The case describes the evolution, design, implementation challenges and policy dilemmas of India’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), the world’s largest publicly financed health insurance programme. Through the narratives of Rani, a beneficiary struggling to access care, and Nisha Kumari, a policymaker preparing recommendations for a meeting, the case examines tensions associated with cost sustainability, provider participation, accessibility inequities, fraud and the prospective expansion of the scheme, particularly the debate on inclusion of outpatient coverage and enhancement of quality oversight. The case also reveals that demographic pressures, shifting disease burdens and difference in federal implementation can play a role in the strategic decisions made for the future of the programme.