Citizen Service · Official Guide
Open Heart Surgery under Ayushman Bharat: Coverage, Package Rates & the Real ₹5 Lakh Limit Math (2026)
Citizen Services
Does Ayushman Bharat (PM-JAY) cover open heart surgery, bypass (CABG), valve replacement and pediatric heart operations? How package rates and the ₹5 lakh limit work, plus pre-authorization and a 2026 comparison with Swasthya Sathi.
Required Documents
Ensure you have self-attested copies of the following documents ready before applying:
Official Portal & Helpdesk
Visit the official government portal for direct application, tracking status, and departmental updates.
Frequently Asked Questions (FAQ)
Is open heart surgery 100% cashless under Ayushman Bharat?
Costs within the package — surgeon, operation theatre, general cabin, implants of the specified standard — are 100% cashless. However, each package has a fixed rate; if expensive imported alternatives for grafts/valves, an AC private cabin, etc. fall outside the package, the patient must pay the difference. Get a written estimate before admission.
Does open heart surgery fall within the ₹5 lakh limit?
Yes, in almost all cases. PM-JAY's heart surgery package rates are set below ₹5 lakh as single-surgery packages. The limit is per family and per financial year — if multiple major treatments happen in the same year, they together draw down the ₹5 lakh; it refreshes again the following year.
Are pediatric congenital heart operations (ASD/VSD) covered?
Yes. The PM-JAY list includes packages for congenital heart disease surgery and device closure (ASD/VSD/PDA). For those aged 70+, an Ayushman Vay Vandana (VVS) enrolment is required first; for children, a regular PM-JAY card works.
If I have heart surgery outside the state (e.g. AIIMS Delhi), do I get the same coverage?
Yes. Ayushman Bharat is a national scheme — the same packages and ₹5 lakh coverage apply at any empanelled hospital in the country. This is the biggest difference from Swasthya Sathi (state-restricted).
In detail
Open heart surgery, bypass (CABG) or valve replacement — in a word, several lakh rupees. After Ayushman Bharat (PM-JAY) launched in West Bengal on 16 August 2026, these operations became possible cashless for empanelled families — the condition being a clear understanding of the package rules and the ₹5 lakh limit. Below is the complete math.
Which Heart Treatments Are Covered?
PM-JAY’s package list (roughly 2,000 packages) includes, in the cardiology category:
- CABG (bypass surgery) — off-pump and on-pump, with separate rates for single and multiple grafts
- Valve replacement / repair — mitral, aortic, double valve; rates depend on mechanical vs bio valve
- Congenital heart disease — ASD/VSD/PDA device closure and surgical repair (especially important for children)
- Aneurysm repair, pericardium operations and more
- PTCA/stenting (angioplasty) — separate packages depending on the number and type of stents
- Pacemaker implantation
How the ₹5 Lakh Limit Actually Works
This is where most confusion arises, so step by step:
- The limit belongs to the family, not the individual — whichever member incurs the cost, a total of ₹5,00,000 is drawn down per financial year.
- The limit is per financial year — any unused amount lapses at year-end, and the ₹5 lakh refreshes when the year turns. So if a bypass uses ₹3.5 lakh in one year, the full limit is available again the next year for a subsequent angiogram.
- The “limit” does not mean a separate cap for heart operations — in PM-JAY there is no separate sub-limit for cardiac, neuro or oncology. Every treatment has its own package rate; those rates are added together and deducted from the family’s ₹5 lakh.
- Package rates cover the entire episode — diagnostics up to 3 days before admission, the operation, medicines, general cabin, and follow-up for a specified period after discharge — all are included in the package. There is no scope for separate billing.
What May Have to Be Paid Beyond the Package Rate?
- Premium implants — imported bio-valves, premium drug-eluting stents, etc., if costlier than the package’s fixed rate, the difference falls on the patient
- AC private/super cabin — the package fixes a general ward/AC cabin standard
- Ancillary costs — family’s stay and food, blood arrangements (in some cases)
- Before admission, ask the hospital for a written estimate and make clear which part is cashless and which part is yours
Comparison with Swasthya Sathi
| Aspect | Swasthya Sathi | Ayushman (PM-JAY) |
|---|---|---|
| Bypass/valve surgery coverage | Yes (at state hospitals) | Yes, at fixed package rates |
| Outside the state (AIIMS Delhi, etc.) | No cashless benefit | Yes — portable |
| Basis of package rates | State’s own rates | PM-JAY’s national/state-modified rates |
| Pre-authorization | Applicable | Required — the hospital applies on the portal |
Note that under the new SOP, once the Ayushman card is made, hospital treatment generally happens under PM-JAY; Swasthya Sathi acts as backup (details here).
What to Do Before the Operation
- Get your Ayushman card made — Swasthya Sathi to Ayushman porting guide.
- Choose the hospital — a PM-JAY empanelled hospital experienced in cardiac surgery (inside or outside the state).
- Arrange the echo/angiography reports — pre-authorization requires the doctor’s recommendation and reports.
- Get admitted only after pre-authorization approval — if admitted before approval, the cost may fall on you.
- If aged 70+, complete Ayushman Vay Vandana enrolment first; if not on the PM-JAY list, look at MMSBY.
Caution
- Never pay anyone in the name of pre-authorization or package approval — the entire process is free.
- Never share your Aadhaar OTP with anyone.
- Helpline: 14555 (Ayushman) / 1800 345 5384 (Swasthya Sathi).
Related articles: Ayushman Bharat for cancer treatment at Vellore (CMC) and the complete MMSBY application guide.
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