Ayushman Bharat Yojana: Benefits, Gaps, and How Crowdfunding Fills the Void [2026]

Quick Summary

• Ayushman Bharat Yojana (PMJAY) is the world’s largest government-funded health insurance scheme, offering ₹5 lakh annual coverage to over 55 crore Indians.
• As of March 2025, more than 43.52 crore Ayushman cards have been issued, and over 11.69 crore hospital admissions have been recorded since the launch.
• The scheme was expanded in October 2024 to cover all senior citizens aged 70 and above, irrespective of income.
• Despite its reach, PMJAY has real coverage gaps: OPD costs, dental care, fertility treatments, and bills exceeding ₹5 lakh are excluded.
• Medical crowdfunding on platforms like ImpactGuru helps patients raise funds quickly when Ayushman Bharat coverage falls short.

Introduction

India’s healthcare landscape has been transformed by Ayushman Bharat Yojana, also known as Pradhan Mantri Jan Arogya Yojana (PMJAY). Launched in September 2018, it is the world’s largest publicly funded health assurance programme, providing cashless hospitalisation coverage of up to ₹5 lakh per family per year to economically vulnerable households.

The scheme has delivered remarkable results. According to the Economic Survey 2024–25, AB PM-JAY has generated recorded savings of over ₹1.25 lakh crore for beneficiaries, while out-of-pocket expenditure (OOPE) as a share of total health spending fell from 62.6% in FY2015 to 39.4% in FY2022. These are meaningful gains, but they do not tell the whole story.

For millions of families, PMJAY is a lifeline that still has limits. Treatments outside its coverage list, bills that exceed the ₹5 lakh cap, or the simple reality of not being enrolled in the scheme can leave patients stranded mid-treatment. This is where medical crowdfunding in India has stepped in as a powerful complementary tool. This blog explains what Ayushman Bharat Yojana covers, where it falls short, and how crowdfunding helps patients bridge the gap.

What Is Ayushman Bharat Yojana (PMJAY)?

Quick Answer: Ayushman Bharat Yojana (PMJAY) is India’s flagship government health insurance scheme, launched in 2018, offering free secondary and tertiary hospitalisation worth up to ₹5 lakh per family per year to economically weaker sections and, since October 2024, to all senior citizens above 70 years of age.

History and Background

Ayushman Bharat Yojana was announced in the Union Budget 2018 and operationalised on 23 September 2018 under Prime Minister Narendra Modi. Its design was informed by India’s Global Burden of Disease Study findings, which revealed that over 6 crore Indians were pushed into poverty each year due to out-of-pocket medical expenses. PM-JAY was conceived as a direct policy response, eliminating financial barriers to secondary and tertiary hospital care for the bottom 40% of the population.

The scheme operates through two pillars: Ayushman Arogya Mandirs (formerly Health and Wellness Centres), which provide comprehensive primary care at the community level, and PM-JAY, which covers hospitalisation costs at empanelled public and private hospitals.

Key Features and Updated Coverage (2024–25)

Metric	Figure
Annual cover per family	₹5 lakh (secondary & tertiary hospitalisation)
Eligible families	12 crore+
ABHA accounts created	86,64,46,563
Health records linked to ABHA	90,70,14,529
Ayushman cards issued	43.52 crore+
Hospital admissions	11.69 crore+
Medical procedures covered	1,961 (Health Benefit Package) + 27 medical specialities
Total treatment value	₹1.73 lakh crore+
Empanelled hospitals	36,229 total 19,483 public hospitals 16,746 private hospitals
Budget allocation (2025–26)	₹9,406 crore

New in 2024: In October 2024, the government expanded PMJAY to cover all senior citizens aged 70 years and above, regardless of income level. These beneficiaries receive a separate ₹5 lakh top-up cover through a dedicated Vay Vandana Card, which does not reduce the coverage available to other family members below 70 years of age. Additionally, in March 2024, the scheme was expanded to include 37 lakh ASHA workers, Anganwadi workers, and their families.

Who Is Eligible for PMJAY?

Eligibility is determined by the Socio-Economic Caste Census (SECC) 2011 data, covering deprived rural families and identified occupational categories in urban areas. In 2022, the government revised the beneficiary base to 12 crore families based on a decadal growth rate of 11.7%. States and UTs have been allowed to use supplementary databases, including the National Food Security Act (NFSA) list- to identify eligible beneficiaries who could not be verified through SECC alone.

Broadly, eligible groups include:

• Rural households classified under deprived categories per SECC 2011 (single-room mud houses, households with no adult earner, SC/ST households, etc.)
• Urban workers in specified occupational categories, such as construction workers, domestic helpers, sanitation workers, street vendors, and transport workers
• All senior citizens aged 70 years and above, irrespective of income (from October 2024)
• ASHA workers, Anganwadi workers, Anganwadi helpers, and their families (from March 2024)
• Households already enrolled under the Rashtriya Swasthya Bima Yojana (RSBY)

How to check your eligibility: Visit pmjay.gov.in and click on ‘Am I Eligible’. Enter your mobile number, generate an OTP, and search by name, ration card number, or household ID.

Ayushman Bharat Yojana Benefits: What Does PMJAY Cover?

Quick Answer: PMJAY covers over 1,961 medical procedures across 25 specialties, including cancer treatment, heart surgery, kidney care, orthopaedics, and maternity care. Coverage includes hospital room, diagnostics, medicines, surgeon fees, and post-discharge follow-up up to 15 days, all cashless at empanelled hospitals.

Under the revised Health Benefit Package (HBP), AB PM-JAY provides cashless and paperless access to the following:

• Medical examination, specialist consultation, and treatment
• All non-intensive and intensive care services (ICU, general ward)
• Medicines and medical consumables during hospitalisation
• Diagnostic tests and laboratory services tied to the admission
• Surgeon, anaesthetist, and medical team fees
• Medical implants (wherever applicable within package rates)
• Food and accommodation during hospitalisation
• Pre-hospitalisation costs for up to 3 days before admission
• Post-hospitalisation follow-up for up to 15 days after discharge
• Transport allowance for hospital transfers
• Day-care procedures that do not require overnight stays

Key specialties covered include: Cardiology (bypass surgery, angioplasty), oncology (chemotherapy, radiation), nephrology (dialysis, kidney transplant support), neurosurgery, orthopaedics (joint replacement), maternity and newborn care, ENT, ophthalmology, burns, and plastic surgery for trauma cases. Pre-existing conditions are covered from Day 1 with no waiting period.

Empanelled hospitals: As of February 2026, over 36,229 hospitals are empanelled under PMJAY, both public and private. All government hospitals with inpatient services are deemed empanelled by default. Patients can use the Ayushman Card at any empanelled hospital anywhere in India, enabling portability of benefits across states.

What Is Not Covered Under Ayushman Bharat Scheme India: Key Gaps to Know

Quick Answer: PMJAY does not cover OPD consultations, dental treatments, fertility treatments (IVF), cosmetic surgery, drug rehabilitation, individual diagnostic tests outside hospitalisation, general health supplements, and medical expenses incurred abroad. Bills exceeding the ₹5 lakh annual cap are also the patient’s responsibility.

Understanding what PMJAY does not cover is just as important as knowing what it does. Based on the National Health Benefit Package (HBP) guidelines published by the National Health Authority, the following are excluded:

Excluded Category	Detail
OPD Consultations	Doctor visits, consultations, and treatments that do not require hospitalisation are not covered.
Dental Treatments	Most dental procedures, including extractions, crowns, and orthodontics, are excluded.
Fertility Treatments	In-vitro fertilisation (IVF), surrogacy, and other infertility treatments are not covered.
Cosmetic Surgery	Procedures performed for aesthetic purposes (not for trauma, burns, or medical necessity) are excluded.
Drug Rehabilitation	Treatment for substance abuse and drug rehabilitation is not included.
Individual Diagnostics	Stand-alone tests (blood tests, MRIs, X-rays) not linked to an active hospitalisation episode are excluded.
General Supplements	Vitamins, tonics, and nutritional supplements, unless prescribed as essential for a hospitalisation.
Non-Allopathic Care	Ayurveda, Homeopathy, Unani, and other AYUSH-based treatments are generally not covered unless included under specific state packages.
Treatment Abroad	Medical expenses incurred outside India are not eligible for reimbursement.
Bills Beyond ₹5 Lakh Cap	The annual ₹5 lakh cap per family is a ceiling. Costs beyond this limit must be borne by the patient.

Important: General check-ups, vaccination programmes, and artificial life-support (non-emergency) are also excluded from PMJAY coverage. Always verify with the empanelled hospital and the NHA’s HBP guidelines before assuming coverage.

Always confirm coverage details with your empanelled hospital before admission, as packages may vary by state.

Healthcare Funding in India for Needy: Why PMJAY Alone Is Often Not Enough

Despite being transformational, PMJAY faces operational challenges that leave many beneficiaries financially exposed. Understanding these gaps helps patients and families plan better.

1. The ₹5 Lakh Cap Can Run Out

For serious illnesses, multi-stage cancer treatment, complex cardiac procedures, extended ICU care, or conditions requiring multiple surgeries, ₹5 lakh per year can be exhausted quickly. A bone marrow transplant, for instance, can cost ₹15–30 lakh. A patient’s family may use the full annual limit in a single hospitalisation, leaving subsequent treatment episodes unfunded.

2. Awareness and Enrollment Remain Low

A report by the Confederation of Indian Industry (CII) and Boston Consulting Group (BCG) found that approximately two-thirds of eligible households had not enrolled under PMJAY. Low awareness, particularly in urban areas, means many families who qualify are not accessing their entitlements. Without an Ayushman Card, a patient is treated as a private patient and bears the full cost.

3. Not All Hospitals Are Empanelled

Specialist hospitals, super-specialty centres, and many private hospitals, especially in tier-2 and tier-3 cities, are not empanelled under PMJAY. When a specific treatment or surgeon is only available at a non-empanelled facility, patients must pay privately, regardless of their PMJAY eligibility.

4. Reimbursement Delays Disrupt Care

Hospitals, particularly smaller private hospitals, have at times faced delays in reimbursement from state governments or insurance companies under the scheme. These delays can lead to hospitals requesting upfront deposits or delaying admission, undermining the cashless promise of PMJAY.

5. Some States Have Not Fully Adopted the Scheme

India’s states each make their own decision on PMJAY participation. West Bengal operates its own state scheme and is not part of PMJAY. Odisha only joined in April 2025. Residents of non-participating states or those who have relocated may find PMJAY benefits unavailable in their area.

How Crowdfunding Supports Ayushman Bharat Patients in India

Quick Answer: Can crowdfunding help after PMJAY coverage ends?

Yes, medical crowdfunding helps PMJAY beneficiaries raise funds for treatments not covered under the scheme, bills exceeding the ₹5 lakh limit, or emergencies where Ayushman coverage cannot be accessed. Platforms like ImpactGuru allow families to share their story online and receive donations from thousands of individuals within days.

Medical crowdfunding in India has grown significantly as a practical financial bridge for patients whose needs exceed what government schemes can provide. Here is how crowdfunding directly supports Ayushman Bharat Yojana beneficiaries and those who fall through its gaps:

Supplementing Costs Beyond the ₹5 Lakh Cap

When a treatment exceeds the annual PMJAY coverage limit, such as liver transplants, bone marrow transplants, or prolonged cancer chemotherapy, the residual cost can be devastating. Crowdfunding campaigns can mobilise funds from family, friends, colleagues, and compassionate strangers across India and abroad, often within days of the campaign going live.

Funding Excluded Treatments

Procedures and care categories that PMJAY explicitly excludes, such as dental reconstruction following an accident, IVF treatment for infertility, or rehabilitation after a major surgery, represent real financial burdens. Crowdfunding gives families a legitimate, dignified way to seek support for these specific needs without going into debt.

Bridging the Gap When Enrollment Has Not Happened

Patients who are theoretically eligible for PMJAY but have not completed enrollment, or whose verification is pending, may face an immediate medical emergency. Crowdfunding can provide rapid emergency funding while the official process is resolved, preventing delayed or denied treatment due to paperwork.

Supporting Treatment at Non-Empanelled Hospitals

When a specific surgery, clinical trial, or specialist consultation is only available at a hospital not empanelled under PMJAY, patients must self-fund the entire cost. Crowdfunding allows families to raise money for treatment at the best available facility, rather than settling for a lesser option due to coverage constraints.

Covering Non-Medical but Essential Costs

Hospital stays bring indirect costs that PMJAY does not cover: travel from a remote village to a city hospital, accommodation for caregivers, loss of daily wages, and post-discharge nutritional support. These costs can be crippling for low-income families. Crowdfunding campaigns can be structured to include these legitimate ancillary needs.

Ayushman Bharat vs Crowdfunding for Medical Treatment in India: Which Is Right for You?

PMJAY and crowdfunding are not alternatives; they are complementary tools. Here is a side-by-side comparison:

Factor	PMJAY (Ayushman Bharat)	Medical Crowdfunding
Who can access it	SECC-listed families, ASHA/AWW workers, senior citizens, 70+	Anyone; no eligibility restriction
Coverage amount	Up to ₹5 lakh per family per year	No fixed limit; depends on what you raise
Excluded treatments	OPD, dental, IVF, cosmetic, drug rehab, etc.	Any medical need can be fundraised for
Hospital restriction	Only empanelled hospitals	Any hospital, anywhere in India
Speed of access	Cashless if enrolled; admin process required	Funds can begin arriving within 24 hours
Pre-existing conditions	Covered from Day 1	Not relevant; donors give based on need
Ongoing coverage	Annual renewal	Each campaign is for a specific need
Best used for	Primary hospitalisation coverage	Gaps, emergencies, excluded treatments, large bills

How to Pay Medical Bills Beyond Ayushman Bharat Scheme: A Step-by-Step Guide to Crowdfunding

Quick Answer: The best way to pay medical bills when Ayushman Bharat is not enough is to start a medical crowdfunding campaign on a trusted platform like ImpactGuru. Share your story with documents, set a realistic goal, and spread the campaign via WhatsApp and social media to reach donors quickly.

Starting a medical crowdfunding campaign is straightforward. Here is what the process typically looks like on a platform such as ImpactGuru:

1. Create your campaign: Sign up on the platform, provide details about the patient, the medical condition, and the treatment required. Upload hospital documents, doctors’ letters, and cost estimates.
2. Set a fundraising goal: Calculate the total cost of treatment, including excluded expenses. Set a realistic target that accounts for what PMJAY will cover and what it will not.
3. Share your campaign: Use WhatsApp groups, Facebook, Instagram, and community networks to spread the campaign link. Personal appeals and regular updates significantly improve donations.
4. Receive funds: Donations are collected by the platform and disbursed to the fundraiser’s bank account. ImpactGuru allows multiple withdrawals, so funds can be accessed as they arrive.
5. Update your donors: Regular health updates and transparency about fund usage build trust and encourage additional donations.

Tips for a successful campaign: Use the patient’s real name and photograph. Share a genuine, specific description of the illness and treatment plan. Provide cost breakdowns. Post updates at least once a week. Always acknowledge donations personally when possible.

Conclusion

Ayushman Bharat Yojana is one of India’s most important public health achievements. With over 43.52 crore Ayushman cards issued, more than 11.69 crore hospital admissions facilitated, and ₹1.25 lakh crore saved in out-of-pocket spending since 2018, the scheme has meaningfully reduced financial catastrophe for millions of Indian families. The 2024 expansion to all citizens above 70 years further extends its reach.

But no government scheme is all-encompassing. The ₹5 lakh cap, exclusion of OPD costs, dental care, fertility treatments, and the reality that not every hospital is empanelled mean that gaps will always exist. For the families who fall into these gaps, mid-treatment, mid-crisis, medical crowdfunding is not a last resort. It is a practical, fast, and community-powered financial tool answering how to raise funds when Ayushman Bharat is not enough.

ImpactGuru has helped thousands of Indian families raise the funds they needed when public health coverage ran out. If you or someone you know is facing a medical emergency that PMJAY cannot fully address, starting a campaign takes just a few minutes and can make all the difference.