PM-JAY meaning: what Ayushman Bharat covers What the National Health Authority's guidelines and the 2024 Cabinet decision say, and why a small OPD clinic is usually outside it.

PM-JAY, or Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, is the Government of India's publicly funded health assurance scheme that covers secondary and tertiary care hospitalisation of up to ₹5 lakh per family per year, delivered through public and empanelled private hospitals. It is run nationally by the National Health Authority (NHA) and in each state by a State Health Agency (SHA), which decides which hospitals join the network.

What is PM-JAY?

A government-funded cover for hospital care. NHA's empanelment guidelines say the government launched it in September 2018 to reduce the financial burden of care on the poorest and most vulnerable families, initially the bottom 40 percent of the population identified through the Socio-Economic Caste Census 2011. A PIB release of 11 Sep 2024 describes it as "the world's largest publicly funded health assurance scheme", covering 55 crore individuals in 12.34 crore families, and says all members of an eligible family are covered irrespective of age.

Where does the definition come from?

The National Health Authority's Guidelines on Hospital Empanelment and De-Empanelment (Version 3.0, November 2021), paragraph 1.1:

PM-JAY covers secondary and tertiary care costs of up to Rs. 5,00,000 annually for each entitled family, provided through a network of public and empaneled private hospitals.

Paragraph 1.2 adds that government facilities with 5 or more beds that provide inpatient services are part of the network by deemed empanelment. On 11 Sep 2024 the Union Cabinet extended cover to all senior citizens aged 70 and above irrespective of income: those in families already covered get a top-up of up to ₹5 lakh a year for themselves, others get up to ₹5 lakh a year on a family basis. Seniors in CGHS, ECHS or Ayushman CAPF may keep their scheme or opt for PM-JAY, and those with private insurance or ESI are also eligible. NHA's scheme website, pmjay.gov.in, did not load when we checked on 31 Oct 2026, so confirm current terms there or with your State Health Agency.

What it means for a small clinic

A consultation-only clinic is outside PM-JAY's payment network. The scheme pays for hospital care, and section 7.1 of the guidelines says a private hospital is empanelled with the approval of the State Health Agency if, among other criteria, it has "at least 10 inpatient beds", with exemptions for dental and day-care procedure hospitals such as eye, ENT and standalone dialysis centres. The guidelines do not describe a route for paying an OPD consultation at a private clinic.

Take Sunrise Clinic, a sample single-doctor clinic. A patient shows an Ayushman card at the desk and asks whether the consultation is free. It is not, at a clinic that is not empanelled: the patient pays the clinic's normal fee. If the doctor advises admission, the patient can be referred to a hospital that is on the PM-JAY network, which the State Health Agency can confirm. Joining the network is a choice for a clinic that has the beds and staff the criteria ask for, and our post on PM-JAY, CGHS and ESIC empanelment for private clinics sets those criteria out.

Does PM-JAY apply to a single-doctor clinic?

Not as a provider, unless the clinic is also a hospital that meets the State Health Agency's criteria. The guidelines let states relax criteria with NHA's prior approval, but not the minimums in their Annexure 1, and section 7.2 lowers the bed minimum to 5 inpatient beds in NITI Aayog's aspirational districts. Patients covered by PM-JAY still visit private OPD clinics as ordinary fee-paying patients.