Eligibility Of Pradhan Mantri Ayushman Bharat Yojana

The eligibility of Pradhan Mantri Ayushman Bharat Yojana is determined using SECC 2011 data, state-specific beneficiary databases and approved occupational categories under Ayushman Bharat PMJAY. The scheme provides eligible families and senior citizens with health insurance coverage of up to ₹5 lakh per year for cashless treatment at empanelled hospitals. 

Key Highlights

• Rural Eligibility: Based on six SECC 2011 deprivation criteria for vulnerable households
• Urban Eligibility: Covers specific occupational categories such as labourers, domestic workers, and street vendors
• Senior Citizen Coverage: All individuals aged 70 years and above are eligible irrespective of income since September 2024
• ASHA & Anganwadi Coverage: ASHA workers, Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHs) covered under PMJAY expansion
• Automatic Inclusion: SC/ST households, bonded labourers, manual scavengers, and vulnerable tribal groups are automatically eligible

What is Ayushman Bharat Health Insurance?

Ayushman Bharat is a health protection scheme to provide health insurance to citizens. It provides insurance coverage of up to ₹5 lakh on a family floater basis to beneficiaries every year in order to receive primary, secondary, and tertiary healthcare services. 

• The scheme was earlier referred to as AB-NHPS as it is an initiative under the existing National Health Protection Scheme (NHPS). Currently, it is known as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). 
• The scheme is implemented by the Central and State Governments through empanelled insurance companies and trust-based models. 
• The scheme subsumes the existing senior citizen health insurance scheme as well as the Rashtriya Swasthya Bima Yojana.

In January 2022, the Government revised the PMJAY beneficiary base from 10.74 crore families to 12 crore families to account for population growth. States were also allowed to use alternate beneficiary databases in addition to SECC data for identifying eligible households.

Ayushman Bharat Yojana Eligibility Criteria for Rural Families

There are seven deprivation criteria used to identify eligible rural households under PMJAY. The eligible categories are:

• Families without an adult member aged between 16 and 59 years
• Female-headed households without an adult male member aged between 16 and 59 years
• Households with a single-room house having kucha walls and roof
• SC/ST households
• Households with disabled members and no able-bodied adult member
• Landless households dependent on manual casual labour
• Households with no literate adult above 25 years

In addition, the following households are automatically eligible:

• Destitute families who rely on alms.
• Families of manual scavengers.
• Families of bonded labourers.
• Primitive and particularly vulnerable tribal groups.

Apart from the above households, all senior citizens aged 70 years and above are covered under this scheme, irrespective of income.

Eligibility Criteria for Urban Families

An urban family must belong to one of the listed occupational categories to be eligible for the scheme:

• Street vendors, cobblers, hawkers or other service providers working on streets.
• Domestic workers.
• Rag pickers and beggars.
• Construction site workers, plumbers, masons, painters, welders, security guards or other head-load workers.
• Coolies.
• Sweepers, sanitation workers, and gardeners.
• Transport workers such as conductors, drivers, cart pullers, and others.
• Artisans, home-based workers, handicraft workers, and tailors.
• Washermen and watchmen.
• Electricians, mechanics, repair workers, and assemblers.
• Peons, helpers, shop workers, delivery assistants, attendants, and waiters.
• ASHA workers, Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHs) and their families are also covered under the PMJAY expansion announced in March 2024.

Senior Citizen Coverage under Pradhan Mantri Ayushman Bharat Yojana

On 11 September 2024, the Union Cabinet approved Ayushman Bharat PMJAY coverage for all citizens aged 70 years and above irrespective of income or socio-economic status.

Eligible senior citizens receive the Ayushman Vay Vandana Card with separate health coverage benefits under PMJAY.

• All citizens aged 70 years and above are eligible under PMJAY
• Eligible senior citizens receive a separate Ayushman Vay Vandana Card
• Senior citizens receive health insurance cover of up to ₹5 lakh per year
• Senior citizen coverage is separate and not shared with family members
• Existing PMJAY beneficiary families receive additional top-up benefits for eligible senior citizens
• Beneficiaries covered under CGHS, ECHS or Ayushman CAPF may continue existing schemes or opt for PMJAY
• Senior citizens with private insurance or ESI coverage are also eligible
• The expansion is expected to benefit around 6 crore senior citizens across India

Eligibility Criteria for Hospitals

Similar to setting eligibility criteria for beneficiaries, the government has framed eligibility criteria for a hospital to be empanelled. The criteria are:

• The hospital must be registered with state health agencies.
• Qualified medical and nursing staff must be available 24/7.
• The hospital must have a minimum of 10 in-patient beds.
• The medical facility must have an accessible washroom.
• An interoperable IT system should be in place to manage data.
• A complete record of Ayushman Bharat patients must be maintained and shared with the government as per the requirement.
• Ambulance and other emergency services must be available.
• A dedicated medical officer should be appointed to manage PMJAY operations and beneficiary services.
• There should be a blood bank and testing laboratory in the vicinity.
• The medical facility must have all the equipment and technical necessities.
• The hospital must have facilities such as regulated water, electricity, and bio-medical waste disposal.

How to Register for Pradhan Mantri Ayushman Bharat Yojana Online?

Eligible beneficiaries can verify their details and check registration status online through the official PMJAY beneficiary portal using Aadhaar-linked mobile verification.

Step 1: Visit the official Pradhan Mantri Ayushman Bharat Yojana beneficiary portal.

Step 2: Enter the mobile number, captcha code, and click the ‘Generate OTP’ button.

Step 3: Enter the OTP received on the registered mobile number to log in.

Step 4: Select the state from the drop-down list.

Step 5: Choose a search method to check eligibility:

• Aadhaar Number
• Mobile Number
• Name
• Family ID
• Ration Card Number
• RSBY URN Number

Step 6: Enter the required details and click ‘Search’.

Step 7: If eligible, the beneficiary details will appear on the screen. Click the ‘Family Members’ tab to view covered family members under PMJAY.

How to Claim the Cashless Bills under the Pradhan Mantri Ayushman Bharat Yojana?

Eligible beneficiaries can avail cashless treatment at empanelled government and private hospitals under the PMJAY scheme by completing identity verification at the hospital.

Step 1: Visit an empanelled hospital under the Ayushman Bharat PMJAY scheme.

Step 2: Approach the ‘Ayushman Mitra’ helpdesk available at the hospital.

Step 3: Provide the Ayushman card, enrollment details, or valid identification proof for verification.

Step 4: The Ayushman Mitra verifies eligibility by checking the beneficiary details in the PMJAY database.

Step 5: Once verified, the hospital initiates the cashless treatment process for covered procedures and hospitalisation expenses.

Step 6: Eligible beneficiaries can receive treatment without making direct payments for covered medical services under the scheme.

Note: Certain specialised or surgical procedures may require pre-authorisation approval before treatment under PMJAY coverage.

State-Specific Expanded Eligibility under PMJAY

Several states have expanded PMJAY coverage beyond SECC 2011 beneficiary data using NFSA databases and state-specific welfare lists.

States such as Karnataka, Tamil Nadu, Rajasthan, Andhra Pradesh and Telangana have implemented expanded beneficiary coverage models under PMJAY. Beneficiaries who are not listed under SECC data may still qualify under state-specific eligibility databases.

Final Word