Is Hernia Surgery Covered by Ayushman Bharat (PM-JAY)?

Quick answer

Hernia surgery is covered by the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) for eligible beneficiaries, offering cashless treatment. For central government employees and pensioners, the Central Government Health Scheme (CGHS) covers hernia surgery. Individuals not covered by these schemes can opt for government self-pay, which offers subsidized costs, or private self-pay, where the full cost is borne by the patient. Private health insurance may also cover the procedure.

Understanding PM-JAY Coverage for Hernia Surgery

PM-JAY, a government initiative, provides health coverage up to ₹5 lakh per family per year for secondary and tertiary care. Hernia surgery is included in the scope of procedures covered by PM-JAY.

Eligibility for PM-JAY

Eligibility is based on the Socio-Economic Caste Census (SECC) 2011 data. This includes deprived households in rural areas and specific occupational categories in urban areas. You can check eligibility via the official PM-JAY website's "Am I Eligible" portal using your mobile number, ration card number, or SECC name. Alternatively, call the PM-JAY helpline (14555 or 1800-111-565) or visit an Ayushman Mitra at an empanelled hospital.

Package Coverage for Hernia Surgery

PM-JAY offers comprehensive coverage for hernia surgery, including pre-hospitalization, surgery costs, post-hospitalization care, and diagnostics. This covers various types of hernia repairs, such as inguinal, umbilical, and incisional hernias. Package rates are pre-defined by the National Health Authority (NHA) and are standardized across empanelled hospitals, ensuring cashless treatment.

Pre-authorization Process

For planned hernia surgeries under PM-JAY, a pre-authorization process is typically required. The empanelled hospital initiates this request, submitting the patient's medical details and proposed treatment plan. Approval is granted if criteria are met, ensuring medical necessity and coverage. This process can be expedited in emergencies.

Exclusions

While PM-JAY provides extensive coverage, procedures that are not medically necessary or are cosmetic are generally excluded. Hernia surgery, being a necessary medical intervention, is typically covered. It is advisable to confirm any specific exclusions with an Ayushman Mitra at the hospital.

How to Verify Current Entitlement

To verify your PM-JAY entitlement, you can:

1. Visit the official PM-JAY website and use the "Am I Eligible" tool.
2. Call the PM-JAY helpline at 14555 or 1800-111-565.
3. Visit an Ayushman Mitra at any empanelled hospital for assistance with eligibility checks and scheme information.

Cost Routes for Hernia Surgery (Beyond PM-JAY)

• Government Self-Pay: Government hospitals offer services at significantly lower, subsidized costs compared to private facilities for those not covered by PM-JAY. Patients pay directly for these services.
• Private Self-Pay: In private hospitals, patients are responsible for the full cost. It is essential to obtain a detailed written estimate covering all anticipated expenses, including surgeon's fees, anesthesia, hospital stay, and post-operative care.
• CGHS (Central Government Health Scheme): Central government employees, pensioners, and their dependents are covered under CGHS. Hernia surgery is covered, allowing for cashless treatment at empanelled private hospitals or treatment at government facilities. Rates are fixed under CGHS.
• Private Health Insurance: If you have private health insurance, check your policy documents for specific coverage details, waiting periods, deductibles, and any required pre-authorization process.

Related guides

• Hernia Surgery Cost in India: CGHS, Govt, Private & Insurance
• Hernia Surgery CGHS Rates: Package, Eligibility & Documents

Sources

• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) Official Website
• National Health Authority (NHA) Guidelines and Packages