Chapter 6B - Section 6B.2Gaps in Pradhan Mantri Jan Arogya Yojana (PM-JAY) Scheme

Pradhan Mantri Jan Arogya Yojana (PMJAY) scheme, launched in 2018, is a health assurance scheme which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization. The households included are based on the deprivation and occupational criteria of Socio- Economic Caste Census 2011 (SECC 2011). Though the progress of issuance of PMJAY cards has been impressive with more than 40.8 crore Ayushman cards issued as of May 2025, the scheme is not able to cover all health expenses of all rural poor.

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Emergency Healthcare Financing Solutions Through Micro Lending Institutions (MLIs)

6B.2: Gaps in Pradhan Mantri Jan Arogya Yojana (PM-JAY) Scheme

Pradhan Mantri Jan Arogya Yojana (PMJAY) scheme, launched in 2018, is a health assurance scheme which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization. The households included are based on the deprivation and occupational criteria of Socio- Economic Caste Census 2011 (SECC 2011). Though the progress of issuance of PMJAY cards has been impressive with more than 40.8 crore Ayushman cards issued as of May 2025, the scheme is not able to cover all health expenses of all rural poor.

Area Why PM-JAY Is Not Fully Sufficient
Primary healthcare PMJAY does not cover outpatient care (OPD), diagnostics, or medicines—these form the bulk of routine healthcare expenses.
Out-of-pocket expenses According to the NSSO and National Health Accounts data, over 60% of healthcare expenses are still paid out-of-pocket, mainly for outpatient care and medicines.
Non-covered services Mental health, chronic disease management, rehabilitation, and long-term care are largely excluded.
Access and Awareness Many eligible households are not aware or do not use the scheme effectively. Rural and remote areas may lack empanelled facilities.
Quality of care Variability in the quality and availability of services across states and between public and private hospitals.
Private hospital participation Some private hospitals hesitate to join due to low package rates, leading to limited choices in some regions.

Given the poor penetration of (less than two percent) health insurance schemes in rural India, and the fact that many of them are covered under Ayushman card may not cover all the medical and non-medical expenses, villagers may have to fall back on borrowings for meeting such health emergencies.

6B.2: Gaps in Pradhan Mantri Jan Arogya Yojana (PM-JAY) Scheme

Pradhan Mantri Jan Arogya Yojana (PMJAY) scheme, launched in 2018, is a health assurance scheme which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization. The households included are based on the deprivation and occupational criteria of Socio- Economic Caste Census 2011 (SECC 2011). Though the progress of issuance of PMJAY cards has been impressive with more than 40.8 crore Ayushman cards issued as of May 2025, the scheme is not able to cover all health expenses of all rural poor.

Area Why PM-JAY Is Not Fully Sufficient
Primary healthcare PMJAY does not cover outpatient care (OPD), diagnostics, or medicines—these form the bulk of routine healthcare expenses.
Out-of-pocket expenses According to the NSSO and National Health Accounts data, over 60% of healthcare expenses are still paid out-of-pocket, mainly for outpatient care and medicines.
Non-covered services Mental health, chronic disease management, rehabilitation, and long-term care are largely excluded.
Access and Awareness Many eligible households are not aware or do not use the scheme effectively. Rural and remote areas may lack empanelled facilities.
Quality of care Variability in the quality and availability of services across states and between public and private hospitals.
Private hospital participation Some private hospitals hesitate to join due to low package rates, leading to limited choices in some regions.

Given the poor penetration of (less than two percent) health insurance schemes in rural India, and the fact that many of them are covered under Ayushman card may not cover all the medical and non-medical expenses, villagers may have to fall back on borrowings for meeting such health emergencies.