Ayushman Bharat PM-JAY is the world's largest government-funded health assurance scheme. It provides a health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalization to over 12 crore poor and vulnerable families, offering cashless treatment at empaneled hospitals across India.
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Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is the world's largest government-funded health assurance scheme, to provide a cashless health cover for secondary and tertiary hospitalization to poor and vulnerable families.
Launched in 2018, it is the world’s largest government-funded health assurance scheme.
Vision and Objectives:
It offers an annual health cover of ₹5 lakh per family for hospitalization in secondary and tertiary care, on a family floater basis—usable by any member without limits on age or gender.
All pre-existing diseases are covered from day one. The National Health Authority (NHA) manages national-level operations, while State Health Agencies (SHAs) handle execution at the state level, often through trust, insurance, or hybrid models.
AB PM-JAY is the secondary and tertiary care arm of the Ayushman Bharat initiative. The other pillars under Ayushman Bharat include:
Initially, beneficiaries were identified through the 2011 Socio-Economic Caste Census (SECC), covering about 12 crore families (roughly 55 crore people) in the lowest 40% income group.
Reducing Out-of-Pocket Expenditure (OOPE
The Economic Survey 2024-25 indicates that PM-JAY has reduced Out-of-Pocket Expenditure (OOPE) from 62.6% in FY15 to 39.4% in FY22, saving beneficiary families over ₹1.52 lakh crore by October 2025.
This reduction helps ease financial burdens on households and prevents medical crises from causing poverty.
Increased Access to Healthcare
As of October 2025, the PM-JAY scheme has enabled over 9.19 crore hospital admissions and treatments totaling ₹1,29,386 crore, improving healthcare access for vulnerable groups. (Source: NHA)
The NHA's 2024-25 report indicates women account for 49% of admissions, suggesting improved access to institutional healthcare for women.
Digital Transformation and Efficiency:
As of October 2025, over 76.5 crore Ayushman Bharat Health Accounts (ABHA) have been created, with 51.3 crore health records linked. (Source: NHA)
The National Health Claims Exchange (NHCX), developed by NHA in collaboration with IRDAI, facilitates paperless settlement of claims, enhancing transparency and efficiency.
Fraudulent Claims: Over 4.6 lakh suspicious claims were flagged between 2023 and 2025, worth ₹272 crore. (Source: NHA)
Low Public Health Spending: Public health expenditure stands at around 1.84% of GDP—below the 2.5% target set by the National Health Policy 2017.
Hospital-Based Focus: PM-JAY mainly covers secondary and tertiary hospitalization, while outpatient and preventive care remain underfunded.
Private Sector Dependence: About two-thirds of PM-JAY funds go to private hospitals, where service quality and pricing vary widely. (Source: Indiaforum)
Uneven State Performance: Implementation varies widely, and some states like West Bengal have opted out.
The “Missing Middle”: Those not poor enough for PM-JAY but unable to afford private insurance remain uncovered.
Weak Primary Care Links: Coordination with Ayushman Arogya Mandirs (AAMs) is still developing. Rural areas face shortages of trained healthcare staff.
Reimbursement Delays: Delayed payments to empanelled hospitals, especially small ones, disrupt operations and affect patient care.
Increase Health Spending
Raise public health expenditure to at least 2.5% of GDP, prioritizing primary healthcare, infrastructure, and human resources.
Strengthen Primary Care
Link PM-JAY more effectively with Ayushman Arogya Mandirs. Over 1.76 lakh centers already offer free diagnostics, essential medicines, and teleconsultations.
Cover the “Missing Middle”
Introduce new models or partnerships to provide health coverage for those not currently eligible.
Reinforce Anti-Fraud Systems
Expand use of AI-based analytics and ensure stricter penalties for fraudulent claims.
Regulate and Support Private Hospitals
Establish transparent pricing and quality standards while ensuring timely reimbursements.
Enhance Awareness
Run targeted, multilingual campaigns and simplify grievance redressal to help beneficiaries access their entitlements.
Address Workforce Gaps
Expand medical and nursing education, provide incentives for rural service, and strengthen community health training.
Ayushman Bharat PM-JAY has transformed healthcare by reducing medical costs, expanding access, and promoting inclusivity, marking a major step toward Universal Health Coverage and equitable healthcare for all.
Source: PIB
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PRACTICE QUESTION Q. Critically evaluate the performance of Ayushman Bharat PM-JAY in providing financial protection and reducing out-of-pocket expenditure. 250 words |
The Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world's largest health assurance scheme fully funded by the government. It aims to provide free and cashless secondary and tertiary healthcare services to over 12 crore poor and vulnerable families (the bottom 40% of the Indian population).
Eligibility is based on the deprivation and occupational criteria of the Socio-Economic Caste Census (SECC) 2011 data for rural and urban areas, respectively. The scheme covers over 12 crore poor and vulnerable families across the country.
An Ayushman Mitra (AM) is a certified frontline health service professional positioned at every empanelled hospital (EHCP). They help beneficiaries identify their eligibility, verify documents, guide them through the process of receiving cashless treatment, and coordinate with the relevant state health agencies regarding pre-authorization and claims.
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