Government Health Insurance Schemes in India [2026]

Overview

India has several major government health insurance schemes designed to help families manage medical expenses.

Major National Schemes

Ayushman Bharat PM-JAY (Pradhan Mantri Jan Arogya Yojana): Provides up to ₹5 lakh per family each year for secondary and tertiary hospitalization. It covers vulnerable families and all senior citizens aged 70 and above, regardless of income.
Central Government Health Scheme (CGHS): Offers comprehensive medical care to central government employees, pensioners, and their families through wellness centers and empaneled hospitals.
Employees’ State Insurance Scheme (ESIS): Covers organized-sector workers within wage limits for treatment, maternity, and sickness benefits.
Pradhan Mantri Suraksha Bima Yojana (PMSBY): A low-cost personal accident cover that provides death and disability coverage.

State-Level Schemes: Many states run programs alongside national plans. For example, Mahatma Jyotirao Phule Jan Arogya Yojana in Maharashtra, Ayushman Bharat Arogya Karnataka, and PM-JAY + Delhi Arogya Kosh.

A single major hospitalization can cost lakhs, and not every Indian family has private health insurance to fall back on. That's where government health insurance schemes step in, from Ayushman Bharat PM-JAY's ₹5 lakh family cover to CGHS for central government employees and ESIC for organized-sector workers.

But these schemes don't all work the same way. Eligibility, coverage limits, and hospital networks differ sharply from one scheme to another and from state to state.

In this guide, we break down India's major central and state government health insurance schemes, what they cover, who's eligible, and where private health insurance can help fill in the gaps.

Central Government Health Insurance Schemes in India

Ayushman Bharat PM-JAY

Ayushman Bharat PM-JAY offers up to ₹5 lakh annual family cover for secondary and tertiary hospitalization to about 33% of India’s population. It also covers pre-existing diseases from day 1. Under the senior citizen expansion, every Indian citizen aged 70 and above gets an additional ₹5 lakh in annual cover for their household, on top of any existing PM-JAY coverage, regardless of income.

Central Government Health Scheme (CGHS)

CGHS is a healthcare benefit for serving central government employees and pensioners. Unlike retail health insurance, there’s no fixed ₹5 lakh cap. It covers Outpatient Department (OPD) care, medicines, diagnostics, and hospitalization. As of March 2026, CGHS covers around 43 lakh beneficiaries across India.

Employees' State Insurance Scheme (ESIS)

ESIS is a statutory social security scheme for eligible employees earning up to ₹21,000 per month (₹25,000 for persons with disabilities). It provides medical, sickness, maternity, and other social security benefits through ESIS facilities and approved arrangements. As of March 2025, the scheme covers about 14.91 crore beneficiaries.

Niramaya Health Insurance Scheme

Niramaya Health Insurance Scheme is designed for individuals with autism, cerebral palsy, intellectual disability, and multiple disabilities. It offers a ₹1 lakh annual cover, including sub-limits for hospitalization, OPD care, and therapies. Between 2025 and 2026, around 71,537 beneficiaries were enrolled.

Ayushman CAPF (Central Armed Police Forces)

Ayushman CAPF covers Central Armed Police Forces personnel and their dependents. It combines the CGHS and National Health Authority networks to provide cashless hospitalization and OPD services. The scheme currently covers around 41.21 lakh beneficiaries.

Ex-Servicemen Contributory Health Scheme (ECHS)

ECHS provides comprehensive healthcare to ex-servicemen pensioners and eligible dependents through a network of polyclinics and network hospitals, with no fixed treatment cap. As of August 2026, it covers about 66.75 lakh beneficiaries.

PMSBY (Pradhan Mantri Suraksha Bima Yojana)

PMSBY is not a health insurance but a personal accident cover offering ₹2 lakh for accidental death or permanent total disability for ₹20 per year. It’s not a health insurance plan and doesn’t cover hospitalization expenses.

State-Wise Government Health Insurance Schemes in India

State	Scheme	Beneficiaries & Eligibility	Key Coverage & Features
Maharashtra	Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY) + PM-JAY	Eligible residents of Maharashtra.	Up to ₹5 lakh per family per year for secondary and tertiary care. Pre-existing diseases covered from day 1.
Karnataka	Ayushman Bharat Arogya Karnataka	Below Poverty Line (BPL) and National Food Security Act households and eligible residents.	Up to ₹5 lakh cover for eligible households. Co-payment applies for general category residents.
Tamil Nadu	Chief Minister’s Comprehensive Health Insurance Scheme	Families with annual income below ₹1.2 lakh.	Up to ₹5 lakh per family per year cashless treatment at empaneled hospitals.
Telangana	Rajiv Aarogyasri	Economically weaker and BPL households.	Up to ₹10 lakh annual cover for listed surgical and medical procedures.
West Bengal	Swasthya Sathi + PM-JAY	Eligible state residents.	Up to ₹5 lakh per family per year. Female head of family coverage. Pre-existing diseases covered from day 1.
Uttar Pradesh	Mukhyamantri Jan Arogya Yojana + PM-JAY	Low-income households not fully covered under central PM-JAY list.	Up to ₹5 lakh per family per year aligned with PM-JAY package rates.
Delhi	PM-JAY + Delhi Arogya Kosh	Eligible residents and government hospital referrals.	Up to ₹5 lakh PM-JAY cover plus additional financial support for diagnostics, surgeries, and trauma care.

Key Insight on State Health Schemes

Most state schemes work alongside PM-JAY, with the central and state governments sharing the cost. This lets people access cashless treatment and, in many cases, use their benefits even outside their home state.
PM-JAY focuses on low-income households, while states expand eligibility to broader resident groups.
Some states offer higher coverage limits. Telangana, for instance, provides up to ₹10 lakh.
States like Maharashtra and West Bengal expand coverage to wider resident populations.
West Bengal’s Swasthya Sathi issues health cards in the name of the eldest female member to improve inclusion and access.

For a detailed breakdown of eligibility rules, coverage structures, and claim processes across states, check out our detailed guide on state government health insurance schemes.

Eligibility and Coverage Across Government Health Insurance Schemes

Hospitalization Expenses

Schemes like PM-JAY, CGHS, and ESIS cover inpatient doctor fees, surgery, ICU charges, consumables, and nursing costs. PM-JAY typically provides general ward accommodation.

Pre- and Post-Hospitalization Expenses

PM-JAY covers diagnostics and medicines up to 3 days before admission and up to 15 days after discharge. Schemes like CGHS and ECHS also include ongoing consultations and medicines through network dispensaries.

Day Care Procedures

PM-JAY and state integrated schemes cover defined day care surgical procedures that do not require 24-hour hospital admission.

Pre-Existing Diseases

Pre-existing diseases are covered from day 1 under PM-JAY, CGHS, and ESIS without the waiting periods commonly seen in private health insurance policies.

How to Apply for a Government Health Insurance Scheme?

Application processes depend on the scheme type:

PM-JAY: Eligible families can verify details and generate an Ayushman Card through the official PM-JAY beneficiary portal, mobile app, Common Service Centers, or hospital Arogya Mitra desks. Seniors aged 70 and above can self-register using Aadhaar-based eKYC.
CGHS and ECHS: Central government employees apply through departmental channels or CGHS portals. Ex-servicemen register online for the ECHS Smart Card using pension PPO records.
ESIS: Employers register eligible workers on the ESIS portal when they enter insurable employment.
Niramaya: Applicants register on the National Trust portal using a valid UDID card.

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Government Health Insurance Schemes: Common Exclusions and Limitations

Package Limits and Empaneled Networks: Treatment is restricted to specified package rates and empaneled network hospitals.
Routine Outpatient (OPD) Exclusions: Inpatient-focused schemes like PM-JAY exclude standalone OPD visits and routine diagnostics.
Strict Sublimits: Schemes like Niramaya limit OPD and therapies within small sublimits.
General Ward Restrictions: Hospitalization under PM-JAY is limited to general ward beds.

Government Health Insurance Schemes vs. Private Health Insurance: Do You Still Need Cover?

Feature	Government Health Insurance Schemes	Private Health Insurance
Sum Insured or Coverage Limit	Fixed annual limits such as up to ₹5 lakh under PM-JAY and ₹1 lakh under Niramaya. CGHS and ESIS work on package rates instead of a fixed cap	Flexible coverage options from ₹10 lakh to ₹1 crore or unlimited to manage rising medical costs
Pre-Existing Diseases	Covered from day 1 under PM-JAY, CGHS, and ESIS with no waiting period	Waiting period of 2 to 3 years (reducible) as per IRDAI guidelines
Hospital Room Category	Usually limited to general ward under PM-JAY package rules	Choice of private rooms or plans with no room rent restrictions
Hospital Choice and Network	Treatment is only available in empaneled hospitals. Referral process required in CGHS and ESIS systems	Large network of private hospitals with both cashless and reimbursement options
Pre- and Post-Hospitalization	Covered up to 3 days before admission and 15 days after discharge under PM-JAY	Longer coverage periods typically 30 to 90 days before and 90 to 180 days after hospitalization
Outpatient Care	Mostly not covered under PM-JAY but included in CGHS, ESIS, ECHS, and Niramaya	Not included in basic plans. Available through add-ons

Ditto's Take

Medical inflation in India has remained around 12% to 14% annually in recent years, which means hospital costs rise quickly over time. A fixed cover like ₹5 lakh under government schemes can be used up quickly on major surgeries or long ICU stays. These schemes work well as baseline protection but may not fully cover high-cost treatment.

Private health insurance fills these gaps. It typically offers a higher sum insured, the choice of a private room, access to hospitals outside the government network, and coverage that continues regardless of your job or income. It isn't dependent on annual government budget allocations.

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Conclusion

Government health schemes like PM-JAY, CGHS, and ESIC do a lot of heavy lifting. They cover pre-existing conditions from day one, need no premium from most beneficiaries, and offer real protection to crores of families who'd otherwise have none.

But they come with real limits: fixed cover amounts up to ₹5 lakh, treatment restricted to empaneled hospitals, and little to no support for outpatient care. With medical inflation running at 12%-14% a year, a single major hospitalization can use up your entire government cover at once.

If you're already covered under a scheme like PM-JAY or CGHS, treat it as your base layer, not your only protection. Check what your scheme doesn't cover, like OPD visits, private rooms, and non-network hospitals, and consider a private health insurance plan to fill those specific gaps rather than replace your existing cover.

Frequently Asked Questions

Which is India's largest government health insurance scheme by beneficiaries?

Ayushman Bharat PM-JAY is India’s largest and flagship government healthcare scheme by beneficiaries. It provides ₹5 lakh per family per year for secondary and tertiary hospitalization to over 12 crore low-income households. It also includes senior citizens aged 70 and above, regardless of income, making it one of the top government health insurance schemes in India.

Can I be covered under both a state government health scheme and Ayushman Bharat PM-JAY?

Yes, many states run integrated models where state schemes and PM-JAY work together, allowing eligible families to receive combined benefits. However, people covered under central schemes like CGHS, ESIS, or CAPF generally need to choose between their existing health scheme and PM-JAY, rather than holding both simultaneously.

Are central government employees covered under CGHS or PM-JAY?

Central government employees and pensioners are covered under CGHS, not PM-JAY. CGHS provides outpatient care, diagnostics, medicines, and hospitalization through impanelled facilities without a fixed annual cap. While they are excluded from PM-JAY, senior citizens above 70 may have options depending on eligibility rules.

Does ESIS cover hospitalization for factory and organized sector workers?

Yes, ESIS covers organized-sector workers earning within prescribed wage limits who are enrolled in the scheme. It provides full medical care, including OPD consultations, diagnostics, maternity care, and hospitalization for employees and dependents from day 1 of employment, without a fixed monetary limit on treatment costs.

Do health schemes in India by government cover OPD consultations?

Coverage for OPD depends on the scheme. PM-JAY focuses mainly on hospitalization and does not cover routine OPD visits. In contrast, CGHS, ESIS, and ECHS include OPD consultations, diagnostics, and medicines. Some specialized schemes like Niramaya also provide structured OPD-related benefits. These differences are common across health insurance schemes in India.

How do I check which government health scheme I am eligible for?

Eligibility depends on income, employment type, disability status, or state of residence. You can check PM-JAY eligibility on the official Ayushman Bharat beneficiary portal using Aadhaar or a ration card. Employers manage ESIS eligibility, government portals manage CGHS eligibility, and state health websites manage state schemes.

Why might medical inflation make government scheme coverage insufficient alone?

Medical inflation in India runs at around 12% to 14% annually, causing healthcare costs to rise quickly. Limited covers like ₹5 lakh under PM-JAY or ₹1 lakh under Niramaya can get exhausted in major surgeries or long ICU stays. Private health insurance helps bridge this gap with higher coverage, broader hospital access, and long-term financial protection.

How are government health schemes implemented in India?

Government health schemes in India do not follow a single implementation model. Some operate through a trust-based system where the government directly manages and pays for claims, while others use insurance companies to handle claim processing. For example, Ayushman Bharat PM-JAY allows states to choose between trust mode, insurance mode, or a mix of both. In contrast, schemes like CGHS work on a service-based coverage model, while ESIS follows a structured social insurance approach linked to employment.

Last updated on: 25 Sep, 2026