Explained: Ayushman Bharat Scheme For Senior Citizens — How To Apply, Pre-Existing Conditions And More

In a bid to increase the safety net for India's senior citizens, the Union Cabinet has approved an extension to its flagship health insurance scheme, the Ayushman Bharat, to include all individuals above the age of 70 years irrespective of income.

In an announcement on Wednesday, the government said that the extended scheme would benefit approximately six crore senior citizens. They will be able to access a health insurance cover of Rs 5 lakh per family.

A launch date for the new policy is yet to be announced, but other details have been made available. Here's what you need to know:

Who Can Apply

Senior citizens belonging to families already covered under the Ayushman Bharat scheme can also apply. This cover will give them an additional top-up of Rs 5 lakh per year. This would need to be shared with other members of the family above the age of 70 years.

Senior citizens above the age of 70 already availing benefits from other public health insurance schemes – Central Government Health Scheme, Ex-Servicemen Contributory Health Scheme and Ayushman Central Armed Police Force – can either choose their existing scheme or opt for the new one.

What's more, those who are currently covered by private health insurance or by the employees' insurance scheme provided by state governments will still be eligible to avail benefits of the extended Ayushman Bharat scheme.

"The scheme is a floater cover,” said Mahavir Chopra of Beshak.org. “If there's a husband and wife over 70 in one family, the Rs 5 lakh cover will be for both. The five-lakh cover for the family worked similarly."

How You Can Apply

Eligible applicants can visit the official website of Pradhan Mantri Jan Arogya Yojana, where they can apply for a new card to register under the scheme. Once they are registered, they will receive an Ayushman card.

This card is needed in order to claim the benefits of the programme. In that sense, it works similarly to other health insurance cards.

Hospitals And Coverage

Unlike many other health insurance policies, the Ayushman Bharat provides full coverage. In other words, there is no co-pay system. This means the full cost of procedures up to the limit of Rs 5 lakh will be covered under the programme. In a co-pay system, some part of the expenses, often 20-30%, is borne by the patient.  

"This scheme is free of cost. It is not backed by any insurance company. It is separately allocated by the government itself. It's almost like offering free treatment. Any treatment that costs up to Rs 5 lakh would be covered by the government," said Chopra.

According to the website, the services listed include approximately 1,929 procedures covering all the costs related to treatment, including drugs, supplies, diagnostic services, physician's fees, room charges, surgeon charges and intensive care unit charges along with others.

"It's a great move, from the protection angle. This is something essential," said Amit Chhabra, chief business officer of general insurance, Policybazaar.com.

The scheme will cover up to three days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.

"Typically, in hospitals, certain facilities may be reserved for people who have coverage under these schemes," he said.

Pre-existing Diseases

Under the larger scheme, all pre–existing conditions, like diabetes and hypertension, are covered from day one. For senior citizens, however, the likelihood of pre-existing conditions is much higher. As things stand, there is no mention of a separate set of rules for senior citizens, so the natural assumption is that pre-existing conditions will be covered. However, there could be clarifications or amendments at a later date.

"Everything depends on the extent of utilisation of the budget allocated for the extension. In the future, some additional conditions might be put," said Chopra.

The standard exclusions that apply to most health insurance policies, like dental treatment, also apply to the Ayushman Bharat.

How Many Are Covered Currently

The Ayushman Bharat scheme was launched in September 2018 with an initial target to provide health insurance to 10.74 crore underprivileged people. It has far exceeded the initial target, with the number of beneficiaries having risen.

According to the government's latest circular, the scheme has covered 7.37 crore hospital admissions including 49 per cent women beneficiaries so far, providing benefits up to Rs 1 lakh crore. The latest approved expansion was announced by PM Modi in April 2024.