Everything You Need to Know about Ayushman Bharat Health Insurance

The Indian Healthcare system has always been characterized by out-of-pocket healthcare systems, limited health insurance penetration, and unequal access to quality medical services.

A study in 2017 revealed the issues of government health policies, where a large percentage of the population is left underserved by the Indian health system, which relies on out-of-pocket payments from patients to fund care.

These payments hinder many patients from receiving significant healthcare services. In 2018, the Indian government described that every year, more than six crores Indians were pushed into poverty because of out-of-pocket medical expenses. Despite various regional and national healthcare programs available in India, there was still much to be done.

To mitigate this challenge and move towards Universal Health Coverage (UHC), the Government of India introduced Ayushman Bharat in 2018 as a comprehensive health reform initiative. The programme was designed to strengthen primary healthcare delivery while simultaneously providing financial risk protection for specialized treatment for common conditions and advanced treatment hospitalisation required for critical conditions

The Ayushman Bharat programme is composed of two components, among which the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is the health insurance component of the initiative.

In this article, we shall delve into how AB-PMJAY is reshaping financial protection and access to quality healthcare for vulnerable and economically disadvantaged populations in India

About AB-PMJAY

Ayushman Bharat Health Insurance Scheme, also known as Pradhan Mantri Jan Arogya Yojana (PMJAY), is a flagship publicly funded health insurance scheme launched by the Government of India on 14 April 2018. The scheme’s main objective is to provide financial protection and access to quality healthcare for vulnerable and economically disadvantaged populations. PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government.

The scheme covers both specialist treatment for common conditions and advanced treatment for complex and critical conditions, and aims to reduce out-of-pocket expenditure.

Under AB-PMJAY, eligible families are entitled to cashless hospitalisation coverage of up to INR 5 lakh per family per year for secondary and tertiary care procedures. The scheme is portable across India and can be availed at empanelled public and private hospitals.

The core objective of the scheme includes

• To mitigate catastrophic health expenditures by offering cashless treatment up to a specified limit.
• To extend health insurance to economically vulnerable families across India.
• To boost access to quality healthcare services, especially among rural and underserved populations.

Key Features

The scheme focuses on expanding access to hospital-based healthcare while reducing out-of-pocket expenditure for economically vulnerable populations, and includes key features such as

Targeted Beneficiary Identification

Eligible households are identified using the Socio-Economic Caste Census (SECC) database and other approved government records.

Coverage of Secondary & Tertiary Care

PMJAY covers a wide range of medical and surgical procedures, including 1,393 procedures covering all the costs related to treatment, such as drugs, supplies, diagnostic services, physicians' fees, room charges, surgeon charges, OT and ICU charges, follow-up care, etc

National Portability & Standardised Care Packages

It enables beneficiaries to access cashless treatment at any empanelled public or private hospital across India, supported by standardised Health Benefit Packages with fixed reimbursement rates

Digital Platform and Ayushman Bharat Health Card

A national IT platform supports beneficiary verification, hospital empanelment, claim processing, and fraud detection. Beneficiaries are issued Ayushman Bharat Health cards for easy access.

Flexible Implementation & Governance

PM-JAY allows States and Union Territories to adopt insurance, trust, or hybrid implementation models based on local capacities, while integrating robust anti-fraud mechanisms, regular audits.

Coverage & Benefits

The cover under the scheme includes all expenses incurred on the following components of the treatment.

• Medical examination, treatment, and consultation
• Pre-hospitalization
• Medicine and medical consumables
• Non-intensive and intensive care services
• Diagnostic and laboratory investigations
• Medical implantation services (where necessary)
• Accommodation benefits
• Food services
• Complications arising during treatment
• Pre-hospitalization up to 3 days & Post-hospitalization follow-up care up to 15 days

Under PM-JAY, the INR 5 lakh annual health cover is provided on a family floater basis, allowing one or more family members to utilise the entire amount. PM-JAY imposes no limit on family size or age. Importantly, pre-existing diseases are covered from day one, enabling eligible beneficiaries to access treatment immediately upon enrolment.

Key Beneficiaries

PMJAY primarily targets economically disadvantaged households identified through national socio-economic datasets. The key beneficiary groups include:

• Deprived rural households identified under the SECC criteria
• Urban households engaged in select occupational categories such as construction workers, domestic workers, street vendors, and transport workers
• Families without access to formal health insurance, particularly those in the informal sector.
• Vulnerable populations, including women, children, senior citizens, and persons with disabilities, within eligible households

The scheme ensures equitable access by eliminating financial contributions from beneficiaries.

How to Avail Benefits Under AB-PMJAY

Eligible beneficiaries can avail services under Ayushman Bharat–PMJAY through a simple, standardised process designed to ensure easy access to cashless healthcare across empanelled hospitals which includes

• Check for eligibility under PMJAY is based on the Socio-Economic Caste Census (SECC) database and other state-specific welfare lists, or verify it through the official website.
• Eligible beneficiaries must obtain an Ayushman card, which serves as proof of coverage.
• Beneficiaries can choose any empanelled public or private hospital across India, as PMJAY offers national portability.
• It further includes verification of the Ayushman Card through the PMJAY IT platform by the hospital.
• The hospital submits a pre-authorisation request online for the required treatment under approved Health Benefit Packages (HBPs), and once approved, beneficiaries receive cashless treatment, including diagnostics, medicines, hospitalisation, and post-hospitalisation care as per package guidelines

Impact

PM-JAY has expanded rapidly since its launch in 2018, becoming one of the world’s largest government-funded health insurance schemes

Over 42.9 crore Ayushman cards have been issued nationwide as of Jan 2026, enabling millions of families to access free hospital care.

More than 10.06 crore hospital admissions have been authorised under PM-JAY since inception, with total authorised financial coverage exceeding ₹1.50 lakh crore.

States like Tamil Nadu (1.102 Cr admissions), Karnataka (1.092 crore admissions), and Chhattisgarh (0.845 Crore), are among the top users of the scheme’s services

Women account for about 49 % of issued Ayushman cards and have utilised significant inpatient care under the scheme, highlighting progress toward gender equity in access.

Wrapping Up

PM-JAY has been transformational in expanding access to quality healthcare for millions of economically vulnerable Indians, reducing financial hardship, and facilitating hospital care across diverse regions. The scale of card issuance, hospital admissions, and financial protection demonstrates the scheme’s potential as a cornerstone of India’s journey toward Universal Health Coverage.

With sustained commitment from the government and key stakeholders, PM-JAY has the potential to advance India’s transition towards a more equitable, accessible, and financially protective healthcare system and ensure it remains responsive, efficient, and financially sustainable in the years ahead.

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