Pradhan Mantri Jan Arogya Yojana, Benefits, Eligibility, Features

PM Jan Arogya Yojana was launched under the Ayushman Bharat, by the Government of India, as a flagship initiative aimed at achieving Universal Health Coverage (UHC) in line with the National Health Policy of 2017. The scheme represents India’s commitment to the Sustainable Development Goals (SDGs), particularly the principle of “leaving no one behind.” It seeks to transform the country’s fragmented healthcare delivery system into a comprehensive, equitable, and need-based model that addresses preventive, promotive, and curative healthcare at all levels. In this article, we are going to cover the PM Jan Arogya Yojana.

Overview of Ayushman Bharat

Ayushman Bharat aims to shift India from a sectoral and segmented approach to a holistic, integrated healthcare system. The program has been designed to cater to healthcare needs at the primary, secondary, and tertiary levels through two interrelated components:

1. Health and Wellness Centres (HWCs)
2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Together, these components provide a continuum of care, focusing not only on curative services but also on prevention, health promotion, and management of non-communicable diseases.

Health and Wellness Centres (HWCs)

In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by upgrading existing Sub Centres and Primary Health Centres. These centres are designed to deliver Comprehensive Primary Health Care (CPHC) closer to communities. HWCs provide services that include maternal and child health, management of chronic non-communicable diseases, and essential drugs and diagnostics—all at no cost to patients.

The vision of HWCs focuses on prevention and health promotion, aiming to empower individuals and communities to adopt healthy behaviours and reduce the risk of chronic illnesses. By extending primary healthcare services to underserved populations, HWCs enhance accessibility, universality, and equity in the Indian healthcare system.

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Pradhan Mantri Jan Arogya Yojana (PM-JAY)

The second pillar of Ayushman Bharat, PM-JAY, was launched on 23rd September 2018 in Ranchi, Jharkhand by Prime Minister Narendra Modi. PM-JAY is recognized as the largest government-funded health assurance scheme in the world, providing coverage of ₹5 lakh per family per year for secondary and tertiary hospitalization. The scheme targets over 12 crore poor and vulnerable families, which amounts to around 55 crore beneficiaries, constituting the bottom 40% of India’s population.

PM-JAY Eligibility and Coverage

The eligibility criteria are based on the Socio-Economic Caste Census (SECC) 2011 for both rural and urban areas. PM-JAY subsumes the earlier Rashtriya Swasthya Bima Yojana (RSBY) and ensures that families previously covered under RSBY but not in SECC 2011 are included. The scheme is fully funded by the Government of India, with implementation costs shared between the Central and State Governments.

PM-JAY Features

Features of PM-JAY include: 

1. World’s Largest Health Assurance Scheme: Provides a cashless cover of ₹5 lakh per family per year.
2. Coverage of Beneficiaries: Over 12 crore families (~55 crore people) are eligible.
3. Cashless Access: Beneficiaries receive treatment at empanelled hospitals without upfront payment.
4. Comprehensive Treatment: Covers 1,929 procedures including diagnostics, medicines, room charges, physician fees, surgeries, and ICU care.
5. Family Floater Scheme: Coverage applies to the entire family, with no restriction on age, gender, or family size.
6. Pre-Existing Conditions: All pre-existing illnesses are covered from day one.
7. Portability Across India: Benefits can be availed at any empanelled hospital nationwide.
8. Pre- and Post-Hospitalization Coverage: Includes 3 days pre-hospitalization and 15 days post-hospitalization care.

PM-JAY Benefits to the Beneficiaries

PM-JAY addresses the shortcomings of previous state-run health insurance schemes, which had lower ceilings (₹30,000–₹3,00,000) and often imposed restrictions on family size. Under PM-JAY, the entire treatment cost is covered for the eligible family, encompassing:

• Medical consultation, diagnosis, and treatment
• Pre-hospitalization and post-hospitalization care
• Medicines and consumables
• Intensive and non-intensive care services
• Implantation services and surgical procedures
• Accommodation, food, and complications arising during treatment

The coverage makes sure that economically vulnerable families are shielded from catastrophic medical expenditures, which push nearly 6 crore Indians into poverty annually.

PM-JAY Importance

Pradhan Mantri Jan Arogya Yojana is significant due to the following reasons: 

1. Financial Protection: Shields poor families from catastrophic healthcare expenses by providing cashless coverage of ₹5 lakh per year.
2. Largest Government Health Scheme: Serves over 50 crore individuals, focusing on the poorest segments of society.
3. Improved Access to Healthcare: Facilitates treatment in public and empanelled private hospitals, covering serious illnesses like cancer, cardiac ailments, and renal disorders.
4. Reduced Out-of-Pocket Expenditure: Encourages beneficiaries to seek medical care without financial constraints.
5. Strengthening Healthcare System: Promotes preventive care through HWCs and improves service quality through private sector participation.
6. Digital & Transparent System: Aadhaar-based identification ensures transparency and prevents fraudulent claims.
7. Boost to Economy & Employment: Expands demand for healthcare services, creating jobs in hospitals, insurance, and healthcare administration.

PM-JAY Challenges and Lacunae

The scheme Pradhan Mantri Jan Arogya Yojana has faced the following challenges: 

1. Limited Coverage: OPD services, diagnostics, and medicines outside hospitalization are not covered. Some high-cost procedures may also be excluded.
2. Insufficient Hospital Participation: Many private hospitals avoid participation due to low reimbursement rates, while overburdened public hospitals face excessive patient loads.
3. Fraud and Misuse: Ghost beneficiaries, fake claims, and unnecessary procedures have been reported.
4. Awareness and Implementation Gaps: Many eligible beneficiaries remain unaware of their entitlements, and digital literacy gaps hinder access.
5. Financial Sustainability: Rapidly increasing demand strains government finances, and state-level disparities affect consistent implementation.
6. Quality of Care: Shortages of specialists and variation in service standards across states affect healthcare outcomes.
7. Claim Settlement Challenges: Delays in reimbursement and complex documentation processes discourage hospital participation.

PM-JAY Funding and Implementation

PM-JAY is fully funded by the Central and State Governments, typically on a 60:40 cost-sharing basis. States can adopt Insurance, Trust, or Mixed Models for implementation, allowing flexibility based on local infrastructure and capabilities.

Related Initiatives

• Health and Wellness Centres (HWCs): Focus on preventive and primary healthcare.
• PMJAY-MA (Mukhya Mantri Amrutum Yojana): State-specific adaptations like Gujarat’s scheme for localized implementation.

PM-JAY Way Forward

The future trajectory of PM-JAY involves:

1. Expanding Coverage: Including more vulnerable groups and reducing exclusion gaps.
2. Strengthening Infrastructure: Enhancing the capacity of hospitals and HWCs to meet rising demand.
3. Fraud Detection: Using AI and data analytics to detect ghost beneficiaries and fake claims.
4. Digital Health Records: Integrating digital platforms for seamless beneficiary tracking and claims management.
5. Private Sector Engagement: Increasing empanelment of private hospitals while ensuring quality standards.
6. Awareness Programs: Conducting campaigns to educate beneficiaries on entitlements and processes.
7. Sustainable Funding: Ensuring long-term financial viability through central and state collaboration.

PM-JAY for UPSC

Ayushman Bharat and PM-JAY have fundamentally transformed India’s approach to healthcare. By providing financial protection to economically vulnerable families and improving access to quality treatment, these initiatives represent a landmark step towards Universal Health Coverage.

PM-JAY not only mitigates catastrophic healthcare costs but also strengthens preventive, promotive, and curative care through HWCs. With ongoing reforms, expanded coverage, and digital integration, the scheme is poised to ensure equitable, transparent, and efficient healthcare delivery, reinforcing India’s commitment to leaving no one behind.

Through Ayushman Bharat, India envisions a healthcare system that is inclusive, accessible, and financially protective, empowering every citizen to lead a healthier, more productive life. This transformative approach lays the foundation for a sustainable, resilient, and robust health system aligned with the Sustainable Development Goals and India’s socio-economic priorities.