Ayushman Bharat PM-JAY

What is Ayushman Bharat PM-JAY?

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) is a publicly funded health cover scheme that pays for secondary and tertiary hospital treatment of eligible families at empanelled public and private hospitals, up to ₹5 lakh per family per year, without any payment by the patient. It was launched in September 2018 and is implemented by the National Health Authority (NHA) with State Health Agencies. Beneficiaries do not pay premium; the Centre and States fund the scheme.

PM-JAY is sometimes called insurance, but in most States it runs as an assurance or trust model, where the State Health Agency pays hospitals directly from a budget instead of buying a policy from an insurer.

Who is covered

• Core beneficiaries. About 12.37 crore families, roughly 55 crore people, identified mainly from deprivation and occupational criteria in the Socio-Economic Caste Census 2011 and later updated lists. There is no cap on family size or age.
• Senior citizens aged 70 and above. Since October 2024, every citizen aged 70 or older is eligible regardless of income, through the Ayushman Vay Vandana card. Where a senior belongs to a family already covered, the family's members aged 70 and above get an additional top-up of up to ₹5 lakh a year, shared among them. A February 2026 parliamentary reply reported 43.52 crore Ayushman cards created, including 1.14 crore Vay Vandana cards.
• State expansions. Many States extend the scheme to more families at their own cost and run it under combined names with their own health schemes.

Coverage across States. West Bengal signed its memorandum of understanding with the NHA on 8 June 2026, becoming the 36th State or Union Territory to implement PM-JAY. Delhi and Odisha had joined during 2025. As of October 2026, all States and Union Territories participate.

How PM-JAY works

Implementation models. In early 2025, 25 States and UTs ran PM-JAY in trust mode, seven in insurance mode and two in a hybrid mode. In insurance mode, the State selects a general or health insurer by tender, pays a per-family premium, and the insurer settles hospital claims. In trust mode, the State Health Agency carries the risk and hires an implementation support agency, often an insurer or TPA, for claim processing.

What PM-JAY means for distribution

• It reshapes the low-income health market. With 55 crore people entitled to free hospital cover, selling basic indemnity health insurance to the same households makes little sense. Private insurers tend to focus instead on the uncovered middle, on OPD and top-up products, and on segments above PM-JAY eligibility.
• The 70-plus expansion changes senior citizen sales. Every senior now has a ₹5 lakh public entitlement. Advisers selling senior citizen health insurance should explain how a private policy adds hospital choice, higher limits and room categories, rather than duplicate cover.
• Insurance-mode States are a tender business. For insurers, PM-JAY in insurance mode is a large, low-margin government contract won on price and claims capability. Success depends on hospital network management, fraud control and claim turnaround.
• Implementation support is a service opportunity. TPAs and insurers acting as implementation support agencies earn fees for claim adjudication, which builds health claims capacity and data skills.
• Hospitals sit between both systems. Network hospitals empanelled for PM-JAY and private insurers manage two sets of rates and rules. Distribution and provider teams that understand PM-JAY package rates can negotiate better with hospitals for their own products.
• Awareness is the gap. Many eligible families still lack an Ayushman card. Agents, Bima Vahaks and CSC operators who help families obtain cards build trust that supports later sales of life and other cover.