Ayushman Bharat vs Private Insurance: What Should You Choose?

In contrast, private health insurance is available to individuals across all income groups. It allows policyholders to customise their coverage, choose their preferred hospitals, and opt for specific room types. However, it involves regular premium payments, monthly or annually, and the claim process may not always be straightforward. This blog will provide a detailed comparison of both options, examining key factors such as hospital network, coverage benefits, and claim procedures.

What is Ayushman Bharat?

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), often called Modicare, is India’s largest health insurance scheme backed by the government. It's designed to give hospital care to low-income families of various states, such as Madhya Pradesh, Rajasthan, Chhattisgarh, and more. Also, the government of India has launched Ayushman Bharat Mahatma Gandhi Rajasthan Swasthya Bima Yojana to cover health expenses of 1.10 crore families of Rajasthan.

Who Can Get It?

• Families listed under the SECC 2011 data (Socio-Economic Caste Census).
• Now, it is extended to all senior citizens above 70 years, with no income bar.

What Does It Cover?

• Free hospitalisation for planned and emergency cases.
• Covers secondary care (specialist-level treatment).
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• Also includes tertiary care (major surgeries, cancer, cardiac treatment, etc.)
• Up to ₹5 lakh per family per year.
• Works on a cashless and paperless model at empanelled hospitals.

Where Can You Use It?

• At the government and selected private hospitals are enrolled under PM-JAY.
• Only valid at empanelled hospitals (you can't use it everywhere).

Limitations

• It's only those who are pre-listed or eligible.
• Coverage doesn’t include OPD visits, diagnostics, or routine checkups.
• The hospital list is limited; not every good private hospital is part of it.

What is Private Health Insurance?

Private health insurance is coverage you buy yourself or get through work. It isn’t run by the government. Instead, it's offered by companies like:

• UnitedHealthcare
• Blue Cross Blue Shield
• Aetna
• Cigna
• Kaiser Permanente

You can grab a plan:

• Through your employer
• On the ACA marketplace
• Directly from the insurance company

How It Works

• You pay a monthly premium to stay covered.
• Plans usually last one year and are renewed annually.
• acivate health plans take care of:
• Hospital care (stays, surgeries, treatments)
• Doctor visits (routine, specialists, outpatient)
• Preventive care (vaccines, screenings)
• Mental health care (therapy, counselling)
• Prescription drugs (some cover more than others)
• Rehab services (like physical or occupational therapy)
• Specialist services (dermatologists, cardiologists, etc.)

Essential Health Benefits (ACA-compliant plans )

• Outpatient care
• Emergency services
• Hospital stays
• Maternity and newborn care
• Mental health & substance use services
• Prescription drugs
• Pediatric care (including dental/vision for kids)
• Lab tests
• Rehab & therapy services
• Preventive care & chronic disease treatment

Which One Should You Pick?

1. Budget

   If paying for insurance isn't in your current budget, Ayushman Bharat, along with other government health insurance schemes, is a huge help. You get up to ₹5 lakh in hospital coverage per family.

2. More Choice

   Private insurance puts more power in your hands. You can pick your insurer, your plan type, and even the hospital you prefer. PPO plans let you access out-of-network care too (at extra cost), something Ayushman Bharat doesn’t support. This kind of control makes private plans attractive if you want more than the basic plans.

3. OPD or Extra Services

   Ayushman Bharat is solid for hospital care, but doesn’t cover outpatient visits, annual checkups, or regular prescriptions. That’s where private insurance pulls ahead. You can pick a plan that includes OPD, maternity care, daycare procedures, and even alternative therapies. If you visit doctors often or want more out of your plan, private insurance offers that room.

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