Who Is Not Eligible for the Ayushman Bharat Scheme?

People usually believe that Ayushman Bharat is a universal scheme and covers anyone and everyone who cannot pay for themselves in the private sector. Well, it is reasonable to think like this. After all, Ayushman Bharat is a massive initiative of the state, one of the most ambitious government schemes in the field of health insurance. But not everyone is eligible for the Ayushman Bharat scheme. The project has its own criteria determining eligibility.

If you or someone in your family has been trying to figure out whether you qualify or not, this blog breaks the whole thing down clearly.

What Is Ayushman Bharat and What Does It Actually Do?

Ayushman Bharat is a central government health scheme launched with the goal of moving away from fragmented, sector-by-sector healthcare delivery toward something more comprehensive. It operates through two connected components:

1. Health and Wellness Centres (HWCs): It is a primary care network consisting of local centres that perform tasks related to the provision of maternal and child health services, non-communicable disease care, and free dispensing of medicines and basic medical examinations.
2. Pradhan Mantri Jan Arogya Yojana (PM-JAY): It is the best-known element and the insurance segment of this initiative. This program guarantees access to secondary and tertiary hospitalisation without any expenses up to Rs. 5,00,000 per family annually.

Thus, this scheme provides for covering healthcare demands from primary visits to serious operations at authorised medical facilities.

Who Is Eligible for the Ayushman Bharat Scheme?

Eligibility is determined primarily by the Socio-Economic Caste Census, or SECC data. The criteria differ for rural and urban populations.

For rural families, a household qualifies if it meets at least one of the following deprivation criteria:

• Only one room with kutcha walls and a kutcha roof
• No member aged between 16 and 59
• No male member between the ages of 16 and 59
• A disabled member with no able-bodied adult in the household
• Scheduled Caste or Scheduled Tribe household
• Landless households deriving income primarily from manual casual labour

Certain categories are automatically included regardless of other criteria:

• Households without shelter
• Families living on alms
• Manual scavenger families
• Primitive tribal groups
• Legally released bonded labourers

For urban families, eligibility is based on occupation. The following categories of workers qualify:

• Ragpickers and beggars
• Domestic workers
• Street vendors, cobblers, and hawkers
• Construction workers, plumbers, masons, painters, welders, security guards, and head-load workers
• Sweepers, sanitation workers, and malis
• Home-based artisans, handicrafts workers, and tailors
• Transport workers, including drivers, conductors, cart pullers, and rickshaw pullers
• Shop assistants, peons, delivery assistants, helpers, and waiters in small establishments
• Electricians, mechanics, assemblers, and repair workers
• Washermen and chowkidars

One important recent update: As of September 2024, the Union Cabinet expanded PM-JAY eligibility to include all citizens aged 70 years and above, regardless of income or socio-economic category.

Who Is Not Eligible for the Ayushman Bharat Scheme?

The scheme has a defined list of exclusion criteria. If a household meets any of the following conditions, it is generally not eligible for PM-JAY:

• Families that own a two-wheeler, three-wheeler, four-wheeler, or a motorised fishing boat
• Households that own mechanised farming equipment
• Those holding Kisan credit cards with a credit limit of Rs. 50,000 or above
• Government employees and their families
• Those working in government-managed non-agricultural enterprises
• Households with a monthly income above Rs. 10,000
• Families that own a refrigerator and a landline phone
• Those living in pucca, solidly built houses
• Households owning five acres or more of agricultural land

The logic behind these exclusions is simple. The scheme is designed for households that are genuinely economically weak. Households owning assets like a vehicle, agricultural land above a threshold, or mechanised equipment are treated as a family that has a level of financial stability that places them outside the target group.

It is also worth noting that families who have an annual income above Rs. 5 lakh are generally not covered, unless they qualify under SECC on other grounds.

How to Check Whether You Are Eligible for the Ayushman Bharat scheme?

The government has made the eligibility check relatively easy. There are three main ways to do it:

1. Online portal: Visit the official PM-JAY website at pmjay.gov.in and use the "Am I Eligible" tool. Then enter your mobile number, name, and state.
2. Mobile application: The PM-JAY app is available on both Android and iOS. Use it to check your eligibility status and access other scheme details from your phone.
3. Ayushman Bharat card: Ayushman Bharat cards are issued once your eligibility is verified. This card is your ticket to cashless treatment at hospitals that are part of the program. 

If you're having trouble navigating the online application, you can also get assistance at your local Common Service Centre or from an Asha worker, who can help you check your status and complete the application.

Documents Required

If you are going for the verification or application process for the scheme, keep the following key documents ready:

• Aadhaar card
• Proof of address
• Income certificate
• Caste certificate
• Contact details, including mobile number and email
• Document proof of current family status, whether joint or nuclear

Having these in order before you start the process will help you save time and reduce the chances of a procedural delay.

Key Benefits of the Scheme

Enrolled families reap cashless hospitalisation coverage of up to Rs. 5 lakh per year. Here is what that coverage actually includes:

• Consultation fees, medicines, diagnostics, surgery, ICU charges, implants, accommodation, and food during the hospital stay
• Three days of pre-hospitalisation expenses and fifteen days of post-hospitalisation costs
• All pre-existing diseases are covered from day one, with no waiting period
• No cap on family size, and no restriction based on age or gender
• Portable across India, meaning you can use it at any authorised hospital in any state
• Approximately 1,929 medical procedures are covered under the scheme

For families that qualify, it is genuinely significant coverage.

Final Thoughts

Ayushman Bharat scheme is a vital safety net for millions of families across India. But it is not designed for everyone, and understanding where the boundaries are is important, whether you are checking for yourself or helping a family member navigate the process.

If you don't meet the eligibility criteria, it does not mean you are left with no options. You can use a personal health insurance plan to fill that gap and get similar financial protection against large medical expenses. Niva Bupa offers health insurance plans designed for individuals and families across income groups, with coverage that includes hospitalisation, pre and post-hospitalisation expenses, and day one coverage for pre-existing diseases in select plans. Knowing your coverage situation, one way or the other, is always better than finding out at the time of hospitalisation.

Frequently Asked Questions

1. What diseases are not covered in the Ayushman Bharat scheme?

According to the latest National Health Benefit Package guidelines by the National Health Authority (NHA), a few diseases and treatments are not covered by Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). This includes outpatient treatments (OPD), hospitalisation only for evaluation, dental treatments without hospitalisation and surgical intervention, cosmetic surgeries, and vaccinations that are not listed under national immunisation programmes.

2. What's the process for applying online to the Ayushman Bharat Scheme?

You can use UMANG to apply for the Ayushman Bharat scheme. Start by going to the official UMANG website and registering with your mobile number. After that, verify your number with an OTP and set up an MPIN to finish the registration. Once you're logged in, click on the "All Services" tab, find the Ayushman Bharat service, and fill out the application form, making sure to include all the necessary details and documents.

Review everything carefully before submitting. You'll get a confirmation message once the application goes through.

3. Does the Ayushman Bharat scheme cover newborns?

Yes, it does. The scheme offers cashless treatment and NICU care for newborns. Newborns are automatically included under their mother's Ayushman card or ID for a specific period. Later, they can be added to the family's beneficiary list using birth documents.

4. Is the Ayushman Bharat card accepted for maternity care?

Yes, the Ayushman Bharat (PM-JAY) Card is accepted. It's widely used to access maternal healthcare services. This encompasses everything from prenatal check-ups and the costs of both normal and cesarean deliveries to the well-being of newborns. The card offers cashless service access at hospitals that are part of the government and private empanelment programs.

5. What are the disadvantages of the Ayushman Bharat card?

The Ayushman Bharat card provides coverage to a large extent, yet there are some major disadvantages to the plan. Firstly, the number of private hospitals covered by the Ayushman Bharat scheme is quite low. Besides, sometimes, the patients experience refusal of service at the designated hospitals. Furthermore, certain vital services are not covered, and there is no refund if treated in unempaneled hospitals.

6. Which state has not implemented the Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana?

Till the start of 2026, the major state that has not yet enrolled itself under the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme has been West Bengal, which had actually opted out of the scheme back in January 2019. Apart from this, even Delhi and Odisha do not fall under the category of states that have enrolled themselves under the scheme due to having their own state-run health insurance schemes.