Ayushman Bharat PM-JAY: India’s Landmark Universal Health Insurance Program

India’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana—commonly known as PM-JAY—is the world’s largest government-funded health insurance scheme and one of the most ambitious public health initiatives ever launched. Announced by Prime Minister Narendra Modi on Independence Day 2018 and officially rolled out on September 23, 2018, PM-JAY aims to reduce catastrophic out-of-pocket health expenditure for the country’s most vulnerable families. Under this program, eligible families receive health coverage of up to ₹5 lakh (approximately USD $6,000) per family per year at any empanelled public or private hospital across India—completely cashless and paperless at the point of care.

What makes PM-JAY truly extraordinary is its scale. The program targets approximately 12 crore (120 million) poor and vulnerable families—translating to roughly 55 crore (550 million) individual beneficiaries—making it not just the largest health assurance scheme in India, but in the entire world. For comparison, PM-JAY covers more people than the entire population of the United States, the European Union, and Japan combined. It has transformed the healthcare landscape for hundreds of millions of Indians who previously faced the impossible choice between seeking medical treatment and falling into poverty.

Opportunity Snapshot

Program Overview and Scale

Ayushman Bharat PM-JAY was created as a core component of the broader Ayushman Bharat initiative, which the Government of India designed as a two-pillar approach to achieving Universal Health Coverage (UHC). The first pillar involves the creation of 150,000 Health and Wellness Centers (HWCs) that deliver comprehensive primary healthcare close to communities. The second pillar—PM-JAY—provides financial protection against the high costs of hospitalization.

The sheer magnitude of PM-JAY is difficult to overstate. Since its inception, the program has facilitated over 7 crore (70 million) hospital admissions and authorized treatments worth over ₹90,000 crore (approximately USD $11 billion). Every single day, tens of thousands of Indians receive cashless treatment at empanelled hospitals under this scheme.

PM-JAY is a centrally sponsored scheme, with costs shared between the Central Government and State Governments in a ratio of 60:40 for most states, 90:10 for northeastern states and special category states, and 100% Central funding for Union Territories without legislatures. This cooperative federalism model allows states to customize implementation while maintaining national standards.

The program also serves as a major driver of healthcare infrastructure development. Thousands of private hospitals across India have become empanelled under PM-JAY, increasing healthcare access in underserved areas. The scheme incentivizes hospitals to provide quality care at pre-defined package rates, which has helped bring transparency and standardization to healthcare pricing in India.

How PM-JAY Works

The PM-JAY system is designed to be as frictionless as possible for the beneficiary. Here is how the program operates from the patient’s perspective:

1. Identification: Families identified as eligible through the Socio-Economic Caste Census (SECC) 2011 data are automatically entitled to benefits. No separate application or enrollment is required to be “in the system”—if your family is on the SECC list, you are eligible.

2. Ayushman Card: Beneficiaries obtain a free Ayushman Card (e-card) that serves as their identification document at empanelled hospitals. This card can be generated at any empanelled hospital, Common Service Center (CSC), or through the Ayushman App.

3. Hospital Visit: When a beneficiary needs hospitalization, they visit any PM-JAY empanelled hospital—public or private—anywhere in India. The scheme is fully portable, meaning a beneficiary registered in one state can seek treatment in any other state.

4. Cashless Admission: The hospital verifies the beneficiary’s identity using the Ayushman Card or Aadhaar number, checks eligibility through the PM-JAY IT platform, and admits the patient without requiring any upfront payment.

5. Treatment: The hospital provides the required medical treatment. All costs—including diagnostics, medications, room charges, surgeon fees, and follow-up care—are covered under the scheme up to the package rate defined by the NHA.

6. Claim Settlement: After treatment, the hospital submits the claim to the State Health Agency (SHA) or the designated insurance company. Claims are processed and paid directly to the hospital. The beneficiary pays nothing.

This cashless, paperless model eliminates the financial barrier to seeking medical care—a critical factor in a country where an estimated 6 crore (60 million) people fall below the poverty line every year due to healthcare expenses.

Coverage Details

PM-JAY provides comprehensive coverage for secondary and tertiary hospitalization. Here is a detailed breakdown of what the scheme covers:

What Is Covered

• Hospitalization expenses: Room charges, nursing and boarding charges in the general ward
• Pre-hospitalization costs: Diagnostic tests and medications up to 3 days before admission
• Post-hospitalization costs: Follow-up care, medications, and diagnostics up to 15 days after discharge
• Surgeon and doctor fees: All specialist consultation and procedure fees during hospitalization
• Diagnostics and lab tests: Blood tests, X-rays, MRIs, CT scans, and other investigations during hospitalization
• Medications: All drugs and consumables required during the hospital stay
• Intensive Care Unit (ICU): ICU charges including ventilator support
• Implants and prostheses: Knee replacements, hip replacements, cardiac stents, pacemakers, and other medical devices
• Day-care procedures: Procedures that require less than 24 hours of hospitalization, such as dialysis and chemotherapy
• Food for the patient: Meals during the hospital stay
• Complications during treatment: Any complications arising from the treatment are covered
• Pre-existing conditions: All pre-existing diseases are covered from the first day of enrollment

What Is Not Covered

• Outpatient consultations: Doctor visits that do not require hospitalization (these are addressed through the HWC pillar)
• Cosmetic surgery: Procedures done purely for cosmetic or aesthetic reasons
• Fertility treatments: IVF and other assisted reproductive technologies
• Organ transplantation: While some transplant-related procedures are covered, organ procurement costs are typically excluded
• Drug rehabilitation: Substance abuse treatment programs

Coverage Cap

The ₹5 lakh annual coverage is a family floater, meaning the entire family shares the ₹5 lakh limit. There is no cap on family size—whether a family has 2 members or 12, all are covered under the same ₹5 lakh pool. The coverage resets every year on the policy anniversary date.

List of Covered Treatments

PM-JAY covers 1,949 treatment packages spanning 27 medical and surgical specialties. These packages are defined with specific rates that hospitals must adhere to, ensuring cost transparency and preventing overcharging. Key specialties and procedures include:

• Cardiology and Cardiothoracic Surgery: Coronary artery bypass grafting (CABG), angioplasty with stent placement, heart valve replacement, pacemaker implantation
• Orthopedics: Total knee replacement, total hip replacement, fracture fixation, spinal surgery, arthroscopy
• Oncology (Cancer Treatment): Chemotherapy, radiation therapy, surgical excision of tumors, mastectomy, bone marrow transplantation
• Neurosurgery: Brain tumor surgery, spinal cord procedures, aneurysm clipping, craniotomy
• Urology: Kidney stone removal (lithotripsy), prostatectomy, nephrectomy, bladder surgery
• General Surgery: Appendectomy, hernia repair, cholecystectomy (gallbladder removal), thyroidectomy
• Ophthalmology: Cataract surgery with intraocular lens implantation, glaucoma surgery, retinal procedures
• ENT (Ear, Nose, Throat): Tonsillectomy, septoplasty, cochlear implant surgery, tympanoplasty
• Obstetrics and Gynecology: Cesarean section, hysterectomy, treatment of ectopic pregnancy
• Pediatric Surgery: Neonatal surgeries, congenital defect corrections
• Burns and Plastic Surgery: Burns management, skin grafting, reconstructive surgery
• Nephrology: Dialysis (both hemodialysis and peritoneal dialysis), AV fistula creation
• Pulmonology: Treatment for respiratory conditions requiring hospitalization, including COVID-19 treatment (added during the pandemic)
• Mental Health: Inpatient psychiatric care and treatment for acute mental health conditions

The complete list of packages with their defined rates is publicly available on the PM-JAY website and is updated periodically by the NHA based on medical cost analysis and stakeholder consultation.

Eligibility Criteria

PM-JAY eligibility is determined primarily through the Socio-Economic Caste Census (SECC) 2011 database. The scheme targets the bottom 40% of India’s population based on specific deprivation and occupational criteria.

Rural Eligibility (Based on SECC 2011 Deprivation Criteria)

Families in rural areas are eligible if they meet any one of the following seven deprivation criteria:

• Households with only one room, kuccha (mud/thatch) walls, and kuccha roof
• Households with no adult member between ages 16 and 59
• Female-headed households with no adult male member between 16 and 59
• Households with a disabled member and no able-bodied adult member
• Scheduled Caste or Scheduled Tribe households
• Households with no literate adult member above age 25
• Landless households that derive a major part of their income from manual casual labor

Additionally, families that are automatically included regardless of other criteria:

• Households without shelter (homeless)
• Destitute or living on alms
• Manual scavenger families
• Primitive tribal groups
• Legally released bonded laborers

Urban Eligibility (Based on SECC 2011 Occupational Categories)

In urban areas, families are eligible if the primary breadwinner’s occupation falls in any of the following 11 categories:

• Ragpicker
• Beggar
• Domestic worker
• Street vendor / cobbler / hawker / other service provider on the street
• Construction worker / plumber / mason / labor / painter / welder / security guard / coolie
• Sweeper / sanitation worker / mali (gardener)
• Home-based worker / artisan / handicraft worker / tailor
• Transport worker / driver / conductor / helper / cart puller / rickshaw puller
• Shop worker / assistant / small establishment helper / delivery assistant / attendant / waiter
• Electrician / mechanic / assembler / repair worker
• Washer-man / chowkidar (watchman)

2024 Expansion: Senior Citizens Aged 70 and Above

In September 2024, the Government of India approved a significant expansion of PM-JAY to cover all senior citizens aged 70 years and above, regardless of their SECC 2011 status or income level. Under this expansion—called the Ayushman Bharat PM-JAY for Senior Citizens—eligible seniors receive a separate top-up cover of ₹5 lakh per year specifically for senior citizen family members, over and above any existing PM-JAY entitlement. This expansion is expected to benefit approximately 6 crore (60 million) senior citizens across 4.5 crore families.

How to Check Eligibility

There are multiple ways to check whether your family is eligible for PM-JAY benefits:

1. Online Through the PM-JAY Website

• Visit pmjay.gov.in
• Click on “Am I Eligible” or navigate to the beneficiary identification section
• Enter your mobile number and captcha to receive an OTP
• Search by name, ration card number, mobile number, or RSBY URN (Rashtriya Swasthya Bima Yojana number)

2. Ayushman App

• Download the official Ayushman App from the Google Play Store or Apple App Store
• Register with your mobile number
• Use the eligibility check feature by entering your Aadhaar number or other details

3. Common Service Centers (CSCs)

• Visit your nearest Common Service Center (there are over 400,000 across India)
• Provide your Aadhaar card or ration card
• The CSC operator will check your eligibility and can also generate your Ayushman Card on the spot

4. PM-JAY Helpline

• Call the toll-free helpline number 14555 or 1800-111-565
• Available in multiple languages
• Operators can verify your eligibility using your identification details

5. Empanelled Hospital Help Desks

• Every PM-JAY empanelled hospital has an Ayushman Mitra (help desk) at the reception
• Walk in with your Aadhaar card and ask the Ayushman Mitra to check your eligibility

Enrollment and Ayushman Card

One of the key features of PM-JAY is that eligible families do not need to formally “enroll” in the traditional sense. If your family is identified in the SECC 2011 database, you are automatically entitled to benefits. However, you do need to obtain an Ayushman Card (also called an Ayushman Bharat Health Account or ABHA-linked PM-JAY e-card) to access cashless treatment.

How to Get Your Ayushman Card

1. At an Empanelled Hospital: Visit any PM-JAY empanelled hospital. The Ayushman Mitra at the help desk will verify your identity using Aadhaar-based e-KYC and generate your e-card on the spot. This is the most common method.

2. At a Common Service Center (CSC): Visit a CSC with your Aadhaar card and any other ID proof. The operator will perform biometric verification and issue your Ayushman Card.

3. Through the Ayushman App: Download the app, complete Aadhaar e-KYC verification, and generate your digital Ayushman Card directly on your smartphone.

Required Documents

• Aadhaar Card (primary identification for biometric verification)
• Ration Card or SECC list reference (for family identification)
• Any government-issued photo ID (voter ID, driving license, PAN card) as secondary verification
• Mobile number linked to Aadhaar for OTP-based authentication

Important Notes About the Ayushman Card

• The card is issued free of cost—no fees at any stage
• One card is issued per family member (not per family)
• The card is valid at all empanelled hospitals across India
• A digital version is stored on the Ayushman App and can be used as a paperless alternative
• Lost cards can be regenerated at any empanelled hospital or CSC

Hospital Network

PM-JAY has built an extensive network of empanelled hospitals across India, ensuring that beneficiaries have access to quality healthcare regardless of where they live.

Types of Empanelled Hospitals

• Government Hospitals: District hospitals, sub-district hospitals, medical college hospitals, and specialty government institutions
• Private Hospitals: Private multi-specialty hospitals, nursing homes, and specialty clinics that meet the NHA’s empanelment criteria
• Not-for-Profit Hospitals: Trust hospitals and charitable institutions

Empanelment Criteria

To become empanelled under PM-JAY, hospitals must meet minimum infrastructure, staffing, and quality standards defined by the NHA. Key requirements include adequate bed capacity, qualified medical professionals, diagnostic facilities, and compliance with fire safety and biomedical waste management regulations. Hospitals must also agree to the pre-defined package rates set by the NHA.

Finding an Empanelled Hospital

• Visit the PM-JAY hospital search portal at pmjay.gov.in
• Use the Ayushman App’s hospital locator feature
• Call the 14555 helpline to find the nearest empanelled hospital
• As of 2025, there are over 30,000 empanelled hospitals across all states and Union Territories

Portability

One of PM-JAY’s most powerful features is full portability. A beneficiary from Bihar can walk into an empanelled hospital in Delhi, Mumbai, or Chennai and receive cashless treatment without any additional approvals or referrals. This nationwide portability is critical for migrant workers and families who travel across states for employment.

Cashless and Paperless Treatment Process

The entire treatment journey under PM-JAY is designed to be cashless and paperless for the beneficiary. Here is a step-by-step walkthrough:

1. Arrival at Hospital: The beneficiary arrives at any empanelled hospital and visits the Ayushman Mitra desk.

2. Identity Verification: The Ayushman Mitra verifies the patient’s identity through Aadhaar-based biometric authentication or the Ayushman Card QR code.

3. Eligibility Confirmation: The PM-JAY IT system confirms the patient’s eligibility and remaining coverage balance for the year.

4. Pre-Authorization: For planned procedures, the hospital submits a pre-authorization request through the Transaction Management System (TMS). The request is reviewed and approved (typically within a few hours) by the State Health Agency or insurance partner.

5. Treatment: The patient receives the necessary medical treatment. All costs are borne by the scheme up to the package rate.

6. Discharge: Upon recovery, the patient is discharged without any payment. The hospital provides discharge summary and follow-up instructions.

7. Post-Discharge Care: Follow-up medications and consultations for up to 15 days after discharge are covered under the same package.

8. Claim Settlement: The hospital submits the claim with supporting documents to the SHA/insurer, and payment is made directly to the hospital within the defined timeline.

Grievance Redressal

If a beneficiary faces any issues—such as denial of treatment, demand for payment, or poor quality of care—they can file a grievance through the PM-JAY grievance portal, the Ayushman App, or the 14555 helpline. The NHA has established a multi-tier grievance redressal mechanism to ensure timely resolution.

State-Level Implementation Variations

While PM-JAY provides a national framework, states have flexibility in how they implement the scheme. This has led to interesting variations:

• Insurance Model vs. Trust Model: Some states (like Tamil Nadu and Rajasthan) implement PM-JAY through a trust model where the state government directly pays hospitals. Others (like Uttar Pradesh and Madhya Pradesh) use an insurance model where a contracted insurance company manages claims. Some states use a hybrid of both.

• State Top-Up Schemes: Several states have expanded PM-JAY coverage by adding their own top-up schemes. For example, Rajasthan’s Chiranjeevi Yojana provides ₹25 lakh of coverage, while Andhra Pradesh’s Aarogyasri has been merged with PM-JAY for expanded benefits.

• Additional Beneficiary Categories: Some states have expanded the eligible population beyond the SECC 2011 list to include additional categories such as unorganized sector workers, farmers, or all families below a certain income threshold.

• Package Rate Enhancements: Certain states have enhanced the package rates for specific procedures to attract more private hospital participation, particularly in underserved areas.

• States Not Participating: It is worth noting that a few states initially chose not to participate in PM-JAY, opting to run their own health insurance schemes instead. West Bengal runs the Swasthya Sathi scheme, while Delhi had its own healthcare model. Odisha operates the Biju Swasthya Kalyan Yojana. However, residents of these states who are on the SECC list can still access PM-JAY benefits at empanelled hospitals in other participating states.

Integration with Ayushman Bharat Health and Wellness Centers

PM-JAY is one half of the Ayushman Bharat vision. The other half is the transformation of 150,000 Sub-Health Centers and Primary Health Centers into Ayushman Bharat Health and Wellness Centers (AB-HWCs). These centers provide:

• Comprehensive Primary Healthcare: Including maternal and child health, communicable disease management, mental health services, and care for chronic conditions like diabetes and hypertension
• Free Essential Medicines and Diagnostics: A defined list of drugs and diagnostic tests available at no cost
• Wellness Activities: Yoga sessions, health awareness campaigns, and preventive health screenings
• Referral Linkage to PM-JAY: HWCs serve as the first point of contact and can refer patients who need hospitalization to PM-JAY empanelled hospitals

Together, the HWCs and PM-JAY create a continuum of care—from prevention and primary care at the community level to cashless hospitalization for serious illnesses. This integrated model is designed to reduce the burden on tertiary hospitals, improve health outcomes, and ensure that healthcare is accessible to even the most remote populations.

Recent Expansions and Developments

PM-JAY has undergone several significant expansions since its launch:

Ayushman Bharat for Senior Citizens (2024)

In one of the most significant expansions, the Union Cabinet approved extending PM-JAY to all citizens aged 70 and above, regardless of their income or SECC status. This universal coverage for senior citizens provides a separate ₹5 lakh annual cover and is expected to benefit approximately 6 crore elderly citizens. Senior citizens who are already covered under PM-JAY through the SECC list receive an additional ₹5 lakh top-up.

COVID-19 Treatment Packages

During the COVID-19 pandemic, PM-JAY played a crucial role by adding dedicated treatment packages for COVID-19 hospitalization, including ICU care with ventilator support. This ensured that eligible families did not face financial hardship due to pandemic-related hospitalizations.

Ayushman Bharat Digital Mission (ABDM)

The NHA has launched the Ayushman Bharat Digital Mission to create a digital health ecosystem. This includes the Ayushman Bharat Health Account (ABHA) number—a unique 14-digit health ID for every citizen—and interoperable digital health records. PM-JAY is being integrated with ABDM to create seamless digital health records for all beneficiaries.

Enhanced Package Rates

The NHA periodically revises package rates based on medical cost inflation and stakeholder feedback. Recent revisions have increased rates for several procedures, including knee and hip replacements, cancer treatment packages, and cardiac surgeries, ensuring that hospitals remain incentivized to provide quality care under the scheme.

Anti-Fraud Measures

To maintain the integrity of the scheme, the NHA has implemented advanced anti-fraud technologies, including artificial intelligence and machine learning-based claim monitoring, biometric verification at the point of care, and a dedicated anti-fraud unit that investigates suspicious claims. Hospitals found engaging in fraudulent practices are de-empanelled and face legal action.

Tips for Beneficiaries

If you or your family are eligible for PM-JAY, here are practical tips to maximize your benefits:

• Get your Ayushman Card early: Do not wait until you need hospitalization. Visit your nearest CSC or empanelled hospital to generate your card proactively. Having the card ready ensures zero delays when you actually need treatment.

• Keep your Aadhaar details updated: Since Aadhaar-based e-KYC is the primary verification method, ensure that your Aadhaar card has your current mobile number and correct biometric data.

• Know your nearest empanelled hospitals: Familiarize yourself with empanelled hospitals in your area, especially those that offer the specialties you might need. Use the Ayushman App or website to search.

• Use the portability feature: If better treatment is available in another city or state, you are fully entitled to seek care at any empanelled hospital across India. Do not let anyone tell you that your card only works in your home state.

• Never pay at an empanelled hospital: PM-JAY treatment is completely cashless. If a hospital demands payment for a covered procedure, report it immediately through the 14555 helpline or the grievance portal.

• Save your discharge summary: Always keep a copy of your discharge summary and treatment records. These documents are useful for follow-up care and in case of any disputes.

• Check your remaining balance: You can check your family’s remaining coverage balance for the year through the Ayushman App. This helps you plan if additional family members need treatment.

• Report fraud or malpractice: If you suspect that a hospital is filing fraudulent claims or providing substandard care, report it through the NHA’s anti-fraud helpline. Protecting the scheme’s integrity benefits all beneficiaries.

Common Questions / FAQ

Is PM-JAY really free? Are there any hidden charges?

Yes, PM-JAY is completely free for eligible beneficiaries. There is no enrollment fee, no monthly premium, no co-payment, and no deductible. The entire cost is borne by the Central and State Governments. If any empanelled hospital demands payment for a covered procedure, it is a violation of PM-JAY guidelines, and you should report it.

Can I use PM-JAY at a private hospital?

Absolutely. PM-JAY works at both public and private empanelled hospitals. Many private multi-specialty hospitals across India are empanelled under PM-JAY. You can search for private empanelled hospitals near you on the PM-JAY website or app.

What if I need treatment that costs more than ₹5 lakh?

The ₹5 lakh limit is per family per year. If the cost of treatment exceeds this amount, the beneficiary would be responsible for the excess. However, for most procedures covered under PM-JAY, the defined package rates are within the ₹5 lakh limit. In practice, the vast majority of hospitalizations are fully covered.

Are pre-existing conditions covered?

Yes. All pre-existing conditions are covered from the very first day. There is no waiting period for any disease or condition under PM-JAY.

Can I get treated in a different state from where I am registered?

Yes. PM-JAY is fully portable across all participating states and Union Territories. You can seek treatment at any empanelled hospital in India, regardless of where your family is registered.

How do I know if a hospital is empanelled?

You can search for empanelled hospitals on the PM-JAY website, the Ayushman App, or by calling the 14555 helpline. Every empanelled hospital also displays the PM-JAY logo and has an Ayushman Mitra help desk.

What if my name is not on the SECC list but I am poor?

The primary eligibility is based on the SECC 2011 database. If your family is not on the list but you believe you should be eligible, contact your local State Health Agency or visit a CSC to inquire about any state-specific expanded eligibility criteria. Some states have added additional beneficiary categories beyond the SECC list.

Can senior citizens above 70 get PM-JAY even if they are not on the SECC list?

Yes. Under the 2024 expansion, all Indian citizens aged 70 years and above are eligible for PM-JAY regardless of their SECC status or income level. They receive a dedicated ₹5 lakh annual cover.

How long does it take to get the Ayushman Card?

The Ayushman Card can typically be generated in 15 to 30 minutes at an empanelled hospital or CSC, provided your Aadhaar-based e-KYC verification is successful. The digital card is available instantly on the Ayushman App after verification.

What documents do I need for hospitalization under PM-JAY?

You need your Ayushman Card (physical or digital) and a valid Aadhaar card for biometric verification. In some cases, the hospital may accept other government-issued photo IDs as secondary verification. No other documentation is required from the patient’s side for admission.

PM-JAY represents a transformative shift in how India approaches public healthcare financing. By removing the financial barriers to hospitalization for the country’s poorest and most vulnerable families, the program has saved millions from medical bankruptcy and enabled access to life-saving treatments that were previously out of reach. Whether you need a simple surgery or complex cardiac care, PM-JAY ensures that no eligible family has to choose between health and financial survival. If you believe you or your family may be eligible, check your status today through the Ayushman App, the PM-JAY website, or your nearest Common Service Center—it could be the most important five minutes you ever spend.