West Bengal signed a Memorandum of Understanding with the National Health Authority to implement the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. This development makes West Bengal the 36th State or Union Territory to adopt the world’s largest publicly funded health assurance program, completing nationwide coverage across all states and territories. The state health department will merge its existing Swasthya Sathi scheme beneficiaries into the central health network. The programmatic integration aims to provide cashless secondary and tertiary care benefits up to ₹5 lakh per family annually, lowering out-of-pocket medical expenditure for millions of residents while enabling complete interstate portability.
Structural Framework of AB PM-JAY
The health assurance delivery model operates as a centrally sponsored entitlement-based scheme. The operational architecture balances federal funding and uniform medical benefit structures across administrative borders.
Financial Coverage and Disease Packages
The program offers a blanket cashless cover of ₹5 lakh per eligible family per year. This entitlement applies directly to acute conditions requiring secondary and tertiary medical hospitalization. The benefit structure encompasses over 1,900 therapeutic and surgical procedures across 24 super-specialty fields, including oncology, neurosurgery, and cardiovascular interventions. The scheme covers pre-existing illnesses from the first day of enrollment, including pre-hospitalization diagnostics up to 3 days and post-hospitalization medical expenses for 15 days.
Funding Patterns and Administrative Oversight
The financial obligation is split between the central and state governments. For regular states, the funding ratio stands at 60:40. For the Northeastern states, Jammu and Kashmir, Himachal Pradesh, and Uttarakhand, the ratio shifts to 90:10. Union Territories without legislatures receive 100% central funding. The National Health Authority functions as the apex body responsible for implementing the scheme at the national level, while State Health Agencies manage ground-level execution and hospital empanelment.
Target Demographics and Eligibility Criteria
The scheme uses objective socio-economic indicators rather than self-declaration to select program beneficiaries.
Household Selection via SECC Data
Initial beneficiary selection relies on the deprivation and occupational criteria identified in the Socio-Economic Caste Census 2011 for both rural and urban sectors.
- Rural Deprivation Categories: Households living in single-room kucha houses, landless families dependent on manual casual labor, female-headed households with no adult male member aged 16 to 59, and Scheduled Caste or Scheduled Tribe households.
- Urban Occupational Clusters: Identified vulnerable workers including street vendors, domestic helpers, construction laborers, ragpickers, sanitation workers, and transport operators.
Systematic Coverage Expansions
The beneficiary baseline has undergone calculated expansions since inception to incorporate critical frontline workforces and demographic cohorts. The scheme extended free health protection to 37 lakh Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), and Anganwadi Helpers (AWHs) along with their dependents.
Senior Citizen Universal Coverage
A distinct universal vertical covers all senior citizens aged 70 years and above, irrespective of their socio-economic status, wealth, or income levels.
Operational Rules for 70+ Cohort
Eligible elderly citizens receive a specialized, distinct Ayushman Vay Vandana Card to access their medical entitlements.
| Current Insurance Status of Senior Citizen (70+) | Applied Treatment Modality Under PM-JAY |
| Enrolled in an existing PM-JAY beneficiary family | Receives an isolated top-up cover of up to ₹5 lakh per year, managed entirely without sharing with family members below 70. |
| Belonging to a family not covered under PM-JAY | Receives a distinct family-basis cover of up to ₹5 lakh per year. |
| Using Central Government Health Scheme (CGHS) / ECHS / CAPF | Retains the explicit legal choice to either stay with their current public health system or shift completely to PM-JAY. |
| Enrolled in private health policies or Employees’ State Insurance (ESI) | Eligible to receive the PM-JAY cover parallel to their existing operational coverage. |
IASPOINT Booster Facts for UPSC
- Statutory Framework and Origin: PM-JAY was launched on September 23, 2018, in Ranchi, Jharkhand, as one of the twin pillars of the Ayushman Bharat umbrella strategy, the other being Ayushman Arogya Mandirs (Health and Wellness Centres).
- Portability Feature: A beneficiary registered in West Bengal can receive cashless treatment at any empanelled public or private hospital across India, including super-specialty centers in New Delhi or Mumbai.
- Aadhaar Mandatory Clause: For the senior citizen category (70+), verification requires mandatory Aadhaar-based biometric or OTP authentication to clear e-KYC protocols.
- Exclusions List: The scheme explicitly excludes Out-Patient Department (OPD) expenses, individual diagnostic tests for evaluation purposes, cosmetic surgeries, drug rehabilitation programs, and fertility treatments.
- Gender Parity: The scheme enforces no cap on family size or age of members, preventing the exclusion of girl children or elderly dependents. Women constitute approximately 49% of total authorized hospital admissions nationwide.
The nationwide expansion of the Ayushman Bharat PM-JAY scheme provides a comprehensive framework for universal health coverage. To learn more about how this digital health infrastructure integrates with individual citizen health records, you can watch this video on the working mechanism of the Ayushman Bharat Digital Mission.
Last Modified: June 8, 2026