Ayushman Bharat PM-JAY: Complete Guide for Clinics & Hospitals (2026)
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world's largest government-funded health insurance scheme, providing coverage of up to Rs 5 lakh per family per year to over 55 crore beneficiaries across India. For hospitals and clinics, participating in PM-JAY means guaranteed government payments, a massive increase in patient volume, and meaningful social impact. This guide covers everything you need to know as a healthcare provider in 2026.
What Is PM-JAY?
Launched on 23 September 2018, PM-JAY is the flagship health assurance scheme under the Ayushman Bharat umbrella. It aims to eliminate catastrophic healthcare expenditure for vulnerable families by covering secondary and tertiary hospitalisation costs. The scheme is fully funded by the Government of India and respective state governments, with no premium charged to beneficiaries.
PM-JAY at a Glance
Who Is Eligible?
Eligibility is determined by the Socio-Economic Caste Census (SECC) 2011 data. Families identified as deprived under the rural and urban categories are automatically included. There is no enrollment process required from the beneficiary side — their data is already in the system.
Key Eligibility Categories
- •Rural families meeting deprivation criteria under SECC 2011 (e.g., households with no adult member aged 16-59, SC/ST households, landless labourers)
- •Urban workers in identified occupational categories (e.g., ragpickers, street vendors, domestic workers, construction workers)
- •All families listed under state-specific health insurance schemes merged with PM-JAY
- •Senior citizens aged 70 and above (added in September 2024 expansion, regardless of income)
September 2024 Expansion
The Union Cabinet approved the extension of PM-JAY to all senior citizens aged 70 years and above, irrespective of their income. This adds an estimated 4.5 crore additional families. A separate top-up card is issued to eligible seniors who may already have other insurance.
How PM-JAY Works for Hospitals
Understanding the end-to-end workflow is essential for any hospital that wants to serve PM-JAY patients efficiently. Here is the typical flow from patient arrival to claim settlement:
Patient Identification & Verification
When a patient arrives claiming PM-JAY benefits, the hospital verifies their identity and eligibility through the Beneficiary Identification System (BIS). This uses Aadhaar-based biometric or OTP authentication. Verification is done at the Ayushman Mitra desk or Pradhan Mantri Arogya Mitra (PMAM) counter.
Pre-Authorization on TMS
After verification, the hospital raises a pre-authorization request on the Transaction Management System (TMS). This includes the selected Health Benefit Package (HBP), estimated cost, and clinical details. The request is reviewed by the Insurance Company/State Health Agency (SHA).
Cashless Treatment
Once pre-authorization is approved, the patient receives cashless treatment. The hospital provides all necessary care within the approved package. No payment is collected from the patient.
Claim Submission
After treatment and discharge, the hospital uploads the discharge summary, treatment records, and supporting documents to TMS. The claim is submitted for review.
Claim Settlement
The Insurance Company or SHA reviews the claim and disburses payment to the hospital. The standard turnaround is 15 to 30 days from submission. Payments are made directly to the hospital's bank account.
Benefits for Hospitals
Many hospital administrators ask: is it worth the effort? The answer is a clear yes, and here is why:
- ✓Guaranteed government payment — no bad debts from PM-JAY patients
- ✓Significant increase in patient volume, especially in Tier 2 and Tier 3 cities
- ✓Social credibility and trust from serving government scheme beneficiaries
- ✓Access to a wider patient base — over 55 crore potential patients across India
- ✓No marketing cost required — patients actively seek empanelled hospitals
- ✓Standardised package rates ensure predictable revenue per procedure
Health Benefit Packages (HBP 2.2)
PM-JAY covers 1,949 procedures across 27 specialities under Health Benefit Packages version 2.2. Each package has a defined rate that includes consultation, diagnostics, medicines, implants (where applicable), food, and accommodation for the specified duration.
| Speciality | Example Procedures | Package Range |
|---|---|---|
| General Surgery | Hernia repair, appendectomy, cholecystectomy | Rs 8,000 - Rs 1,20,000 |
| Orthopaedics | Knee replacement, fracture fixation, spine surgery | Rs 10,000 - Rs 1,70,000 |
| Cardiology | Angioplasty, bypass surgery, valve replacement | Rs 30,000 - Rs 2,40,000 |
| Oncology | Chemotherapy, tumour excision, radiation therapy | Rs 10,000 - Rs 2,00,000 |
| Ophthalmology | Cataract surgery, glaucoma treatment | Rs 10,000 - Rs 60,000 |
| Obstetrics & Gynaecology | C-section, hysterectomy, laparoscopic procedures | Rs 9,000 - Rs 90,000 |
| Paediatrics | Neonatal care, paediatric surgery | Rs 10,000 - Rs 1,00,000 |
The full list of packages with exact rates is available on the NHA website. Hospitals should carefully review applicable packages for their specialities before empanelment to ensure the rates are commercially viable.
Challenges Hospitals Face
While PM-JAY offers significant benefits, hospitals commonly face a few operational challenges:
- •Claim rejections due to incomplete documentation or coding errors
- •Payment delays beyond the standard 15-30 day window
- •Difficulty tracking PM-JAY patients separately from regular patients in existing systems
- •TMS downtime and technical issues during verification or claim submission
- •Package rates that may not cover costs for complex cases
How Zospital CRM Helps Manage PM-JAY Patients
Zospital CRM is designed to help clinics and hospitals streamline their PM-JAY workflows alongside regular patient management. Here is how:
PM-JAY Patient Badge
Tag patients as PM-JAY beneficiaries in their profile. Instantly identify scheme patients during visits and filter them for reporting.
Claim Type Tracking
Track whether a visit is a PM-JAY claim, insurance claim, or out-of-pocket payment. Keep your financials organised without manual spreadsheets.
Package Rate Reference
Quick reference to HBP package rates while creating invoices. Ensure you are billing within the approved package amounts.
Document Management
Attach discharge summaries, pre-authorization documents, and claim receipts directly to patient records. Everything in one place for audit readiness.
WhatsApp Notifications
Send automated appointment reminders and follow-up messages to PM-JAY patients via WhatsApp, improving compliance and satisfaction.
Key Takeaways
- •PM-JAY provides Rs 5 lakh cashless coverage to over 55 crore beneficiaries and is expanding to all seniors aged 70+
- •Empanelled hospitals get guaranteed government payments and access to a massive patient base
- •The process involves BIS verification, TMS pre-authorization, cashless treatment, and claim submission
- •1,949 procedures are covered across 27 specialities under HBP 2.2
- •A good clinic management system like Zospital helps you track PM-JAY patients and claims efficiently
Manage PM-JAY Patients Effortlessly
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