Ayushman Bharat Yojana – Coverages, Exclusions, Key Features, Benefits, Eligibility Criteria, Registration Process

What is Ayushman Bharat Yojana?

Ayushman Bharat Yojana, also known as Pradhan Mantri Jan Arogya Yojana (PM-JAY), is the flagship Health Insurance Scheme of the Government of India, providing Health Insurance Coverage of Rs5 lakh per family for secondary and tertiary care hospitalization. The Scheme does not require the beneficiary to pay any premiums. The Premiums are jointly paid by the Central Government and the State Governments. The Pradhan Mantri – Jan Arogya Yojana was launched by Prime Minister Narendra Modi on 23rd September 2018 in Ranchi, Jharkhand to provide Health Insurance Coverage to economically weaker sections of the society and has covered around 81 million hospital admissions till date. The Scheme subsumed the existing Rashtriya Swasthya Bima Yojana which was launched in 2008.

What are the Coverages under the Ayushman Bharat Yojana?

The Ayushman Bharat Yojana provides coverage for the following:

1. In-Patient Hospitalisation Expenses
2. Pre- and Post-Hospitalisation Expenses of 3 and 15 days respectively
3. Medicine and medical consumables
4. Non-intensive and intensive care services
5. Diagnostic and laboratory investigations
6. Medical implantation services (where necessary)
7. Accommodation benefits
8. Food services
9. Complications arising during treatment

What are the Key Features of Ayushman Bharat Yojana?

1. Coverage for Hospitalisation Expenses: The Ayushman Bharat Yojana provides Health Insurance Coverage of Rs5 lakhs per family per year for secondary and tertiary care hospitalisation across public and private empaneled hospitals in India. The Scheme covers approximately 1929 medical procedures covering all the costs related to treatment, including but not limited to drugs, supplies, diagnostic services, physician’s fees, room charges, surgeon charges, OT and ICU charges etc.
2. Pre and Post-Hospitalisation Expense Coverage: Ayushman Bharat Yojana covers Pre-Hospitalisation Expenses of up to 3 days and Post Hospitalisation Expenses of up to 15 days.
3. Pre-Existing Diseases: Ayushman Bharat Yojana covers Pre-Existing Diseases from Day-1. There is no waiting period for any Pre-Existing Diseases under the scheme and the Person can avail treatment for any diseases as soon as he gets enrolled under the scheme
4. Cashless Treatment: Beneficiaries can avail Cashless Claim Settlement at any empanelled public or private hospital across the country. This means that the Beneficiary will not have to pay any expenses out of his own pocket for availing treatment and seek reimbursement later on.
5. Family Floater Policy: The Ayushman Bharat Yojana provides coverage on a Family Floater basis. The coverage amount of Rs. 5 Lakhs can be used by any single family member or can be shared among all the family members. There is no cap on family size or age of members that can be covered under the Policy.
6. Government Funded Scheme: The Beneficiary does not have to pay any Insurance Premium to get enrolled under the scheme. The Premiums are paid by the State Government and Central government in the ratio of 60:40.

What are the Benefits of Ayushman Bharat Yojana?

The Benefits of Ayushman Bharat Scheme or Pradhan Mantri Jan Arogya Yojana are as follows:

1. Family Floater Coverage: The Ayushman Bharat Yojana provides family floater coverage of up to Rs5 lakhs to all family members. There is no cap on family size or age of members that can be covered under the Policy. The coverage amount of Rs. 5 Lakhs can be used by a single family member or can be shared among all the family members.
2. Pre- and Post-Hospitalisation Expenses Coverage: The PMJAY scheme provides coverage for Pre- and Post-Hospitalisation Expenses for 3 days and 15 days respectively.
3. Coverage for Pre-Existing Diseases: The Ayushman Bharat Yojana provides coverage for Pre-Existing Diseases from Day 1, without any Waiting Period. This is a big benefit of Ayushman Bharat Yojana.
4. Cashless Claim Settlement: Beneficiaries can avail Cashless Claim Settlement at any empaneled hospitals across the country. This means that the Beneficiary does not have to bear the burden of medical expenses out of his own pocket for availing treatment.

What Are the Disadvantages of Ayushman Bharat Yojana?

The drawbacks of Ayushman Bharat Yojana are as follows:

1. Low Sum Insured: The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana offers a maximum Sum Insured of Rs5 lakhs only. This Sum Insured may prove inadequate in case of critical illnesses like cancer or heart ailments.
2. Pre- and Post-Hospitalisation Expenses Coverage: Ayushman Bharat Yojana offers coverage for Pre- and Post-Hospitalisation Expenses only for 3 and 15 days respectively while regular Health Insurance Policies offer coverage for 30 days and 60 days respectively.
3. OPD Expenses Not Covered: The scheme does not cover OPD expenses, such as doctor consultations, diagnostic tests, or medications for non-hospitalized patients. This can be a significant expense for people managing chronic conditions that require regular OPD visits.

What is the Eligibility Criteria for Ayushman Bharat Yojana?

The Ayushman Bharat Yojana targets people from the economically weaker section of the Society and is based on deprivation and occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas, respectively. This number also includes families that were covered under the Rashtriya Swasthya Bima Yojana but were not present in the SECC 2011 database.

Rural Beneficiaries - Eligibility Criteria

Eligibility criteria for Rural Beneficiaries includes: Out of the total seven deprivation criteria for rural areas, PM-JAY covered all such families who fall into at least one of the following 6 deprivation criteria (D1 to D5 and D7).:

1. D1 - Only one room with kucha walls and kucha roof
2. D2 - No adult member between ages 16 to 59
3. D3 - Households with no adult male member between ages 16 to 59
4. D4 - Disabled member and no able-bodied adult member
5. D5 - SC/ST households
6. D7 - Landless households deriving a major part of their income from manual casual labour

Destitutes, People living on alms, Manual Scavenger Households, Primitive Tribal Group, Legally Released Bonded Labour qualify for Automatic Inclusion.

Urban Beneficiaries - Eligibility Criteria

Eligibility criteria for Urban Beneficiaries includes:

For urban areas, the following 11 occupational categories of workers are eligible for the scheme:

1. Ragpicker
2. Beggar
3. Domestic worker
4. Street vendor/ Cobbler/hawker / other service provider working on streets
5. Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and other head-load worker
6. Sweeper/ Sanitation worker/ Mali
7. Home-based worker/ Artisan/ Handicrafts worker/ Tailor
8. Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller
9. Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter
10. Electrician/ Mechanic/ Assembler/ Repair worker
11. Washer-man/ Chowkidar

You can check if you are eligible for Ayushman Bharat Yojana on the official PM-JAY website or you can call the Tollfree Helpline Number on 14555 or 1800-111-565

Who Is not Eligible for Ayushman Bharat Yojana Scheme?

While the majority of the people in the backward socio-economic classes are covered, the following people are excluded from being covered under the Ayushman Bharat Yojana

1. If you own a car, two-wheeler or mechanised farming equipment
2. If you have Kisan cards with a credit limit of ₹ 50k
3. If you work in government jobs
4. If your family’s annual income exceeds Rs.10,000
5. If you have an agricultural land above 5 acres
6. If you have a house with refrigerators, landlines and other facilities.

If you are not eligible for Ayushman Bharat Yojana, you can opt for a regular Health Insurance Policy at nominally higher premiums from Qian Insurance

How to Register for Ayushman Bharat Yojana online?

You can apply for Ayushman Bharat Yojana in 2 ways

1. Online Process
2. Offline Process

How to Apply for Ayushman Bharat Yojana Online?

The step-by-step guide to apply for Ayushman Bharat Yojana online is as follows:

1. Visit PMJAY Website: Visit the official PM-JAY website - https://pmjay.gov.in/. The scheme targets people belonging to the economically weaker sections of society.
2. Click on ‘Am I Eligible’ Tab: Click on the ‘Am I Eligible’ Tab on the website. Enter your Mobile Number and Captcha Code and login using the OTP received. Provide the required details like State, District and Ration Card Number. Click on ‘Apply’ under the Action Column
3. Fill the Application Form: If you are eligible to apply for Ayushman Bharat Yojana, fill in the Application form by providing details such as Name, Address, Aadhaar Card Number, Contact Information etc.
4. Upload Documents and Submit Application: After providing the requisite details, upload the required documents such as Aadhaar Card, Ration Card, Income Certificate etc. and submit your application
5. Receive PMJAY Card: After submitting your application, the same will be reviewed by the concerned authorities. If your application is approved, you will receive the Ayushman Bharat Yojana Card which makes you eligible to avail cashless treatment at empanelled hospitals.

How to Apply for Ayushman Bharat Yojana Offline?

The Offline Process to apply for Ayushman Bharat Yojana is as follows:

1. Visit a nearby Common Service Center (CSC) or empaneled hospital.
2. Provide necessary documents (Aadhaar card, ration card, etc.).
3. Complete the verification process and receive your Ayushman Bharat Yojana Card.

What are the Documents required to apply for Ayushman Bharat Yojana?

Following Documents are required to apply for Ayushman Bharat Yojana:

1. Aadhaar card
2. Ration card
3. Proof of Identity like Driving License, Passport
4. Caste Certificate: For SC/ST households
5. Income certificate (if applicable)
6. Mobile number linked to Aadhaar
7. Family Details such as Name and Aadhaar Card Number of each member
8. Bank Account Details

How to Download the Ayushman Bharat Yojana Card?

Online Process to Download Ayushman Bharat Yojana Card

The step-by-step guide to Download Ayushman Bharat Yojana Card is as follows:

1. Visit PMJAY Website: Visit the official PM-JAY website - https://pmjay.gov.in/.
2. Click on ‘Am I Eligible’ Tab: Click on the ‘Am I Eligible’ Tab on the website. Enter your Mobile Number and Captcha Code and login using the OTP received. Provide the required details like State, District and Ration Card Number. Select the Aadhaar Card Number or PMJAY ID under the ‘Search By’ Option. A Page will display the details of family members registered under the scheme.
3. Download the Ayushman Bharat Yojana Card: Select the name of the family member whose card you wish to download and click on the ‘Download’ Button next to their name. The Card will be downloaded in the PDF format.

Offline Process to Download Ayushman Bharat Yojana

The offline process to get an Ayushman Bharat Yojana Card is as follows:

1. Visit a nearby Common Service Center (CSC)
2. Provide necessary documents (Aadhaar card, ration card, etc.) and other details like Mobile Number for Verification
3. Complete the verification process and receive your Ayushman Bharat Yojana Card from an Authorised Person

What are the PMJAY Toll Free Helpline Numbers?

The Toll-Free Helpline Numbers of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) are listed below:

1. 14555
2. 1800-111-565

Ayushman Bharat for Senior Citizens

The Indian government announced on 12th September 2024 that senior citizens aged 70 and above, regardless of their income, will be covered under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY). Senior Citizens, of age 70 years and above, who are already covered under AB PM-JAY will get an additional top-up cover of upto Rs5 lakh per year which they do not have to share with other family members. Providing separate Health Insurance Coverage to Senior Citizens is extremely beneficial as these people have limited finances and proving insurance coverage eases their financial burden.

What is the difference between a Regular Health Insurance Policy and Ayushman Bharat Yojana Health Insurance Policy?

The main difference between a regular Health Insurance Policy and Ayushman Bharat Yojana is that a regular Health Insurance Policy provides greater benefits such as OPD Coverage, Health Check-Ups and higher Sum Insured. The table below lists the major differences between a regular Health Insurance Policy and Ayushman Bharat Yojana

Conclusion

Ayushman Bharat Yojana is more than just a health insurance scheme—it’s a lifeline for millions of Indians, including senior citizens. By providing financial protection and access to quality healthcare, the scheme is transforming the lives of millions of Indians. If you or your loved ones are eligible, don’t wait—apply for Ayushman Bharat today and secure your right to quality healthcare. If you have any queries regarding Health Insurance, you can call Qian Insurance at 022-35134695 or email at insurance@qian.co.in