The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a groundbreaking flagship scheme launched by the Government of India in 2018. It is widely recognized as the world's largest government-funded health assurance scheme, designed to provide essential healthcare access to the poorest and most vulnerable sections of the Indian population. The core objective of PM-JAY is to significantly reduce the catastrophic healthcare expenditure that pushes nearly six crore Indians into poverty every year and ensure Universal Health Coverage (UHC).
Key Features and Coverage
PM-JAY is structured as the second component of the larger Ayushman Bharat initiative, which also includes the establishment of Health and Wellness Centres (HWCs) for primary care.
Financial Coverage
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₹5 Lakh Per Family Per Year: The scheme provides a health cover of ₹5,00,000 per family per year for secondary and tertiary care hospitalization.
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Family Floater Basis: The cover is provided on a family floater basis, meaning the amount can be used by one or all members of the eligible family collectively.
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No Cap on Family Size or Age: Unlike many commercial insurance schemes, PM-JAY has no restriction on the family size, age, or gender of the members.
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Pre-existing Conditions Covered: All pre-existing diseases are covered from the very first day of the policy.
Cashless and Paperless Access
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Cashless Treatment: Beneficiaries receive completely cashless treatment at the point of service (the hospital). This eliminates the need for beneficiaries to pay upfront for covered services.
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Extensive Package Inclusion: The scheme covers approximately 1,929 medical packages, which include expenses related to:
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Medical examination, treatment, and consultation.
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Pre-hospitalization (up to 3 days) and post-hospitalization (up to 15 days) expenses, including diagnostics and medicines.
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Diagnostics and laboratory investigations.
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Medical implantation services.
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Non-intensive and intensive care services.
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Accommodation benefits and food services.
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National Portability
A key strength of PM-JAY is its national portability. A beneficiary registered in one state/UT can avail of cashless treatment at any empanelled public or private hospital across the entire country. This is vital for migrant workers and families.
Eligibility Criteria: Who is Covered?
The beneficiaries of AB-PMJAY are identified based on the deprivation and occupational criteria derived from the Socio-Economic Caste Census (SECC) 2011 data, covering the bottom 40% of the rural and urban poor families. The scheme aims to cover over 12 crore vulnerable families (approximately 55 crore beneficiaries).
Rural Eligibility Criteria (D1, D3, D4, D5, D7 & Automatic Inclusion)
Families meeting any of the following criteria are eligible:
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Households with only one room with kucha walls and kucha roof (non-durable materials).
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Households with no adult member aged 16 to 59.
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Households with no adult male member aged 16 to 59.
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Households with a disabled member and no able-bodied adult member.
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SC/ST households.
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Landless households dependent on manual casual labour.
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Automatically included households (Destitute/living on alms, manual scavengers, Primitive Tribal Groups, and legally released bonded labour).
Urban Eligibility Criteria (Specific Occupational Categories)
Specific occupational categories are automatically included, such as:
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Rag pickers, domestic workers, street vendors/hawkers.
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Construction workers, plumbers, masons, welders.
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Washermen, chowkidars, sweepers.
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Transport workers (drivers, conductors, helpers).
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Assistants, peons, waiters in small establishments.
Recent Expansions (From 2024 onwards)
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Senior Citizens: An additional top-up of ₹5 lakh is often provided to senior citizens (aged 70 years and above) irrespective of income, to ensure ease of financial expenses.
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Specified Workers: Inclusion of ASHA workers, Anganwadi workers, and certain other welfare workers.
How to Avail the Benefit (The PM-JAY Process)
The process of availing treatment is designed to be simple and seamless for the beneficiary:
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Eligibility Check: The individual checks their eligibility online via the official PM-JAY portal or at a Common Service Centre (CSC) or an empanelled hospital.
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Ayushman Card Generation: Once eligibility is confirmed, the beneficiary's Ayushman Card (often called the Golden Card) is generated, serving as the proof of insurance cover.
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Hospitalization: The beneficiary visits any of the public or private Empanelled Hospitals (EH) across India.
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Cashless Service: At the hospital desk, the Arogya Mitra (Scheme Facilitator) verifies the identity using the Ayushman Card or Aadhaar Card.
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Treatment: The hospital initiates the pre-authorization request for the required procedure/treatment package with the insurer (or the State Health Agency). Once approved, the treatment is delivered.
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Discharge and Claim: Upon discharge, the beneficiary leaves without paying any bill for the covered services. The hospital submits the necessary documents and claims the amount directly from the insurer/SHA.
PM-JAY is fundamentally transforming India’s healthcare landscape by moving from a segmented approach to a comprehensive, need-based system. By providing a substantial financial safety net, the scheme has successfully mitigated financial distress for millions of families and is actively bridging the gap between quality healthcare and accessibility for the vulnerable population. It stands as a beacon of India's commitment to achieving its Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC).
