Why in News?

• An evaluation by NITI Aayog shows that beneficiaries under PMJAY still incur significant Out-of-Pocket Expenditure (OOPE), especially in private hospitals.

Key Findings of the Study

• High OOPE in private hospitals: ~₹53,965 per hospitalization
• Public vs Private gap:
  • Government hospitals: ~₹21,827
  • Private hospitals: more than double
• Limited cashless benefit:
  • 65% patients incurred OOPE
  • Only 35% experienced fully cashless treatment
• Major cost drivers:
  • Medicines
  • Diagnostics
  • Transportation (not covered)
• Marginal relief vs uninsured:
  • PMJAY OOPE: ₹34,790
  • Uninsured: ₹38,084

About PMJAY (Pradhan Mantri Jan Arogya Yojana)

• Launched in 2018 under Ayushman Bharat
• World’s largest government-funded health assurance scheme
• Implemented by National Health Authority

Objective

• Achieve Universal Health Coverage (UHC)
• Reduce catastrophic health expenditure

Coverage & Features

• Insurance cover: ₹5 lakh per family per year
• Scope: Secondary and tertiary hospitalization
• Pre/Post hospitalization:
  • 3 days pre-hospitalization
  • 15 days post-hospitalization
• Pre-existing diseases: Covered from Day 1

Funding Pattern

• 60:40 → General states
• 90:10 → North-East & Himalayan states
• 100% → Union Territories (UTs) without legislature

Eligibility & Beneficiaries

• Based on Socio-Economic Caste Census (SECC) 2011
• Covers ~55 crore population initially
• No cap on family size, age, or gender

Recent Expansions

• Universal coverage for 70+ elderly (Ayushman Vay Vandana Card)
• Inclusion of Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), and Anganwadi Helpers (AWHs)

Key Operational Features

• Cashless & paperless treatment
• National portability across India
• Access in public + private empanelled hospitals
• Health Benefit Packages (HBP): Predefined packages covering treatment, medicines, diagnostics, and hospital charges

Achievements

• 42 crore Ayushman Cards issued
• 11 crore hospital admissions (till Dec 2025)
• Significant gender inclusion

Issues Highlighted

• High Out-of-Pocket Expenditure (OOPE) persists
• Private hospitals impose higher financial burden
• Non-coverage of transport and indirect costs
• Weak regulation and monitoring
• Gap between scheme design and implementation

Way Forward

• Strengthen regulation of private hospitals
• Expand coverage to include Outpatient Department (OPD) care and transport
• Improve package pricing and monitoring
• Increase public healthcare capacity
• Ensure truly cashless implementation

Conclusion

• PMJAY is a major step toward Universal Health Coverage (UHC)
• However, reducing Out-of-Pocket Expenditure (OOPE) is crucial to achieve real financial protection

PRACTICE QUESTIONS

Q1. With reference to the Pradhan Mantri Jan Arogya Yojana (PMJAY), consider the following statements:

1. It provides health insurance cover of ₹5 lakh per individual per year.
2. It covers pre-existing diseases from the first day of enrolment.
3. It includes coverage for outpatient (OPD) treatment.

Which of the statements given above is/are correct?

(a) 2 only
(b) 1 and 2 only
(c) 2 and 3 only
(d) 1, 2 and 3

Q2. Consider the following statements regarding PMJAY:

1. Beneficiaries are identified based on the Socio-Economic Caste Census (SECC) 2011.
2. The scheme is implemented at the national level by the National Health Authority.
3. The scheme provides completely free and cashless treatment in all cases without any out-of-pocket expenditure.

Which of the statements given above is/are correct?

(a) 1 and 2 only
(b) 2 and 3 only
(c) 1 only
(d) 1, 2 and 3

Q3. With reference to health financing in India, consider the following statements:

1. Out-of-Pocket Expenditure (OOPE) is higher in private hospitals compared to public hospitals under PMJAY.
2. Transportation costs are fully covered under PMJAY.
3. PMJAY aims to reduce catastrophic health expenditure and promote Universal Health Coverage (UHC).

Which of the statements given above is/are correct?

(a) 1 and 3 only
(b) 1 only
(c) 2 and 3 only
(d) 1, 2 and 3

Answer Key

• Q1: (a) 2 only
• Q2: (a) 1 and 2 only
• Q3: (a) 1 and 3 only