Optimizing payment processes in the world’s most extensive health insurance program (PMJAY India)

• Jul 26, 2025
• 1 min

The Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world’s largest health insurance program, which provides USD 6,723 (INR 500,000) per family annually for secondary and tertiary care hospitalization. Government and private hospitals are empaneled under the PM-JAY to offer medical treatments, procedures, and surgeries. However, several systemic and operational bottlenecks led to dissatisfaction among empaneled health care providers (EHCPs), which led them to lose confidence in the program and opt out of the program.

MSC provided technical assistance to the National Health Authority (NHA), the central body responsible for the PM-JAY’s governance. We conducted a study across the states of Bihar, Haryana, and Madhya Pradesh to assess the challenges healthcare providers face in the delivery of services under this program. The study mapped the payment process to hospitals and identified key bottlenecks that affected payment timelines. MSC developed recommendations to optimize the claims process, enhance technology platforms, and strengthen human resource capacity while ensuring alignment with government policies.

A key focus was digital transformation and resource optimization to streamline claims processing for EHCPs and governance agencies. Additionally, MSC proposed digital incentives for the EHCP health workforce to improve engagement.

The study provided practical insights to improve efficiency, transparency, and trust in the PM-JAY’s implementation. MSC’s work addressed payment delays and administrative inefficiencies to restore confidence among healthcare providers, ensure their continued participation in the PM-JAY, and strengthen India’s healthcare delivery system.

The Gates Foundation commissioned the project.