Ayushman Bharat PMJAY — Complete Guide for 2026

PMJAY was launched from Ranchi, Jharkhand on 23 September 2018 by the Prime Minister. It subsumed the earlier Rashtriya Swasthya Bima Yojana (RSBY) which provided only Rs 30,000 cover per family — a sum insufficient even for routine hospitalisations. PMJAY increased this cover nearly 17-fold to Rs 5 lakh, making it the most ambitious health assurance intervention in India's history.

The scheme is centrally sponsored with a 60:40 centre-state funding ratio for most states, 90:10 for North-Eastern and Himalayan states, and 100% central funding for Union Territories without legislature. As of 2024, more than 34 crore beneficiaries have been issued Ayushman cards, and over 6 crore hospital admissions worth more than Rs 70,000 crore have been authorised under the scheme.

PMJAY is a demand-driven, entitlement-based scheme — meaning any eligible family can avail cashless treatment at any empanelled hospital (public or private) across India, with no cap on family size or age. This portability feature, called National Portability, is operationally enabled through the IT platform hosted by the National Health Authority (NHA).

Ayushman Bharat has two interlinked components, often confused in exam questions:

Pillar 1: Health and Wellness Centres (HWCs)

These are upgraded Sub-Centres and PHCs delivering Comprehensive Primary Health Care (CPHC). The HWC programme expanded the existing range of services from maternal-child health and limited curative care to a broader package including screening for non-communicable diseases (hypertension, diabetes, oral/breast/cervical cancer), mental health services, ophthalmic services, elderly care, and free essential drugs and diagnostics. As of 2024, more than 1.6 lakh HWCs are operational across India. In 2024, HWCs were rebranded as Ayushman Arogya Mandirs.

Pillar 2: PMJAY (Health Insurance)

This is the secondary and tertiary care hospitalisation component providing Rs 5 lakh per family per year. The two pillars together cover the full continuum of care — primary at HWCs, secondary/tertiary through PMJAY.

Eligibility is determined solely on the basis of deprivation and occupational criteria from the SECC 2011 database, not income certificates. PMJAY covers:

Rural Eligibility (SECC deprivation criteria)

• D1: Households with only one room, kuccha walls and kuccha roof
• D2: No adult member between 16-59 years
• D3: Female-headed households with no adult male member
• D4: Disabled member and no able-bodied adult
• D5: SC/ST households
• D7: Landless households deriving major income from manual casual labour

Urban Eligibility (occupational criteria)

• Rag pickers, beggars, domestic workers
• Street vendors, cobblers, hawkers
• Construction workers, plumbers, masons, painters, welders, security guards
• Sweepers, sanitation workers, gardeners
• Home-based workers, tailors, weavers
• Transport workers, drivers, conductors, helpers

The eligibility list is fixed and frozen to the SECC 2011 database. There is no enrolment fee, no premium, and no application form — eligible families are automatically entitled. Beneficiaries can verify their eligibility at mera.pmjay.gov.in or at any Common Service Centre (CSC).

PMJAY covers 1,929 medical and surgical packages across 25+ specialties. The scheme follows a Diagnosis-Related Group (DRG)-based payment system with package rates fixed by the NHA. Key features of the benefit package include:

• Cashless and paperless treatment at empanelled hospitals
• Pre-hospitalisation up to 3 days and post-hospitalisation up to 15 days covered
• All pre-existing conditions covered from day 1
• No cap on family size or age of members
• Free drugs, diagnostics, implants, surgeon fees, OT charges, ICU stay
• Transportation allowance of Rs 100-300 per admission (state-specific)

Covered specialties include general medicine, general surgery, cardiology, cardiac surgery, oncology (medical, surgical, radiation), orthopaedics, paediatrics, OBG, ENT, ophthalmology, urology, nephrology, neurology, neurosurgery, plastic surgery, burns, and critical care. Package rates include 1-day pre-procedure stay, the procedure itself, and up to 12-day post-procedure stay — though extensions are permitted with proper documentation for complicated cases.

For the Patient

1. Verify eligibility at PMJAY kiosk or via Ayushman Bharat card
2. Visit any empanelled hospital with the Ayushman card and Aadhaar
3. Hospital verifies beneficiary on NHA portal and creates pre-authorisation request
4. Treatment begins within 90 minutes of approval for emergency, same day for planned
5. On discharge, patient pays nothing — settlement is between hospital and NHA

For the Doctor / Hospital

The treating doctor selects the appropriate package code based on the primary diagnosis. The hospital's Ayushman Mitra helps the patient with card verification. Pre-authorisation is mandatory for packages above Rs 50,000. Doctors must document all procedures, drugs and consumables in the prescribed format. Claims are submitted through the NHA's IT platform (TMS — Transaction Management System) and typically settled within 15-21 days. Rejection rates average 10-12%, mostly due to documentation gaps or eligibility disputes.

If you work in any empanelled hospital — public or private — you will encounter PMJAY patients daily. The most common pitfalls for treating doctors are:

• Wrong package code selection: Always check the NHA master package list; selecting the wrong code can lead to claim rejection and hospital loss.
• Inadequate documentation: Discharge summaries must include diagnosis, investigations, treatment given, and follow-up advice in the standard PMJAY template.
• Unnecessary admissions: NHA audits flag hospitals with abnormal admission patterns — over-admission triggers de-empanelment.
• Informed consent: A PMJAY-specific consent form must be signed before any surgical procedure.
• Referral chain: Tertiary care requires referral from HWC/PHC/CHC; bypassing this can invalidate the claim.

For UPSC CMS candidates, PMJAY frequently appears in interview questions on health policy. Knowing the Rs 5 lakh cover, the SECC 2011 basis of eligibility, the HWC rebranding to Ayushman Arogya Mandir, and the National Health Authority as the implementing body is essential. Official reference: pmjay.gov.in.

Ayushman Bharat PMJAY has fundamentally reshaped how India's poor access hospital care. For doctors, it has become an unavoidable operational reality in nearly every empanelled facility. For UPSC CMS aspirants, it is one of the highest-yield current-affairs topics in the personality test. Beyond exam value, PMJAY represents a paradigm shift from out-of-pocket payments to publicly financed entitlement-based healthcare — a shift that will define Indian medical practice for the next decade.