The Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a path-breaking intervention launched under the recommendation of the National Health Policy 2017 to achieve the vision of Universal Health Coverage (UHC) and fulfill Sustainable Development Goal 3.8. It is the world’s largest government-sponsored health assurance scheme. (Note for UPSC Aspirants: The scheme is implemented by the National Health Authority (NHA) under the administrative jurisdiction of the Ministry of Health and Family Welfare (MoHFW). It is not under the Ministry of Food Processing Industries).
Core Institutional and Operational Framework
Institutional Structure
- National Level: The National Health Authority (NHA) is the apex body responsible for implementing the scheme nationwide. It is governed by a Governing Board chaired by the Union Minister of Health and Family Welfare.
- State Level: State Health Agencies (SHA) are set up by respective state governments to manage implementation, empanelment of hospitals, and claim settlements.
Funding Pattern
- It is a Centrally Sponsored Scheme (CSS).
- Cost-sharing ratio between the Centre and States/UTs with legislature is 60:40.
- Cost-sharing ratio for North-Eastern and Himalayan States (Jammu & Kashmir, Himachal Pradesh, Uttarakhand) is 90:10.
- For Union Territories without a legislature, it is 100% centrally funded.
Key Features and Quantum of Benefit
Financial Cover
- Provides a cashless and paperless health insurance cover of ₹5,00,000 per family per year for secondary and tertiary care hospitalization.
- The benefit is on a Family Floater Basis, meaning it can be utilized by one or all members of the family within the annual limit.
Inclusivity and Continuity of Care
- No Cap on Family Size or Age: To ensure that no vulnerable individual (especially women, children, and senior citizens) is left behind, there is no restriction on family size, age, or gender.
- Pre-Existing Diseases: All pre-existing medical conditions are covered from Day One of enrollment.
- Comprehensive Components: Includes up to 3 days of pre-hospitalization (diagnostics and consultations) and 15 days of post-hospitalization expenses (medicines and follow-up care).
Eligibility and Beneficiary Identification
Identification Basis
- It is an entitlement-based scheme with no formal registration or enrollment process for the core pool.
- Beneficiaries are identified automatically based on defined deprivation and occupational criteria using the Socio-Economic Caste Census (SECC) 2011 database for both rural and urban areas.
Rural Eligibility Criteria (Deprivation Categories)
- Households with only one room with kucha walls and kucha roof.
- Households with no adult member between the ages of 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 (SC) and Scheduled Tribe (ST) households.
- Landless households deriving a major part of their income from manual casual labour.
- Automatically Included Categories: Destitute/living on alms, manual scavenger households, primitive tribal groups, and legally released bonded labourers.
Urban Eligibility Criteria (Occupational Categories)
- Covers 11 defined occupational categories of workers such as ragpickers, beggars, domestic workers, street vendors, cobblers/hawkers, construction workers, plumbers, masons, transport workers, electric workers, shop workers, and sanitation workers.
Global Expansion (Senior Citizens 70+)
- A major policy expansion extends comprehensive health coverage to all senior citizens aged 70 years and above, irrespective of their socio-economic or income status.
- Eligible seniors belonging to families already covered under AB-PMJAY receive an additional top-up cover of up to ₹5 lakh per year exclusively for themselves.
- Eligible seniors from non-covered families receive a distinct, independent cover of up to ₹5 lakh per year on a family basis.
Service Delivery and Technological Ecosystem
Hospital Empanelment and Portability
- Empanelled Healthcare Providers (EHCP): Benefits can be availed at any empanelled public or private healthcare facility across the country.
- National Portability: A beneficiary registered in one state can receive cashless treatment in any other state across India.
Core Digital IT Platforms
- Beneficiary Identification System (BIS): Used to verify the identity of the beneficiary at the hospital kiosk using Aadhaar-based biometric or facial authentication.
- Transaction Management System (TMS): Captures real-time inpatient data from admission to treatment, discharge, and electronic claim settlement.
- Health Benefit Packages (HBP): Covers approximately 1,949 medical and surgical procedures across 27 specialties. Differential pricing is applied based on the tier of the city and type of care.
Frontline Human Infrastructure
- Ayushman Mitra (Pradhan Mantri Arogya Mitra – PMAM): Certified frontline health professionals deployed at every empanelled hospital. They operate the Ayushman Kiosk, verify beneficiary identity, handle documents, and facilitate paperless care.
Exclusions under AB-PMJAY
The scheme focuses strictly on secondary and tertiary hospitalization. The following services are explicitly excluded from the insurance wallet:
- Out-Patient Department (OPD) expenses.
- Cosmetic and aesthetic surgeries.
- Drug rehabilitation programmes.
- Fertility-related medical procedures.
- Organ transplants (unless specifically bundled in a complex package).
- Individual diagnostic evaluations not leading to hospitalization.
Comparative Overview: PM-JAY vs. Earlier Schemes
| Feature | AB-PMJAY | Rashtriya Swasthya Bima Yojana (RSBY) |
| Quantum of Cover | ₹5,00,000 per family per year | ₹30,000 per family per year |
| Family Size Limit | No restriction on size or age | Capped at maximum 5 members |
| Type of Care | Secondary and Tertiary hospitalization | Primarily basic Secondary care |
| Pre-existing Diseases | Covered from Day One | Limited/Conditional coverage |
| Portability | Nationwide portability enabled | Non-portable across distinct states |