PMJAY (Ayushman Bharat): how the package rate works, and what to do if a hospital bills you despite eligibility
PMJAY covers ~60 crore Indians for ₹5 lakh of hospitalisation per year. The scheme works on package rates, not itemised billing. Here's how to check eligibility, the common package rates, and the grievance path when a hospital tries to bill you anyway.
Published · Jaanch
Roughly 60 crore Indians are eligible for free hospitalisation under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY). That's 12 crore families, each entitled to Rs 5 lakh per year of cashless hospitalisation across a notified package of 1,961 procedures. Eight years in, this remains the largest publicly funded health insurance scheme in the world by number of beneficiaries.
If you qualify, you should not be paying anything at a PMJAY-empanelled hospital for a covered procedure. In practice, a meaningful fraction of eligible patients are still asked to pay. This is the patient's guide to checking, reconciling, and disputing.
What PMJAY actually covers
The scheme is structured as cashless hospitalisation. The beneficiary walks into an empanelled hospital, the hospital pre-authorises the package with the State Health Authority, the patient is treated, and the hospital is paid directly by the scheme. No money should change hands.
Coverage scope:
- 1,961 procedure packages across 27 medical and surgical specialties
- Up to Rs 5 lakh per family per year, irrespective of family size
- Pre-existing conditions covered from day one
- No upper age limit
- Hospitalisation expenses including pre-hospitalisation (3 days) and post-hospitalisation (15 days) on the same admission
Outpatient treatment is largely not covered — the scheme is built for inpatient and day-care procedures. Cosmetic, fertility, and certain elective surgeries are excluded.
Who is eligible
Eligibility is determined from the Socio-Economic and Caste Census (SECC) 2011. The criteria are demographic deprivation and occupation deprivation. In practice the eligible categories include:
Rural population with any one of:
- Households with kachcha walls and roof
- Households with no adult member aged 16-59
- Female-headed households with no adult male between 16-59
- Households with a disabled member and no able-bodied adult
- SC / ST households
- Landless households earning the majority of income from manual casual labour
Urban population based on occupation, including:
- Ragpickers
- Beggars
- Domestic workers
- Street vendors, cobblers, hawkers
- Construction workers, plumbers, masons, painters, daily wage labourers
- Sweepers, sanitation workers
- Home-based workers, washermen, watchmen
There is also an auto-eligibility list that's been expanding. Some states have added their own additional categories (Telangana, Rajasthan, Madhya Pradesh, Maharashtra all have state-funded extensions on top of the central scheme). So checking your specific state's portal matters, not just the central one.
The fastest eligibility check is the official portal at beneficiary.nha.gov.in. Enter your Aadhaar number, name, or ration card number. If you're eligible, you can also generate the PMJAY card directly from the portal.
How the package rate works
PMJAY does not work on itemised billing. The patient and the hospital do not negotiate individual line items. Instead, each procedure has a package rate — a single notified figure that covers everything needed for that procedure for that admission.
A few examples of package rates currently in force:
| Procedure (Health Benefit Package code) | Rate (Rs) |
|---|---|
| Normal vaginal delivery | 9,000 |
| Lower segment caesarean section | 17,000 |
| Single-vessel coronary angioplasty (with stent) | 65,000 |
| Two-vessel coronary angioplasty (with stents) | 95,000 |
| Single-vessel coronary artery bypass grafting (CABG) | 110,000 |
| Total knee replacement (single knee) | 80,000 |
| Cataract surgery with intraocular lens | 7,500 |
| Appendicectomy (open) | 18,000 |
| Appendicectomy (laparoscopic) | 25,000 |
| Hysterectomy (open) | 22,000 |
| Hernia repair | 15,000 |
| Cholecystectomy (laparoscopic) | 23,000 |
These rates are inclusive of all line items: room rent, surgeon fees, anaesthesia, consumables, medications, follow-ups, post-op stay. There's no separate charge for "consumables" or "OT" or "stent" — the package rate is the entire bill.
The implication for the patient: if you're an eligible PMJAY beneficiary having an eligible procedure at an empanelled hospital, your bill should be Rs 0. You should not see an itemised invoice. You should not be asked for any deposit at admission. You should not be asked for "out-of-package" charges at discharge.
The five common overcharge patterns
In practice, the scheme has well-documented operational issues. The patterns we hear about most often:
1. "Out-of-package" charges at discharge
The bill is split into a PMJAY portion (which is settled with the scheme) and an "out-of-package" portion (which the patient is asked to pay). The hospital justifies this with a generic line like "premium implant" or "advanced consumables".
The rules: the package rate is inclusive. The hospital cannot add beneficiary-side charges for items that fall within the package definition. If a higher-grade implant is genuinely outside the package (rare — most implants are covered), the hospital must have the patient sign a separate written consent BEFORE the procedure, naming the specific out-of-package item and its price.
2. Refusal to admit under PMJAY
Some hospitals empanel for PMJAY but quietly steer eligible patients into private-payment treatment. The reasons usually cited are "PMJAY takes too long to settle" or "the package rate doesn't cover the cost".
The patient-side response: insist on PMJAY pre-authorisation. If the hospital refuses, document it in writing and file a complaint with the State Health Agency. PMJAY empanelment carries an obligation; refusal without legitimate cause is grounds for de-empanelment.
3. Different procedure billed
The patient is admitted for procedure A (which is covered at, say, Rs 65,000) and discharged with paperwork showing procedure B (covered at Rs 95,000). The hospital claims the higher amount from PMJAY. The patient doesn't lose money directly, but the scheme does, and the practice eventually closes off coverage for legitimately needed care.
This isn't a patient-side dispute in the financial sense, but it is something to be aware of when reviewing the discharge summary.
4. Asking for a deposit
PMJAY is cashless. No deposit is permitted at admission, no advance payment is permitted. Some hospitals still ask. The right response is to refuse and to ask for written confirmation that the procedure is covered under PMJAY.
5. Charging for "non-medical" items
Toiletries, attendant food, telephone — items that are not strictly medical. Some hospitals try to bill these separately, even on a PMJAY patient. The package rate is inclusive of all hospitalisation costs; non-medical items like attendant food are not covered separately either way.
What to do if you've been wrongly billed
Three steps, escalating:
Step 1 — the hospital PMJAY desk. Every empanelled hospital has a designated PMJAY coordinator (usually called the Pradhan Mantri Arogya Mitra or PMAM). Ask for them by name. Take the discharge bill, your PMJAY card, and your Aadhaar. The desk should be able to retrieve your pre-authorisation and reconcile the bill against the package rate. In most cases, this resolves at the desk.
Step 2 — the State Health Agency grievance portal. Each state runs a grievance redressal cell for PMJAY. The web portal is the State Health Agency website (specific to your state). File a written complaint with the bill, the discharge summary, and your eligibility proof. SLA for response is generally 30 days.
Step 3 — the National Health Authority grievance portal. At mera.pmjay.gov.in. This is the central escalation. File when the state agency has either not responded within 30 days or has rejected the complaint. The NHA can compel the state to act.
The grievance portal also accepts complaints about hospital refusal to admit under PMJAY, attempts to extract out-of-package payments, and incorrect package selection.
A few honest limitations
PMJAY isn't a perfect scheme. The package rates have not been revised substantially since 2018 in most categories, even as procedure costs have risen. Some procedures are genuinely difficult to deliver at the notified rate without compromise. Some hospitals have de-empanelled themselves in protest of unsettled claims. The scheme depends on state-level Health Agency competence, which varies widely.
So the practical advice for an eligible patient is: PMJAY works well for emergency and routine surgery at hospitals that have a functioning PMJAY desk and a regular settlement cycle with the scheme. For complex elective procedures at hospitals with poor PMJAY infrastructure, you may face friction even if you're entitled to the coverage.
But entitlement is entitlement. If you're eligible and the procedure is covered, the hospital is bound to treat you cashless. The grievance path exists precisely because operational friction is expected.
How to check your eligibility right now
The faster paths:
- beneficiary.nha.gov.in — enter Aadhaar, get an immediate eligibility status
- Call 14555 — the PMJAY central helpline, available in multiple languages
- Common Service Centres (CSC) — accessible across most rural districts, can pull up eligibility and generate the PMJAY card on the spot
- Your state Health Agency website — useful particularly if your state runs an extended scheme on top of central PMJAY
The card is digital first; a physical card can be printed if needed. Aadhaar linkage is mandatory.
Sources: National Health Authority PMJAY operational guidelines; Health Benefit Package (HBP) 2022 rate notification; state-level PMJAY implementation guidance documents. Package rates and eligibility criteria are revised periodically — verify the current versions before relying on specific figures.