PM-JAY Evaluation: 65% of Beneficiaries Incur Out-of-Pocket Expenses Despite Coverage

According to a **NITI Aayog evaluation**, **65% of PM-JAY beneficiaries** incurred out-of-pocket expenses (OOPE) despite having health insurance coverage. Only **35%** received completely cashless treatment. The study was based on **2,283 households across 13 States/UTs**, highlighting persistent gaps in the Pradhan Mantri Jan Arogya Yojana's implementation.

Under **PM-JAY**, the average out-of-pocket expense (OOPE) at **private hospitals** was **₹53,965 per hospitalization**, compared to **₹21,827 at public hospitals** — nearly **2.5 times higher**. This disparity is a key finding of the **NITI Aayog evaluation** revealing that 65% of beneficiaries still paid out of pocket despite insurance coverage.

The **NITI Aayog evaluation of PM-JAY** was based on **2,283 households across 13 States/UTs**. Key findings: - **65%** of beneficiaries incurred out-of-pocket expenses despite coverage - Private hospital OOPE averaged **₹53,965** vs **₹21,827** at public hospitals - Only **35%** received fully cashless treatment The study exposed persistent implementation gaps five years after PM-JAY's launch.

**PM-JAY (Pradhan Mantri Jan Arogya Yojana)** was expanded in **September 2024** to include all citizens aged **70 years and above**, regardless of income. However, a **NITI Aayog evaluation** found that **65% of beneficiaries** still incur out-of-pocket expenses, with private hospital costs averaging **₹53,965 per hospitalization**, undermining the goal of eliminating catastrophic health expenditure.

**PM-JAY's** primary goal is to **eliminate catastrophic health expenditure for the poor** by providing cashless health insurance. The NITI Aayog finding that **65% of beneficiaries** still incur out-of-pocket expenses — averaging **₹53,965 at private hospitals** — is significant because it shows a major gap between the scheme's intent and actual delivery, especially for the economically vulnerable.