The Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched in 2018 to make quality healthcare accessible and affordable to everyone in India. In August 2022, the government announced that AB-PMJAY would also cover transgender individuals and offer them additional access to gender-affirming procedures such as sex reassignment surgery (SRS) and hormone therapy.
Two-and-a-half years since it was announced, the Ayushman Bharat TG Plus card, through which these benefits would be delivered, is yet to be rolled out. The government has also not updated the AB-PMJAY health benefit package to include gender-affirmative care. The most recent package, launched in April 2022, does not list such procedures among the 1,949 treatments offered.
AB-PMJAY has two main arms – free primary care through Ayushman Arogya Mandirs (previously known as Health and Wellness Centres), and an annual health insurance cover of up to Rs 5 lakh per family for hospitalisations. This insurance is valid at over 31,800 empaneled hospitals across the country, of which 45 percent are private. The scheme claims to cover around 620 million people from 147 million families, mostly those identified as vulnerable under the Socio-Economic Caste Census 2011, or by states and union territories, and senior citizens above 70 years. Of these, the programme has verified Ayushman cards of 405.7 million people, or about 65 percent of the target.
Experts say bureaucratic hurdles in getting a card identifying them as transgender, stigma at hospitals and an unclear policy on healthcare access has restricted the enrollment and use of AB-PMJAY by transgender people.
Despite legal guarantees, gender-affirming care remains out of reach
Transition-related care has been shown to improve the mental health and overall well-being of transgender people. Yet, access remains limited. A 2018 study by the National Human Rights Commission (NHRC) found that 57 percent of 900 transgender respondents in Uttar Pradesh and Delhi wanted sex reassignment surgery but couldn’t afford it.
More recently, a 2023 study of 377 transmasculine individuals across India found that only about a quarter had undergone any form of surgery, most commonly chest surgery. The majority said they wanted procedures – ranging from chest surgery to hysterectomy – but hadn’t been able to pursue them, largely due to financial barriers.
The cost of SRS in private hospitals reportedly ranges from Rs 2 to Rs 8 lakh depending on the procedure. This does not include pre and post-operative care. The few public hospitals that provide such procedures do so only after considerable delays and there are issues of quality healthcare, several people told IndiaSpend.
The Transgender Persons (Protection of Rights) Act, 2019 (TGPA 2019), and the 2020 Rules require the government to provide quality public healthcare to transgender people, including gender-affirming healthcare, counselling, medical insurance and separate hospital wards. But implementation has been patchy and inconsistent across states.
So far, Andhra Pradesh, Kerala, Haryana, Karnataka, Assam, Odisha, Maharashtra and Puducherry have adopted state-level transgender policies. Tamil Nadu reportedly offers free gender-affirmative procedures at select government hospitals, while Delhi’s Lok Nayak Jai Prakash Narayan, Guru Teg Bahadur, and Ram Manohar Lohia hospitals provide free SRS. Kerala reportedly reimburses surgery costs and provides Rs 3,000 a month for a year for post-operative care. Maharashtra, despite promising free surgeries, has reportedly made no budgetary provisions for the same.
“Insurers in India do not cover procedures related to sex reassignment under health insurance policies unless these are medically necessitated, say due to an accident or cancer,” said an agent from the insurance advisory platform Ditto Insurance, who did not wish to be named. The Ayushman Bharat TG Plus Card was expected to address these gaps in affordability of gender-affirmative care.
“When the announcement was made back in August 2022, the trans community got really excited about the TG Plus card primarily because the government promised that it would cover gender affirmation procedures,” said Gautam, a 27-year-old trans man based in Mumbai. Gautam started his transition in late 2020, spending Rs 1.25 lakh on getting top surgery through a private hospital in Delhi. This does not include the sum he spent on counseling and hormone therapy.
“I paid for the surgery through my savings. I did not have any insurance back then, because I did not see the point in having something that did not cover such a basic healthcare need for my well-being. My overall experience after the surgery has been positive, but yes, spending most of my savings has stung,” he said.
Delayed payments, low package rates
Aqsa Shaikh, a trans woman and professor of community medicine at Hamdard Institute of Medical Sciences & Research in Delhi, said: “One reason for the delay in extending the health benefit package of Ayushman Bharat to include SRS and such procedures could be the difficulty in finding enough hospitals providing these services to empanel themselves with the National Health Authority, the body responsible for implementing the scheme.”
Complex sex reassignment surgeries like vaginoplasty and phalloplasty often need multi-specialty collaborations (involving urology, plastic surgery, general surgery and gynaecology).
“In India, less than 50 plastic surgeons provide major SRS. Most of these surgeons are only available in private hospitals and have a long list of clients with wait times ranging from four-six months. Most of them don’t really have any incentive to empanel themselves with the NHA, especially when Ayushman Bharat in its current form is saddled with issues of delayed claim settlement and low package rates that don’t cover the cost of providing treatment in private hospitals,” said Shaikh.
Private hospitals face six-eight months’ delay in claim settlement under the scheme, as reported by The Print last year. Since its launch, over 600 private hospitals have opted out of AB-PMJAY, citing reasons such as delayed payments and low reimbursement rates. At the same time, misuse by hospitals is also a concern. Of the 66.6 million claims reviewed by the National Anti-Fraud Unit, 270,000 claims worth Rs 562.4 crore were flagged for abuse or incorrect entries, leading to the de-empanelment of 1,114 hospitals.
Budget for transgender welfare is low and severely underutilised
“The government did not make any corresponding budgetary allocation when they announced the extension of Ayushman Bharat for trans people. Schemes can exist on paper, but implementation cannot happen without funds,” said Rituparna Neog, a transwoman who is Associate Vice Chairperson of the Assam Transgender Welfare Board and a representative for Northeast India on the National Council of Transgender Persons, a statutory body set up under TGPA 2019 to advise on policies and programmes for the transgender community.
Budget figures highlight the continued neglect of the transgender community. For the financial year 2025-2026, the allocation for the Comprehensive Rehabilitation for Welfare of Transgender Persons scheme rose by 12.3 percent to Rs 76.87 crore. The scheme funds scholarships, skill training, Garima Greh (shelter homes), a health package (meant to include AB-PMJAY and gender-affirming procedures), the National Portal for Transgender Persons, and Transgender Protection Cells. Yet, even using the conservative 2011 Census estimate of the nearly 488,000 transgender population, the allocation amounts to just Rs 1,575 per transgender person for the year.
Despite modest allocations, much of the budget meant for transgender welfare remains unused. Between 2021 and 2024, only about 11 percent of the allocated funds were spent.
Poor uptake and unclear eligibility
For transgender individuals to be eligible for the scheme, they should have a Transgender Certificate and Identity Card, and shouldn't be enrolled in similar welfare schemes.
Activists and community members told IndiaSpend they were unsure whether transgender persons were accessing healthcare through AB-PMJAY. Both Gautam and Shaikh said they did not personally know anyone in the community who had used the scheme. Neog had only heard secondhand accounts, the details of which she couldn’t confirm.
In August 2024, Health Minister J P Nadda told Parliament that 3,029 transgender individuals had been included under AB-PMJAY through the Comprehensive Rehabilitation for Welfare of Transgender Persons scheme. Meanwhile, the AB-PMJAY dashboard shows over 446,000 Ayushman Bharat cards issued to individuals marked as ‘Other’ gender, and it is unclear whether these are all from the transgender community.
As of February 5, 2024, 794 hospital admissions for transgender beneficiaries had been approved under the scheme, with claims worth Rs 1.21 crore, translating to an average of Rs 15,000 per admission.
In November 2024, Minister of State for Health and Family Welfare Prataprao Jadhav stated to the Parliament that “any individual including transgenders eligible as per the criteria defined under SECC 2011 or those prescribed by State/UTs for non-SECC beneficiaries is entitled to free healthcare services” under AB-PMJAY. This appears to contradict earlier claims that all transgender persons with a valid TGID, and not receiving similar benefits under other schemes, were eligible for coverage.
“Beneficiary identification under SECC for Ayushman Bharat is done at the family level, not at the individual level. However, most trans people do not live with their families,” said Shaikh. A study by The Humsafar Trust of 366 transgender individuals across Delhi, Mumbai and Bengaluru found that only 17 percent lived with their biological families. The rest lived alone, with friends or partners, or within hijra/kinnar communities.
IndiaSpend reached out to the Department of Social Justice and Empowerment for clarification on eligibility criteria and data on the scheme’s utilisation by transgender individuals. We will update the story when we receive a response.
Healthcare system needs an overhaul
“A large part of the work on trans health is happening within community networks. Transgender people have a huge amount of anticipatory anxiety about the stigma they would face in a healthcare setting, a fear that is not unfounded,” said Sharin Dsouza, a researcher with Sangath, a non-profit working in the field of health equity. “Further, the health needs of transgender people are not very well understood. The community is not a monolith, and therefore, any solution that tries to make healthcare more accessible to them needs to be multi-pronged.”
Academic research on the health of transgender people, especially relating to non-communicable diseases and sexual and reproductive health, is scarce, possibly due to lack of funding for topics other than HIV and sexually transmitted infections in the community.
Since 2021, Sangath has worked with nearly 300 medical educators and students to sensitise them on gender inclusive education and care.
“Ayushman Bharat could be a great opportunity to ensure that hospitals become more inclusive spaces for the transgender community. Instead of leaving such decisions to the political will of hospital administrations, NHA can require hospitals to be more transgender or disabled-friendly as a condition for empanelment,” Dsouza suggested.
Bureaucratic, technical and social hurdles
Addressing the budget session in February 2024, Prime Minister Narendra Modi had said, “Those on the margins have been reassured that there is a government…We have given transgender persons an identity.”
Since their launch in November 2020, 26,449 TGIDs had been issued as of April 15, 2025, representing less than five percent of the transgender population as per the 2011 census. Nearly 4,774 applications are currently pending. Data for pendency of applications by duration is only available for about 2,483 applications, two-thirds of which have been pending for more than three months, despite the Transgender Rules stating that such applications be processed within 30 days.
The community has cited bureaucratic delays, lack of awareness among officials, invasive verification visits, website glitches, digital illiteracy, and lack of necessary documents among trans people as challenges in applying for and obtaining TGID.
IndiaSpend has asked the Department of Social Justice and Empowerment for the reasons behind the low number of applications and the delay in processing applications. We will update the story when we receive a response.
TGIDs are mandatory for availing welfare schemes for transgender people. “Most trans people do not have an incentive to apply for TGID because they feel that government welfare schemes do not provide any tangible benefits to the community. From skill development to scholarships to Garima Grehs, these measures have been poorly implemented and largely inaccessible,” said Neog.
Shaikh sees community interest in TGIDs picking up if the government starts issuing Ayushman Bharat TG Plus cards.
This report is republished with permission from IndiaSpend, a data-driven, public-interest journalism non-profit. It has been lightly edited for style and clarity.
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