Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY) is a government-backed health insurance scheme providing up to ₹5 lakh per family per year for secondary and tertiary hospitalization. The coverage is on a floater basis, meaning the entire family shares the insured amount.
The scheme primarily targets economically vulnerable families identified through socio-economic criteria. Coverage includes hospitalization expenses, pre- and post-hospitalization costs, and certain diagnostics linked to admitted treatment.
Understanding eligibility and coverage prevents misinformation.
Who Is Eligible Under Ayushman Bharat
Eligibility is not based on income declaration alone. It is primarily determined through socio-economic data and deprivation criteria.
Broad eligibility categories include:
| Rural Criteria Examples | Urban Criteria Examples |
|---|---|
| Families with no adult earning member | Street vendors |
| Households with kutcha houses | Domestic workers |
| Landless laborers | Construction workers |
| SC/ST households (as per data lists) | Sanitation workers |
Eligibility is pre-determined. You cannot simply apply by submitting income proof unless your name exists in the official beneficiary database.
Coverage Amount and Family Size
Ayushman Bharat provides:
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₹5 lakh coverage per family per year
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No restriction on family size
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Cashless treatment at empaneled hospitals
Here is a summary:
| Feature | Detail |
|---|---|
| Annual Coverage | ₹5,00,000 |
| Family Size Limit | No cap |
| Premium Payment | Paid by government |
| Mode | Cashless hospitalization |
The coverage resets annually based on scheme guidelines.
What Treatments Are Covered
The scheme covers over 1,500 treatment packages across multiple specialties including:
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Cardiology
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Orthopedics
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Oncology
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General surgery
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Neurology
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Maternity care
However, outpatient treatment (OPD) is generally not covered unless hospitalization is required. Cosmetic procedures and non-essential treatments are excluded.
How to Check Eligibility
To check eligibility, individuals must verify whether their name appears in the beneficiary database.
Steps typically involve:
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Visiting the official beneficiary search portal
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Entering mobile number linked to Aadhaar
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Verifying through OTP
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Checking family member inclusion
If your name appears, you can proceed with card generation.
How to Download or Check Ayushman Card Status
After eligibility confirmation, beneficiaries can generate an Ayushman card.
| Step | Action |
|---|---|
| Step 1 | Verify eligibility |
| Step 2 | Complete eKYC if required |
| Step 3 | Generate card through portal or authorized center |
| Step 4 | Download digital card |
Card status can also be tracked through the same portal using registered mobile number.
How to Check Hospital Coverage
Not all hospitals are part of the network. Only empaneled hospitals provide cashless treatment under the scheme.
You should:
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Search hospital list by state
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Confirm treatment package availability
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Verify empanelment validity
Empanelment may vary by specialty and state implementation.
How Claims Work
Under Ayushman Bharat, beneficiaries do not pay upfront at empaneled hospitals for approved procedures. The hospital raises the claim directly with the implementing agency.
Here is how the process works:
| Stage | Action |
|---|---|
| Pre-authorization | Hospital submits treatment request |
| Approval | Agency verifies package |
| Treatment | Cashless service provided |
| Settlement | Hospital reimbursed |
If treatment is outside approved package list, cashless benefit may not apply.
Common Reasons for Claim Rejection
Claims may be denied if:
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Treatment is not part of covered package
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Beneficiary identity mismatch
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Hospital not empaneled
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Pre-authorization not obtained
Always confirm coverage before admission whenever possible.
Ayushman Bharat vs Private Health Insurance
| Feature | Ayushman Bharat | Private Health Insurance |
|---|---|---|
| Premium | Government-funded | Paid by individual |
| Coverage Limit | ₹5 lakh | Varies (₹3–₹50 lakh) |
| OPD | Limited | Rarely covered |
| Network | Empaneled hospitals | Insurer network hospitals |
Ayushman Bharat is a safety net, not a replacement for comprehensive private coverage for middle- and high-income families.
Conclusion
Ayushman Bharat provides critical health coverage of ₹5 lakh per family per year for eligible households. Eligibility is database-based, not open application-based. Beneficiaries must verify their inclusion, generate card properly, and confirm hospital empanelment before treatment.
Understanding coverage limits and package inclusion helps avoid confusion during hospitalization. The scheme offers strong financial protection for vulnerable families when used correctly.
FAQs
Can anyone apply for Ayushman Bharat?
No. Eligibility is based on pre-identified socio-economic criteria in the beneficiary database.
Is the coverage ₹5 lakh per person?
No. It is ₹5 lakh per family per year on a floater basis.
Are all hospitals covered?
Only empaneled hospitals under the scheme provide cashless treatment.
Does it cover OPD treatment?
Primarily hospitalization is covered. Routine outpatient treatment is generally not included.