialysis, minor surgeries and chemotherapy.

Beneficiaries facing unauthorised charges can lodge complaints with the Nagaland Health Policy Scheme (NHPS) grievance redressal cell, the minister said. Complaints are investigated and, if irregularities are established, beneficiaries may receive reimbursement while hospitals found guilty can face penalties.

According to Konyak, six AB-PMJAY hospitals, including facilities within and outside Nagaland, and six CMHIS hospitals were served show-cause notices, directed to reimburse beneficiaries and subsequently de-empanelled for violating scheme norms.

In his written reply, the minister said AB-PMJAY provides cashless coverage for secondary and tertiary hospitalisation, covering around 1,970 treatment procedures across 25 specialities. The coverage includes hospitalisation and specified day-care treatments such as dialysis, chemotherapy, radiation therapy and minor surgeries.

He said the National Health Authority also provides for unspecified surgical packages for eligible procedures that are not specifically listed, subject to prescribed criteria and approval under NHA guidelines.

However, outpatient services and certain procedures excluded under the PM-JAY policy, including cosmetic and aesthetic procedures, dental treatment and fertility services such as IVF and surrogacy, are not covered under the scheme, Konyak said.