Pradhan Mantri Jan Arogya Yojana

• 20 Mar 2026

Source: IE 

Why in News?  

An evaluation study commissioned by NITI Aayog has revealed that patients availing treatment in private hospitals under the Pradhan Mantri Jan Arogya Yojana (PMJAY) incur significant out-of-pocket expenditure (OOPE).  

• The study submitted to the Development Monitoring and Evaluation Office (DEMO) of NITI Aayog highlights the continued financial burden on beneficiaries despite insurance coverage. 

What are the Key Findings of the Study on PMJAY? 

• High OOPE in Private Facilities: Beneficiaries utilizing private hospitals under the scheme incurred an average OOPE of around Rs 53,965 per hospitalisation. 
• Public vs. Private Disparity: In government facilities, the average OOPE was significantly lower at Rs 21,827.  
  • Thus, out-of-pocket spending in private hospitals is more than double that in public hospitals. 
• Prevalence of Financial Burden: Despite PMJAY being promoted as a cashless scheme, 65% of the beneficiaries still had to pay from their own pockets, while only 35% enjoyed completely cashless hospitalisation. 
• Primary Cost Drivers: The major expenses forcing patients to spend out of pocket were medicines, diagnostic services, and transportation.  
  • The study acknowledged that transport costs are explicitly not covered under the scheme. 
• Marginal Relief Compared to Uninsured: The average OOPE for PMJAY patients overall was Rs 34,790.  
  • This is only slightly lower (Rs 3,294 less) than the average spending by uninsured patients (Rs 38,084), indicating that the scheme's financial shield is currently inadequate in entirely preventing distress financing. 

What are the Key Facts About Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)? 

• About: Launched in September 2018 as a flagship component of the Ayushman Bharat initiative. PMJAY is the world’s largest government-funded health assurance scheme. 
  • PMJAY aims to achieve Universal Health Coverage (UHC) and mitigate catastrophic healthcare expenditure that pushes millions into poverty annually. 
  • The National Health Authority (NHA) under the Ministry of Health and Family Welfare implements AB-PMJAY at the national level, while State Health Agencies (SHAs) are responsible for its implementation at the state level. 
• Coverage and Financial Architecture 
  • Insurance Cover: Provides a health cover of Rs. 5 lakhs per family per year. 
  • Scope of Care: Strictly covers secondary and tertiary care hospitalization (not primary outpatient care). 
  • Pre and Post-Hospitalization: Covers up to 3 days of pre-hospitalization (diagnostics, consultation) and 15 days of post-hospitalization expenses (medicines, follow-up). 
  • Pre-existing Diseases: All pre-existing conditions are covered from Day 1 of the policy. 
• Funding Pattern: It is a Centrally Sponsored Scheme. Funding is shared between the Centre and States in the ratio of: 
  • 60:40 for normal States and UTs with a legislature. 
  • 90:10 for North-Eastern States and Himalayan States. 
  • 100% Central funding for UTs without a legislature. 
• Eligibility and Beneficiary Identification: Originally targeted the bottom 40% of the Indian population (roughly 12 crore vulnerable families or 55 crore individuals). 
  • Beneficiaries are identified based on the deprivation and occupational criteria of the Socio-Economic Caste Census (SECC) 2011 for rural and urban areas respectively. 
  • There is no cap on family size, age, or gender, ensuring that women, children, and the elderly are not left behind. 
  • In September 2024, PM-JAY was expanded to cover all citizens aged 70 years and above, irrespective of income or SECC status, through the Ayushman Vay Vandana Card, benefiting nearly 6 crore elderly persons. 
  • It was expanded to cover ASHA workers, Anganwadi Workers (AWWs), and Anganwadi Helpers (AWHs). 
• Key Operational Features: 
  • Cashless and Paperless: Beneficiaries experience completely cashless and paperless access to services at the point of care in empanelled hospitals. 
    • Digital initiatives such as the Ayushman App have simplified self-verification and card creation.  
  • National Portability: A beneficiary from one state (e.g., Bihar) can avail of treatment in any empanelled hospital across India (e.g., in Maharashtra or Delhi). 
  • Public and Private Empanelment: Beneficiaries can seek treatment in both public (government) hospitals and empanelled private healthcare facilities. 
  • Health Benefit Packages (HBP): Treatments are strictly provided based on predefined packages that include all costs related to treatment, medicines, supplies, diagnostics, physician's fees, room charges, and food for the patient. 
• Achievements:  By December 2025, over 42 crore Ayushman Cards had been issued, enabling nearly 11 crore hospital admissions.  
  • The scheme has promoted gender equity, with women accounting for nearly half of all cards and hospitalisations.   

Read more: Ayushman Bharat 

Frequently Asked Questions (FAQs) 

1. What is PMJAY under Ayushman Bharat? 
PMJAY is a government-funded health assurance scheme providing ₹5 lakh per family per year for secondary and tertiary hospitalization.

2. What did the NITI Aayog evaluation reveal about PMJAY? 
It found high out-of-pocket expenditure (₹53,965 in private hospitals) and that 65% beneficiaries still pay despite “cashless” claims.

3. What are the major drivers of OOPE under PMJAY? 
Key drivers include medicines, diagnostics, and transportation costs, with transport not covered under the scheme.

4. Who implements PMJAY in India? 
The National Health Authority (NHA) implements it at the national level, while State Health Agencies (SHAs) handle state-level execution.

UPSC Civil Services Examination, Previous Year Question (PYQ)

Prelims 

Q. With reference to the National Rural Health Mission, which of the following are the jobs of ‘ASHA’, a trained community health worker? (2012)

1. Accompanying women to the health facility for antenatal care checkup 
2. Using pregnancy test kits for early detection of pregnancy 
3. Providing information on nutrition and immunization. 
4. Conducting the delivery of baby 

Select the correct answer using the codes given below:  

(a) 1, 2 and 3 only  

(b) 2 and 4 only  

(c) 1 and 3 only  

(d) 1, 2, 3 and 4  

Ans: (a) 

---

Mains

Q. The public health system has limitations in providing universal health coverage. Do you think that the private sector could help in bridging the gap? What other viable alternatives would you suggest? (2015)