What is Pradhan Mantri Jan Arogya Yojana (PMJAY)?

Even though India’s constitution promises free healthcare for the natives, how many have access to proper medical facilities? Amidst the growing incidence of lifestyle diseases, people often struggle to get adequate treatment due to the monetary crunch.

However, the healthcare scenario has changed with the introduction of several government initiatives. For instance, government-backed health protection schemes like Pradhan Mantri Jan Arogya Yojana (PMJAY), also known as the Ayushman Bharat Yojana, provide financial coverage to people belonging to the economically weaker section during medical emergencies.

So how does it benefit 40% of India's population deprived of tertiary and secondary care services?

Read on to know more!

Team Digit

What is PMJAY?
Features and Benefits
What is Covered & Not Covered
Eligibility Criteria
List of Critical Diseases Covered
Apply for PMJAY Online
Documents Required
Download a PMJAY Card
What is an ABHA Account?
Benefits of Creating an ABHA Account
Frequently Asked Questions

Pradhan Mantri Jan Arogya Yojana (PMJAY) Scheme

The Government of India's Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) is a national public health insurance system designed to give low-income individuals in the nation free access to health insurance coverage.

Participants in the programme can see their family doctor initially for primary care, but when they require further care, PMJAY offers free secondary and tertiary healthcare for people who need hospitalisation or specialised treatment. The means-tested scheme is a component of the Indian government's national health policy.

Features of the PMJAY Scheme

The government of India launched the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) on September 23, 2018. It is a centrally sponsored scheme. Here are the features of the PMJAY scheme:

Features	Description
Funding and Financial Structure	The Government entirely funds it, and the funding is shared between the Centre and State governments as per prevailing guidelines of the Ministry of Finance.
Coverage and Beneficiaries	PMJAY provides health cover up to Rs. 5 lahks per family per year for secondary and tertiary hospitalisation to around 12 crore poor and vulnerable families (approx. 55 crore beneficiaries).
Implementation and Operational Framework	PMJAY is an entitlement-based scheme. It covers poor and vulnerable families based on deprivation and occupational criteria, as per the SECC database.
Inclusivity and Scope	PMJAY provides cashless and paperless access to services for the beneficiary at the point of service in any (both public and private) impanelled hospitals across India.
Mixed Model Implementation	Under PMJAY, the states are free to choose the implementation modalities. They can implement the scheme through insurance companies, directly through the trust/society, or through a mixed model.
Restrictions	There is no restriction on family size, ensuring all members of designated families, specifically girl children and senior citizens, get coverage.
Complaints and Grievance Mechanism	A well-defined Complaint and Public Grievance Redressal Mechanism has been put in place through which complaints/ grievances are registered, acknowledged, escalated for relevant action, resolved, and monitored.
Technological Infrastructure	PMJAY has created a robust IT system for the implementation and role of real-time transaction data.
Administrative Oversight	At the national level, the National Health Authority (NHA) has been set up as an attached office to the Ministry of Health and Family Welfare to manage the scheme's implementation.
Resources and Information	The details of the package, operational guidelines, and key features are available at www. pmjay.gov.in

Benefits of the PMJAY Scheme

PMJAY aims to help them access proper health services and prevent exorbitant medical expenses, eventually helping and supporting the middle-class population to avoid poverty.

So, here are some of the benefits you can expect from this government-backed health insurance scheme:

The beneficiary family under this scheme is supposed to receive a benefit cover of Rs.5 lakhs per year.
The scheme covers nearly 1929 procedures, including room charges, doctor’s fees, diagnostic services, treatment costs, ICU and operation theatre expenses, etc.
The beneficiary can claim cashless medical facilities across both public and private hospitals in India.
Under this scheme, you will get pre-hospitalisation coverage for 3 days and post-hospitalisation coverage for 15 days. During that time, the patient will also get complete coverage for medicines and diagnostics.

One of the great advantages of this scheme is that it does not restrict anyone to avail of these benefits based on their gender, age, or family size. However, one must keep a prescribed ID handy to utilise Ayushman Bharat benefits at the hospital.

Know about: Pre-Post Hospitalization Expenses in Health Insurance

What is Covered Under the PMJAY?

The PMJAY covers critical diseases and pre and post-hospital expenses. Here is a list of diseases covered under the Ayushman Bharat Yojana:

Coronary artery bypass grafting
Skull base surgery
Anterior spine fixation
Double valve replacement
Prostate cancer
Pulmonary valve replacement
Laryngopharyngectomy with gastric pull-up
Carotid angioplasty with stent
Tissue expander for disfigurement following burns

Beneficiaries can also seek free COVID-19 testing and treatment under this scheme.

What is Not Covered Under the PMJAY?

While this scheme extends financial coverage for most critical illnesses, there are certain facilities that the PMJAY scheme does not cover. Here are a few things that PMJAT does not cover

Organ transplants
OPD
Individual diagnosis
Cosmetic related procedures
Drug rehabilitation programme
Fertility related procedures

With all the necessary facilities and monetary coverage without any premium cost, the Ayushman Bharat Yojana is an ideal health insurance policy for citizens. From pre-existing diseases to severe medical problems, you can now deal with all of them under the PMJAY scheme.

Who is Eligible for Pradhan Mantri Jan Arogya Yojana?

The eligibility criteria are stringent since the government focuses on extending these benefits to the economically challenged section of society. Therefore, make sure to go through the following eligibility parameters of this national health protection policy and see if you are qualified to avail its benefits:

The following are the ones who will receive health coverage under the PMJAY scheme:

Eligible for PMJAY in Urban Areas

The government has created 11 occupational categories, and only those who belong to these categories will be eligible for the Ayushman Bharat Yojana.

Electrician/repair worker/mechanic
Construction worker/ security guard/ plumber/ painter/ etc.
Washerman/chowkidar
Ragpicker
Beggar
Domestic worker
Driver/ transport worker/conductors and other people associated with this
Cobbler/ street vendor/hawker/other service providers who are working on streets
Home-based worker/tailor/artisan
Delivery assistant/shop worker

Eligible for PMJAY in Rural Areas

SC/ST households
Families having physically challenged members (at least one)
Female-led family with no male adult member aged between 16 and 59 years
Legally released bonded labourers
Landless households whose sole earning source is manual casual labour
People living in single-room houses with kutcha roofs and walls

List of Critical Diseases Covered by Pradhan Mantri Jan Arogya Yojana

Each of these procedures addresses specific medical conditions or injuries, aiming to improve the quality of life and long-term health outcomes for patients. The PMJAY covers all of the following diseases

Sl.No.	Disease	Description
1	Prostate Cancer	Treatment options depend on the stage and include surgery, radiation therapy, hormone therapy, chemotherapy, or a combination.
2	Coronary Artery Bypass Grafting	Surgery to improve blood flow to the heart by bypassing blocked arteries using healthy blood vessels.
3	Double Valve Replacement	Surgery to replace both the aortic valve and the mitral valve in the heart with prosthetic valves.
4	Carotid Angioplasty with Stent	Procedure to open narrowed carotid arteries (neck arteries that supply blood to the brain) using a stent to prevent stroke.
5	Pulmonary Valve Replacement	Surgery to replace a defective pulmonary valve in the heart with a prosthetic valve.
6	Skull Base Surgery	Complex surgery to treat tumours or abnormalities located at the base of the skull often involves collaboration between neurosurgeons and ENT specialists.
7	Laryngopharyngectomy with Gastric Pull-up	Surgery to remove the larynx (voice box) and pharynx, then reconstruction using a portion of the stomach to restore swallowing function.
8	Anterior Spine Fixation	Surgical procedure to stabilise the spine from the front (anterior) using rods, screws, or plates to treat spinal instability or fractures.
9	Tissue Expander for Disfigurement Following Burns	A procedure involves inserting a tissue expander under the skin near the burn scar to stretch healthy tissue for subsequent reconstruction gradually.

How to Apply for Pradhan Mantri Jan Arogya Yojana Online?

There is no separate process for Ayushman Bharat registration since all the recipients who are already part of the Rashtriya Swasthya Bima Yojana were identified by the SECC 2011 data. Besides checking the eligibility parameters, you can directly check if you are eligible for the scheme using the PMJAY website. Here is what you need to do:

Step 1: Log in to their official website: https://pmjay.gov.in/.

Step 2: Enter the captcha code on the screen and your mobile number now.

Step 3: You can access the PMJAY login screen by entering the OTP issued to your registered mobile number.

Step 4: Now, choose the state in which you want to apply for this programme.

Step 5: Choose how you wish to look up your eligibility requirements: Name, RSBY URN, Ration card number, or mobile number

Step 6: If you are eligible, your name will appear on the right side of the page.

Step 7: You can view the beneficiary data by selecting the 'Family Members' tab.

Know More About: Best Health Insurance Plan

Documents Required to Apply for the PMJAY Scheme

If you are thinking about applying for an Ayushman Bharat card online to get all of its salient advantages, keep these documents prepared:

Caste certificate
PAN Card and Aadhaar Card as age and identity proof
Voter ID, passport, or utility bill as proof of residence
Income certificate (maximum annual income up to Rs.5 lakhs)
Current status of the family (joint/nuclear) and supportive document regarding the same
Caste Certificate
Bank Account Details

How to Download a PMJAY Card Online?

Beneficiaries can apply for the Ayushman Bharat Yojana Golden Card to get the convenience of paperless, cashless, and portable transactions under the PMJAY scheme. You can simply present the card at the hospital to get fast and hassle-free service.

Here is the process to avail the card:

Step 1: Visit the official website of PMJAY website and use your registered mobile number to log in.

Step 2: Generate the OTP by entering the captcha code and look for the HHD code.

Step 3: After that, you need to provide the HHD code to CSC or the Common Service Center, where Ayushman Mitra or CSC representatives will help you complete this process.

How to Generate PMJAY Patient Card?

You can obtain a PMJAY patient card through the official website after qualifying for PMJAY benefits. Here are the steps for card generation:

Step 1: Log in to the official website.

Step 2: At the PMJAY kiosk, your ration card or Aadhaar card will be validated before a card is issued.

Step 3: Verify family identification of the certified list using a PM letter and an RSBY card.

Step 4: Print the e-card with the unique AB-PMJAY ID after verification.

Step 5: Use the e-card as proof in the future.

How to Check Your Name in the PMJAY Beneficiary List?

There are different methods you can use to check if your name is on the PMJAY beneficiary list. As mentioned earlier, you can simply use the online portal to check whether you are eligible for the scheme or not. Apart from the online process, there are two other convenient methods you can try out:

Common Service Centre (CSC): Find the nearest CSC or any empanelled hospital to determine your eligibility for the healthcare scheme.
Helpline numbers: You can also use the helpline numbers 1800-111-565 or 14555 to acquire all the necessary information.

Stepwise Process to Check Names in PMJAY Beneficiary List Online

You can check the names in the PMJAY beneficiary list online using the Beneficiary NHA portal. Below are the steps to log in:

Step 1: Visit the official website beneficiary.nha.gov.in.
Step 2: Input your mobile number and verify. Enter OTP from your mobile.
Step 3: Select the scheme name, state, sub-scheme, and district.
Step 4: Get beneficiary details on the screen after adding all details.

Medical Packages Under PMJAY Scheme

The PMJAY offers various medical packages for the benefit of the cardholders. Below is a list of specialty situations and the number of packages available for them:

S.No.	Specialty	Packages
1	Burns Management	12
2	Cardiology	39
3	Cardio-thoracic & Vascular surgery	92
4	Emergency Room Packages (Care requiring less than 12 hours stay)	4
5	General Medicine	72
6	General Surgery	253
7	Interventional Neuroradiology	15
8	Medical Oncology	52
9	Mental Disorders Packages	17
10	Neo-natal care Packages	10
11	Neurosurgery	83
12	Obstetrics &Gynaecology	79
13	Ophthalmology	42
14	Oral and Maxillofacial Surgery	9
15	Orthopaedics	101
16	Otorhinolaryngology	94
17	Paediatric Medical management	102
18	Paediatric Surgery	34
19	Plastic & reconstructive Surgery	9
20	Polytrauma	12
21	Radiation Oncology	14
22	Surgical Oncology	48
23	Urology	161
24	Paediatric Cancer	38
25	Unspecified Surgical Package	1

Benefits coverage under India's different state-funded health insurance programmes has traditionally been capped at INR 30,000 per family per year, with the maximum amount varying across States, leading to a disjointed system.

Every qualifying household can receive a cashless cover of up to INR 5,00,000 from PM-JAY annually for specified secondary and tertiary medical problems.
All costs related to the following treatment components are covered under the plan.
Medical diagnosis, care, and advice.
Before hospitalisation, pharmaceuticals and supplies for healthcare.
Services for both intensive and non-intensive care.
Laboratory and diagnostic tests.
Services for medical implantation (when necessary).
Accommodation advantages.
Catering services problems that develop while receiving treatment up to fifteen days of post-hospitalisation follow-up care.

How to Find a Hospital List Under the PMJAY?

Numerous hospitals have been empanelled since the Ayushman Bharat Yojana was implemented. The Ayushman Hospital list is available on the official PMJAY website. Here, you can quickly find out how to check the Ayushman Card list. You must follow these steps to locate the list of Ayushman Card hospitals:

Step 1: Go to hospitals.pmjay.gov.in to view registered hospitals.

Step 2: Decide the state and district you live in.

Step 3: Decide if you want to go for a public, private, for-profit, or nonprofit hospital.

Step 4: Decide which medical specialisation you require. For instance, paediatric, general, neurosurgery, cancer, etc.

Step 5: Type the Captcha.

Step 6: Click on ‘Search’.

Hospitalisation Process in the PMJAY Scheme

As a recipient, you will be given the Ayushman health card, allowing you to access hospital stays and treatments without using cash. You can use your golden card to get the program's benefits at any public or private hospital with an affiliation.

The hospitalisation and treatment procedure is cashless because the centre and the state have a 60:40 cost-sharing agreement. You have access to around twenty-five different medical specialities. Anyone hospitalised under the PMJAY can get free hospitalisation at any government or private hospital.

PMJAY Toll-free Number and Address

Beneficiaries can call the ESIC toll-free number: 1800-11-4477/ 1477 or mail ayushmanbharat.csc@gmail.com for further information. The address for the PMJAY office is 7th & 9th Floor, Tower-L, Jeevan Bharati Building, Connaught Place, New Delhi - 110001.

What is an ABHA Account?

The Ministry of Health and Family Welfare introduced the Ayushman Bharat Digital Mission (ABDM) programme, which is primarily concerned with laying the groundwork for the nation's healthcare system to become digital. One of the main components of India's government's ABDM plan is the Ayushman Bharat Health Account (ABHA), which provides you with a health card bearing a unique identifying number.

India's residents benefit greatly from this mission, which includes easy access to healthcare facilities and medical treatments, simple options for signing up for personal health record applications (like the ABDM ABHA app), and reliable identities.

Benefits of Creating an ABHA Account

An ABHA card has many advantages and makes it easier to document your medical history. Here are a few of the ABHA card's features:

Benefits	Description
Electronic Medical Records	As previously mentioned, your Ayushman Bharat Health Account allows you to digitally store all your medical records and reports on one platform.
Mutual Consent for Access to Medical Records	If you have an ABHA health card, your doctor can view your medical records. However, no doctor may obtain these documents without your permission.
Elevated Security	With ABHA, you needn't worry about your medical information being compromised. The platform's robust encryption mechanism is a security precaution.
Availability of Multiple Physicians	You can quickly, simply, and securely contact a licensed physician and/or other healthcare providers through ABHA to seek advice.
The Ability to Switch On or Off ABHA	Having an ABHA health card to obtain medical care is unnecessary. With ABHA, you can generate a health card ID that you can deactivate whenever you stop using the site.
Choice to Add a Beneficiary	Once you have your health card, you can add a beneficiary to your ABHA. This facility has not yet been introduced to the Indian public, but it will be accessible soon.

Regular Health Insurance Plan vs Ayushman Bharat Yojana Scheme

Here's a comparison table between a Regular Health Insurance Plan and the Ayushman Bharat Yojana Scheme (PMJAY):

Point of Differentiation	Regular Health Insurance Plan	Ayushman Bharat Yojana Scheme
Coverage	Typically covers hospitalisation, outpatient care, etc.	Primarily focuses on hospitalisation
Scope	Coverage based on chosen plan and premium paid	Covers specified treatment packages
Target Audience	Individuals and families based on the policy purchase	Economically weaker sections and identified vulnerable groups
Government Involvement	Provided by private insurers or government agencies	Fully funded by the government
Premium Payments	Premiums vary based on coverage, age, health status	No premium for beneficiaries
Network Hospitals	Access to network hospitals based on insurer's tie-ups	Empaneled hospitals under the scheme
Cashless Treatment	Available depending on policy terms and hospital network	Available at empanelled hospitals
Beneficiary Identification	Policyholders identified through standard procedures	Identified based on the Socio-Economic Caste Census (SECC) database
Coverage Limit	Limited by sum insured and policy terms	No upper limit on family size or age
Benefits and Services	Comprehensive as per plan coverage	Pre-defined packages for specific treatments
Pre-existing Conditions	Coverage may exclude pre-existing conditions	Covered under the scheme's provisions
Portability	Portability options available between insurers	Portability not applicable
Administration	Managed by insurance companies or TPA.	Managed by the National Health Authority

The PMJAY programme is the best in India for impoverished people who lack access to online health insurance or the Internet. They are the target audience for this programme. It serves numerous families who cannot avail of quality treatment.

Use your PMJAY Card according to the diseases it covers to get its benefits. Check your eligibility before applying for the card, and enjoy the benefits once you have it.

FAQs about the PMJAY Scheme

All

Does the PMJAY scheme provide coverage to 80-year-olds?

Yes. Since there is no specific age criteria for this scheme, people above the age of 80 years can also benefit from this scheme by enrolling in the Ayushman Yojana registration process.

Who should the PMJAY beneficiary contact during medical emergencies?

PMJAY representatives or Ayushman Mitra are always available at the empanelled hospital, and beneficiaries can contact them to get medical facilities under the PMJAY scheme.

Is the Ayushman Bharat scheme available to pregnant women?

Under PMJAY or Ayushman Bharat Yojana, pregnant women can get financial coverage up to Rs.5 lakhs.

Will I be able to obtain death benefits if I have the Ayushman Yojana card?

No, the PMJAY scheme does not provide death benefits to the beneficiaries of policyholders.

What is the full form of PMJAY?

The full form of PMJAY is Pradhan Mantri Jan Arogya Yojana (PM-JAY).

How to register for PMJAY online?

One can register for the PMJAY plan by going to the official PMJAY website and selecting the 'Am I Eligible' option provided on the homepage.

Will an ID card be given to beneficiaries of the PMJAY?

Yes, eligible families will receive a PMJAY e-card and a unique ID card at the time of hospitalisation.

What is the HHD number in PMJAY?

In the PMJAY online registration process, HHD stands for Healthcare Provider Identification.

Does PMJAY cover pre-existing diseases?

Yes, pre-existing ailments are covered under the Pradhan Mantri Jan Arogya Yojana (PMJAY) programme.

Who should the beneficiaries contact at the time of hospitalisation?

The beneficiaries of the PMJAY can contact their Arogya Mitra for assistance during hospitalisation.

Will scheme beneficiaries have to pay to get healthcare coverage under the scheme?

No, beneficiaries of the Pradhan Mantri Jan Arogya Yojana (PMJAY) do not have to pay to get healthcare coverage under the scheme.

What is the death benefit for Ayushman card holders?

There is no death benefit for the beneficiary of Ayushman card holders. Instead, it is for the treatment purpose.

How to change your mobile number in PMJAY?

If you are a programme beneficiary, you can update your information by calling the 1800-111-565 or 14555 Ayushman Bharat helpline or by going to the Common Service Centre (CSC).

How to update your data in PMJAY?

If you are a programme beneficiary, you can update your information by calling the 1800-111-565 or 14555 Ayushman Bharat helpline or going to the Common Service Centre (CSC).

Are diabetic patients covered under the PM PMJAY Scheme?

Yes, benefits under PMJAY will be accessible for diabetic patients from day one.

What should I do if the hospital refuses to treat a beneficiary under the PMJAY Scheme?

If the hospital refuses to treat the beneficiary, the scheme's cardholders may file complaints by calling the national Ayushman Bharat Yojana toll-free number, 14555.

Does a beneficiary need to pay for medicines for the treatment under this scheme?

No, the government health insurance programme covers most medical treatment expenditures, prescription drugs, diagnostic fees, and pre-hospitalisation costs.

Does the scheme only entitle beneficiaries to admission to the general ward?

Yes, if the beneficiary requests a better room, the PMJAY programme will not pay for all medical costs. ICU admission is permitted for specific packages.

I have been a diabetic for years. Will I now be able to get treatment under PMJAY?

Yes, benefits under PMJAY will be accessible for inpatient diabetes care starting on the first day of the program's implementation.

If a family has five members who have already availed themselves of benefits under PMJAY, will a newborn be covered?

Yes, the size, age, or gender of the family is not restricted. From the beginning, all pre-existing conditions are covered. The program's benefits are transferable throughout the nation, so a recipient can receive cashless care at any public or private hospital in India that has been accredited.

Is cancer treated under PMJAY?

Yes, however, not all malignancies require the same kind and length of treatment. Like a "tumour board concept," cancer care treatments must be approved as a comprehensive treatment plan to determine the optimal course of patient management.

Is post-hospitalisation expenses covered in PMJAY?

Yes, PMJAY pays for up to three days of pre-hospitalisation and fifteen days of post-hospitalisation costs, including medications and diagnostics.

What document or proof must a patient carry to avail of PMJAY benefits?

The principal identity card provided to qualified beneficiaries under PMJAY is the PMJAY Golden Card. It has all the information required for verification and identity.

What if there is an emergency treatment has to be done?

Emergency hospitalisation is available under PMJAY registered hospitals, provided you have the card and are a beneficiary. Cashless hospitalisation is available under any empanelled government or private hospital, and you can show your PMJAY e-card.

What is meant by packages in the PMJAY scheme?

Packages under PMJAY mean the type of medical benefits available to the beneficiaries. PMJAY has around 1,350 medical packages that cover many health services. These packages include daycare treatment, medical examination, implantation services, diagnostic and laboratory services, and many more.

What should I do if I forget the login ID or password for PMJAY?

To reset your password, go to the official PMJAY website and look for the login section. There should be an option like "Forgot Password" or "Forgot ID". Click on that. You will receive an OTP to reset your password or retrieve your login ID.

Which types of treatments are available under the PMJAY scheme for a beneficiary?

The health insurance covered by AB-PMJAY includes a range of services, including medical consultation, examination, and treatment; pre-hospitalisation; non-intensive and intensive care; prescription drugs and medical supplies; diagnostic and laboratory testing; lodging; and medical implants.

How many days will I receive payment for the claims submitted under PMJAY?

According to PMJAY's Claims-Adjudication-Manual, claims from within the State must be resolved within 15 days, while claims from outside the State (portability cases) must be resolved within 30 days.

I have not received reimbursement for claims for more than 1 month under PMJAY. Who should I follow up with?

The ABDM Grievance Redressal System is an online site that handles complaints filed by various ABDM stakeholders. Anyone can use this method to file a complaint or grievance, which will be handled in a predetermined amount of time.