Ayushman Bharat vs State Health Schemes — Coverage, Benefits, and How They Work Together

Ayushman Bharat vs State Health Schemes — Overview

India has both a central government health scheme — Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) — and numerous state-level health insurance schemes. Understanding how they compare and interact is crucial for accessing the maximum healthcare benefits available to you.

What is Ayushman Bharat (PMJAY)?

Ayushman Bharat PMJAY is the world's largest government health insurance scheme, providing coverage of ₹5 lakh per family per year for secondary and tertiary hospitalization. Launched in 2018, it targets the bottom 40% of India's population.

Key features:

• ₹5 lakh coverage per family per year
• Covers 1,949+ treatment packages across 27 specialties
• Cashless treatment at empanelled hospitals
• No age limit, family size limit, or pre-existing disease exclusion
• Based on SECC 2011 database for eligibility

For details, see our Ayushman Bharat guide.

Major State Health Schemes

Comparison: PMJAY vs State Schemes

How Do They Work Together?

Many states have integrated their existing health schemes with PMJAY:

Fully Integrated States

• Kerala (KASP): Merged state scheme with PMJAY — single card, combined coverage
• Gujarat: State scheme integrated with PMJAY
• Chhattisgarh: Merged with PMJAY under same implementation

Parallel Implementation

• Andhra Pradesh: Aarogyasri runs alongside PMJAY with additional state coverage
• Tamil Nadu: CMCHIS and PMJAY coexist — patients can claim from either
• Maharashtra: Mahatma Phule + PMJAY both available

States Not in PMJAY

• West Bengal: Did not join PMJAY; runs Swasthya Sathi independently
• Delhi: Not part of PMJAY; runs Delhi Arogya Kosh
• Odisha: Initially opted out; runs BSKY (Biju Swasthya Kalyan Yojana)

Coverage Comparison

What PMJAY Covers

• 1,949+ medical packages including surgeries, day care, follow-up
• Pre and post hospitalization (3 days before, 15 days after)
• Medicine, diagnostics, accommodation, food during hospitalization
• No cap on family size
• Pre-existing diseases covered from day one

What State Schemes May Add

• Higher coverage: Rajasthan Chiranjeevi offers ₹25 lakh — 5x more than PMJAY
• Broader eligibility: West Bengal Swasthya Sathi covers ALL families, not just BPL
• Outpatient benefits: Some state schemes cover OPD consultations
• Additional procedures: Some states cover procedures not in PMJAY package list
• Free medicines: States like Tamil Nadu provide free medicines through separate schemes

Eligibility Differences

PMJAY Eligibility (Fixed Criteria)

Based on SECC 2011 database — you either qualify or don't:

• Rural: Households with deprivation criteria (kutcha house, no adult member, female-headed, SC/ST, bonded labour, etc.)
• Urban: Occupational categories (rag picker, domestic worker, street vendor, construction worker, etc.)
• Check eligibility at mera.pmjay.gov.in

State Scheme Eligibility (Varies Widely)

• Income-based: Tamil Nadu CMCHIS (< ₹1.2 lakh/year)
• Universal: West Bengal Swasthya Sathi (all families), Rajasthan Chiranjeevi
• BPL card: Andhra Pradesh Aarogyasri, Telangana Aarogyasri
• Ration card: Many states use ration card status

Which Offers Better Value?

Important Tips

1. Check both eligibility — you may qualify for PMJAY and your state scheme simultaneously
2. Get Ayushman Card — even if your state has its own scheme, an Ayushman card works pan-India
3. Know your empanelled hospitals — both PMJAY and state scheme hospitals may differ
4. Carry both cards — if eligible for both, keep both cards when visiting hospital
5. Report denial — if an empanelled hospital refuses cashless treatment, report to the scheme's grievance portal

FAQs

Can I use both Ayushman Bharat and state health scheme?

In integrated states, benefits are combined under one card. In states running parallel schemes, you may be eligible for both but typically claim from one scheme per hospitalization. You cannot claim the same treatment from both simultaneously.

I'm not eligible for PMJAY. Can I still get state health benefits?

Yes. Many state schemes have broader eligibility than PMJAY. For example, Rajasthan Chiranjeevi and West Bengal Swasthya Sathi cover all families regardless of income. Check your state's specific health scheme eligibility.

Does PMJAY work in any state?

Yes. PMJAY is portable across India — you can get treatment at any empanelled hospital in any state. This is a major advantage over state schemes which typically work only within that state.

Why did some states not join PMJAY?

States like West Bengal, Delhi, and Odisha chose not to join PMJAY either due to political reasons or because they felt their existing state schemes were already providing better coverage. Citizens in these states can still benefit from their state health schemes.

How do I check if I'm eligible for PMJAY?

Visit mera.pmjay.gov.in or call the helpline 14555. Enter your mobile number, name, or ration card number. You can also visit a Common Service Centre (CSC) or empanelled hospital's Ayushman Mitra for eligibility check.

Are private hospitals covered under these schemes?

Yes. Both PMJAY and most state schemes empanel private hospitals alongside government hospitals. Patients can choose any empanelled hospital for cashless treatment. Check the hospital list on the respective scheme's website or app.

Disclaimer: CitizenNest is an independent platform and is not affiliated with any government body. Information is for educational purposes. State scheme details may change — verify on your state government's official health scheme website.