New Delhi: The central government has extended the benefits of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY) to all senior citizens above the age of 70. All senior citizens who are 70 years of age and older, irrespective of their income, are now included in the scheme. Ayushman Bharat Pradhan Mantri Jan Arogya Yojana was introduced to cover bottom 40% of the Indian population. It provided health insurance for secondary and tertiary care hospitalisations.
While the scheme offers a lot of benefits, however, it is not a silver bullet which will solve all health-related woes for senior citizens. Read on to find out the benefits and limitations of the Ayushman Bharat Yojana to help senior citizens make an informed choice.
Which senior citizens are eligible for Ayushman Bharat PMJAY scheme?
All senior citizens aged 70 years or above are eligible to receive free medical treatment up to a limit of Rs 5 lakh under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, irrespective of their socio-economic status.
Senior citizens who are part of a family already enrolled in the PMJAY scheme will receive an additional Rs 5 lakh coverage, exclusively for their medical needs. Senior citizens currently under other public health insurance schemes such as the Central Government Health Scheme (CGHS), Ex-servicemen Contributory Health Scheme (ECHS), and Ayushman Central Armed Police Force (CAPF), can either stick with their existing scheme or switch to Ayushman Bharat PMJAY. It has been clarified that senior citizens of 70 years and above who are under private health insurance policies or Employees’ State Insurance scheme will be eligible to avail benefits under AB PMJAY.
“This progressive move creates ease of financial expenses and acknowledges the unique healthcare needs of our senior citizens, ensuring they have access to essential medical support without financial strain. This initiative is poised to bring peace of mind and health security to nearly six crore seniors across India,” says Manju Dhake, Senior Vice President, Insurance at 1 Finance.
What are the key benefits of the Ayushman Bharat PMJAY scheme for senior citizens?
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana for senior citizens covers a wide range of medical treatments, including hospitalisation, surgeries, and diagnostic procedures.
The policy covers a wide range of treatments, including pre-existing conditions, and offers coverage for surgeries, critical illnesses, and post-hospitalisation care. This ensures that elderly citizens are not left out due to age-related conditions, says Col Sanjeev Govila (retd), Certified Financial Planner, CEO, Hum Fauji Initiatives, a financial advisory firm. Moreover, senior citizens do not have to pay any premium to avail of the coverage under the Ayushman Bharat PMJAY scheme. “It provides a safety net, which is crucial given the rising healthcare costs in India and the affordability of our general masses, especially those who can no longer be in the regular workforce and depend on others for their well-being,” Govila adds.
“One of the key highlights of the expanded scheme is that pre-existing diseases will be covered from the very first day of policy inception unlike traditional health insurance policies,” says S. Sridharan, Founder and CEO, of Wallet Wealth LLP.
Parthanil Ghosh, Director and Chief Business Officer, HDFC ERGO General Insurance says, “The policy covers pre-existing conditions such as hypertension, diabetes, etc. which are common among seniors, along with secondary and tertiary care for hospitalisation, surgeries, and follow-up consultations. This holistic approach ensures comprehensive medical care for senior citizens.”
To provide holistic healthcare, the scheme also covers pre-hospitalisation and post-hospitalisation expenses.
Senior citizens can avail of cashless treatment at more than 29,000 empanelled, both public and private, hospitals across the country.
There are no co-payment clauses under PMJAY. So the senior citizens do not have to bear a percentage of the treatment out of pocket.
What are the limitations of the Ayushman Bharat PMJAY 70+?
While the scheme offers substantial benefits, there are certain limitations.
Limited coverage amount of Rs 5 lakh per family: “The coverage is limited to 5 lakhs as a family floater,” says Sridharan. It means Rs 5 lakh coverage is provided on a family basis. The Rs 5 lakh limit will be shared between family members who are part of the same family.
Coverage of Rs 5 lakh may not be adequate for senior citizens: Govila adds, “While Ayushman Bharat provides free healthcare services, the coverage may be inadequate for serious illnesses or prolonged hospital stays. The Rs 5 lakh per family per year may not suffice for major surgeries or cancer treatments which is what a large number of seniors face and could be left out by their families to fend for themselves.”
Dhake of 1 Finance adds, “The coverage may fall short for extensive treatment procedures or chronic conditions requiring frequent hospitalizations, and limited pre- and post-hospitalisation benefits may restrict the overall support seniors can access.”
This means that beneficiaries may still have to bear out-of-pocket expenses for certain procedures.
Restricted hospital network: Narendra Bharindwal – Vice President at Insurance Brokers Association of India (IBAI) says, “The coverage primarily includes general wards, which may not suit the comfort preferences of senior patients. The empanelled hospital network, while broad, often excludes many premium private hospitals due to lower treatment tariffs, reducing access to high-tier care. Furthermore, the treatment rate structure agreed upon with hospitals may restrict the range and quality of available treatments, creating a need for supplementary policies to ensure adequate comfort and access to specialized facilities.”
No reimbursement option: The PMJAY scheme does not offer reimbursement for medical expenses incurred at non-empanelled healthcare facilities. Consequently, beneficiaries are limited to seeking treatment at hospitals and clinics that are part of the PM-JAY network. This restriction may pose a significant challenge for individuals who prefer specific healthcare providers or require immediate medical attention.
The newly introduced Ayushman Bharat Pradhan Mantri Jan Arogya Yojana for senior citizens marks a significant step toward universal healthcare for India’s elderly population, says Ashish Yadav, Head Product and Operations, ManipalCigna Health Insurance.
While Ayushman Bharat opens doors, it may not always cover the entire medical journey, says Govila.
The empanelled hospital also needs to be looked at it, say experts. “The government is not approaching the hospital for empanelment, rather the option is given to the hospitals. The contribution of 60:40 from central and state government, the implementation is purely depending on the state,” says S. Sridharan.
