Ayushman Bharat and PM Health Insurance (PM-JAY) explained

Q: Is insurance valid immediately after enrollment?

Yes. Once enrolled under PMJAY, benefits are available right away without any waiting period for covered treatments.

Q: Is Pradhan Mantri Jan Arogya Yojana(PM-JAY) related to Ayushman Bharat Digital Mission(ABDM)?

Ayushman Bharat PMJAY and the Ayushman Bharat Digital Mission (ABDM) are separate schemes handled by the National Health Authority. PMJAY offers health insurance, while ABDM builds digital health records and issues the Ayushman Bharat Health Account (ABHA) cards. They are linked digitally for a smoother and more transparent healthcare delivery.

Quick Overview

In everyday conversations, the terms “Ayushman Bharat”, “PM health insurance”, and “PM-JAY” are often used interchangeably. However, they are two different initiatives under the same umbrella. Ayushman Bharat envisages universal health coverage by providing preventive care through a network of Ayushman Arogya Mandirs (AAMs) and health insurance for admissible hospitalizations through the free-of-cost PM-JAY scheme.

PM-JAY provides coverage of ₹5,00,000 for all individuals (even over 70 years of age) and a wide range of people from different socio-economic backgrounds who meet the eligibility criteria.

In 2015, the United Nations adopted the ‘2030 Agenda for Sustainable Development’. One of the goals adopted being, “Leave no one behind”. To honor this goal, the central government of India came up with the ‘Ayushman Bharat program’ in 2018. It was conceived to provide well-rounded healthcare to the bottom 40% of the population, representing nearly 50 crore beneficiaries.

It not only covers primary healthcare (common illnesses and preventive health checkups through 1.5 lakh AAMs), but also secondary and tertiary healthcare (specialized and ultra-specialized treatments covered in empanelled public or private hospitals across India through PM-JAY health insurance). For better implementation of PM-JAY, the National Health Authority (NHA) was reconstituted by the cabinet from the National Health Agency in January 2019.

In this guide we will walk you through these PM health insurance programs in detail.

What Is the PM Health Insurance (PM-JAY) Scheme?

The PM-JAY Health Insurance scheme, also known as Ayushman Bharat PM-JAY or AB-PMJAY, provides coverage of ₹5,00,000 per family annually for eligible individuals. It covers over 1,900+ procedures as per set packages with empanelled public or private hospitals, along with associated expenses. Notably, there are no waiting periods under the plan. The scheme is paid for by a combination of funds from the central and state governments. While most states follow a 60:40 cost split between the center and the state (90:10 for north-eastern and Himalayan states), some union territories are fully funded by the center.

Eligibility Criteria for PM Health Insurance (PM-JAY) Scheme?

Ayushman Bharat and PM Health Insurance (PM-JAY)

Who is Excluded From the PM Health Insurance (PM-JAY) Scheme?

Inclusions and Exclusions of PM Health Insurance (PM-JAY)

Included	Excluded
Hospitalization expenses like nursing charges, boarding charges, and medication	Any condition that can be treated under outpatient care
Day care treatment (as applicable), like blood transfusion, cost of implants and more	Most routine or cosmetic dental treatments
3 days of pre-hospitalization and 15 days of post hospitalisation expenses	Any assisted reproductive techniques or infertility-related procedures, unless featured in the ‘Health Benefit Packages’ list
Follow-up care	Vaccination and immunization
Expenses for treatment of newborn children	Surgeries related to ageing face & body, purely cosmetic procedures

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How to Apply for the PM Health Insurance (PM-JAY) Scheme?

You can download your PM-JAY card through the official website or the ‘Ayushman’ mobile app. Here is a step-by-step guide to apply for the PM health insurance scheme:

PMJAY Website

Visit the official PM-JAY website.
Click on “Am I Eligible” in the top menu.

Search for your beneficiary record using your State, District, Aadhar number, Family ID, or PM-JAY number.

Complete Aadhaar-based e-KYC.
Once verified, your application will be sent for approval. Once approved, you can use the same page to download the card.

‘Ayushman’ App

Install the ‘Ayushman’ app on Android or iOS.
Log in using your mobile number and OTP.
Follow the same steps as on the PM-JAY website to download the card.

In-person through Atal Seva Kendras(CSCs)

Request for PM-JAY card generation or download.
Verify your mobile number, and provide the OTP.
Submit the required documents.
After verification, the staff will process your request.
You can collect your card within a few days.

Note: Aadhaar OTP verification is required at least once to activate and download the card.

Differences Between PM Health Insurance (PM-JAY) and Private Health Insurance

Metric	PM-JAY Health Insurance	Private Health Insurance
Premium	Free-of-cost	Payable for policy’s lifetime
Coverage	Restricted to ₹5,00,000/family/year	No restriction (depends on the plan’s highest SI)
Eligibility	Only for people with certain socio-economic backgrounds, and all people over 70 years of age (based on SECC-2011 data)	Anyone can apply; Issuance based on medical underwriting
Duration	Lifetime	Renewable for lifetime
Geographical Coverage	Pan-India	Pan-India (unless mentioned otherwise)
Waiting period	No waiting period	Waiting periods applicable (Can be up to 3 years)
Network Range	Cashless treatment at empanelled hospitals, no reimbursement option	Cashless treatment at empanelled hospitals, reimbursement option available for non-network hospitals(unless blacklisted)

PM-JAY is an excellent scheme working towards providing universal coverage for the marginalized population and the elderly. This means that not everyone is eligible for the scheme. In our experience, the cover amount of ₹5,00,000 is not enough, especially in urban areas, considering a 14% annual medical inflation. This necessitates having private health insurance for a well-rounded coverage.We recommend enrolling in the scheme if you are eligible for it, or if you are not able to get or afford private health insurance due to your medical history or age.

Key Insights: Since the launch of PMJAY, some private healthcare providers have shown reluctance to accept patients under the scheme due to concerns about delayed payouts. It is advisable to check with your hospital or treating doctor in advance to avoid such issues.

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Ditto’s Take on Ayushman Bharat Program and PM-JAY

The Ayushman Bharat program is a great effort by the Indian government to provide well-rounded healthcare to the lowest rung of the population, who might not be able to afford the expenses otherwise. It provides accessible preventive care and reasonable health insurance coverage of ₹5,00,000 for a wide range of ailments. However, whether it is suitable for you depends on factors like your budget, age, pre-existing conditions, and location.

Comparing options carefully and choosing a comprehensive private health insurance alongside at a price you’re comfortable with can help ensure adequate coverage. Do not forget to read the terms of the scheme carefully to avoid any surprises later.

Frequently Asked Questions

Can I check if my family is covered under PM health insurance?

Yes. You can search your family member’s name on the official PM-JAY beneficiary list online using details like their name, mobile number, or Aadhaar.

Are all family members covered?

Yes. The scheme covers all members of the eligible family without any age or gender limit, based on SECC-2011 data.

Is insurance valid immediately after enrollment?

Yes. Once enrolled under PM-JAY, benefits are available right away without any waiting period for covered treatments.

Is Pradhan Mantri Jan Arogya Yojana(PM-JAY) related to Ayushman Bharat Digital Mission(ABDM)?

Ayushman Bharat PM-JAY and the Ayushman Bharat Digital Mission (ABDM) are separate schemes handled by the National Health Authority. PM-JAY offers health insurance, while ABDM builds digital health records and issues the Ayushman Bharat Health Account (ABHA) cards. They are linked digitally for a smoother and more transparent healthcare delivery.