Ayushman Bharat (PM-JAY)

Pradhan Mantri Jan Arogya Yojana, the insurance arm of the larger Ayushman Bharat umbrella, was launched in September 2018. The headline benefit is well known: ₹5 lakh of cashless hospital cover per family per year, valid at any of the roughly 30,000 empanelled hospitals across India. Less well-known is the perimeter of that cover. PM-JAY pays for secondary care (think appendix surgery, normal childbirth complications, fracture management) and tertiary care (cancer chemotherapy, cardiac stenting, joint replacement). It does not pay for outpatient consultations, routine diagnostics done outside a hospital admission, or cosmetic procedures.

The package list has grown from 1,393 procedures at launch to 1,949 as of the latest Health Benefit Package 2022 revision. Each procedure has a fixed rate, for example, a coronary angiography is reimbursed at ₹8,000, an angioplasty with single stent at ₹40,000. These rates are revised periodically and matter to you because they determine whether a hospital will admit a PM-JAY patient at all. If the listed rate is far below the hospital's commercial rate, you will sometimes find the hospital quietly steering you toward a paid bed.

Eligibility was originally pinned to the Socio-Economic and Caste Census of 2011. For rural India, families are eligible if they fall under at least one of seven deprivation criteria, for instance, households with no adult member aged 16-59, or those depending on manual casual labour. For urban India, eligibility is occupation-based: rag pickers, domestic workers, construction workers, sanitation workers, and eight other categories.

The largest expansion came on 29 October 2024, when the Union Cabinet extended coverage to every Indian aged 70 and over, irrespective of income. This added an estimated 6 crore senior citizens, and notably included senior citizens already enrolled under CGHS or ECHS, who can now choose between the two for any given hospitalisation. If you are over 70 and have not yet enrolled, this is the single most underused entitlement in the system at the moment. The Vay Vandana Card is issued separately and can be downloaded from pmjay.gov.in or generated at any empanelled hospital kiosk.

There is also a small but important set of state-level expansions. Maharashtra, Tamil Nadu, Karnataka, Rajasthan and a handful of others have integrated their own health-insurance schemes with PM-JAY so that the cover is effectively universal. In Maharashtra, for example, a family on an orange ration card qualifies even if not on the SECC list, because the state pays the differential premium to the NHA.

When you walk into an empanelled hospital with a medical emergency, ask for the Ayushman Mitra. This is a designated person, a hospital employee paid for by the scheme, whose only job is to handle PM-JAY admissions. They will verify your card and Aadhaar, identify the relevant package, raise a pre-authorisation request to the State Health Agency, and admit you against that request.

Pre-authorisation, in normal cases, is approved within hours. For emergencies, hospitals are permitted to admit and seek post-facto authorisation. At discharge, the hospital files a claim with the SHA and you sign a satisfaction note. You should not pay any money for any item covered by the package. The package is inclusive, it covers the bed, the surgeon's fee, drugs administered during admission, diagnostics done as part of the procedure, and follow-up care for the notified period (usually 10-15 days post-discharge for most surgical packages).

If a hospital asks you for cash, that is your single most important signal that something is off. Call the helpline (14555) from the hospital reception, give the hospital's empanelment ID, and ask for a complaint to be lodged. The NHA's grievance redressal portal has, in our reading, become genuinely responsive over the last 18 months, with most class-I complaints resolved within 30 days.

We have repeatedly encountered families turned away at hospitals because the head of the family has an Ayushman Card but the patient, a daughter-in-law, an elderly mother, does not. PM-JAY is family-coverage, but each individual member needs to be added to the family unit on the portal before they can use the cover. The fix is to walk into any CSC with the patient's Aadhaar, the family's existing card, and the ration card. The addition takes ten minutes and is free.

If your name is wrongly absent from the SECC list and you are clearly eligible, the appeal process runs through the District Implementation Unit. In states like Bihar and West Bengal, where the SECC-to-PMJAY mapping was imperfect, the State Health Agency runs periodic verification drives, usually around Republic Day and Independence Day. Watch the local panchayat noticeboard, or ask the ASHA worker.

Independent evaluations, including the Lancet Public Health study of 2023 and the NITI Aayog mid-term review, have converged on a clear finding: PM-JAY has measurably reduced catastrophic health expenditure for the bottom two income quintiles, especially for cardiac, oncology and renal procedures. For these high-cost, low-frequency events, the cover is genuinely transformative.

Where it helps less is in the long tail of small, recurrent costs, chronic-disease drugs, dialysis between hospitalisations, mental-health care, and the cost of getting to a tertiary-care hospital in the first place. Several state schemes are beginning to fill these gaps, and Ayushman Arogya Mandirs, the primary-care wing of Ayushman Bharat, were designed precisely for this. If you live near a wellness centre, registering there is the cheapest way to establish a longitudinal medical record, which itself smooths every subsequent hospital admission.

Most readers contact us not when they are choosing a hospital but at the admission desk, when a private hospital is quoting a deposit despite an active Ayushman Card. The single most useful instruction we can give is to ask, by name, for the Ayushman Mitra. This is a designated employee of the hospital, paid for by the scheme, whose entire job is to process PM-JAY admissions. Every empanelled hospital has one or more on duty.

Once located, the Mitra will verify your card on the Beneficiary Identification System and run a package search for the diagnosed condition. Ask in writing for the package code that has been selected. The package code determines what is included in your cover, and it is the single piece of information that prevents a hospital from quietly billing you for items already bundled in the rate. If the Mitra is unavailable or the desk is unresponsive, call 14555 from the hospital reception and ask for a grievance ticket; the ticket number alone often unlocks the desk within an hour.

Document everything. Take a photograph of the package code, the pre-authorisation approval, and the discharge summary. These three documents are sufficient evidence in any subsequent complaint about cash demand or service denial.

The 29 October 2024 extension to all senior citizens aged 70 and above is the single most underused entitlement in the system at the moment. Three points are widely misunderstood. First, the income test does not apply; a senior citizen from a high-income household is just as eligible as one from an SECC-listed family. Second, an existing CGHS or ECHS member can hold a Vay Vandana Card in parallel and choose, at each hospitalisation, which to use. Third, the Vay Vandana Card is issued separately from the family Ayushman Card; do not assume that a son's existing card extends to a parent over 70.

• 01Family appears in the SECC-2011 deprivation database (rural) or one of 11 occupational categories (urban)
• 02All senior citizens aged 70 and above, regardless of income (extension notified 29 October 2024)
• 03No upper cap on family size or age within a listed family
• 04Beneficiaries already covered by ESIS, CGHS or ECHS are excluded from concurrent PM-JAY use

• §Aadhaar card (primary identifier)
• §Ration card to establish family composition
• §Ayushman Card, issued free after verification at a CSC or hospital kiosk

• Family name absent from the SECC-2011 list (most common in urban migrants)
• Aadhaar not seeded against the ration card, so family composition cannot be verified
• Hospital chosen is not empanelled, or empanelment lapsed
• Procedure not in the 1,949 packages currently notified

• PM-JAY Annual Report 2023-24, National Health Authoritylink ↗
• Cabinet decision on senior-citizen extension, PIB, 29 October 2024
• "Effect of PM-JAY on catastrophic health expenditure", Lancet Public Health, 2023