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Health Insurance Scheme for the Central Government Employees waits for Approval of Planning Commission

New Delhi, May 18, 2012(PIB): There is a proposal for introduction of a health insurance scheme for the central government employees and pensioners on pan-India basis, with special focus on pensioners living in non-CGHS areas.

The proposal is to make this scheme voluntary cum contributory for serving employees & pensioners.

However, it is proposed to be made compulsory for the new entrants in Government service.

The salient features of the proposed Health Insurance Scheme are as under;

•  Optional for serving Central Government employees and pensioners including future pensioners,
•  Compulsory for new recruits,
•  Covers all the members of family as per CGHS norms,
•  Sum insured – Rs. 5 lakh per year on a family floater basis,
•  Corporate buffer of Rs 25 Crore to take care of cases exceeding Rs. 5 lakh,
•  All pre existing diseases covered from the day one,
•  Pre and post hospitalisation benefits available,
•  Domiciliary Hospitalisation benefit,
•  Maternity benefit upto two living children,
•  OPD not covered however OPD consultations will be free,
•  Payment of FMA for meeting OPD needs,
•  Cashless treatment facility,
•  Govt. to subsidise significantly the payment of premium,
•  Employees / pensioners to contribute 20 to 30 percent of the premium,
•  Identification of beneficiaries through a Smart Card.

The proposed scheme will be an alternative to the CGHS and it will provide an option to the serving employees and pensioners to choose a scheme as per his/her convenience.

The Scheme will have special focus on the pensioners living in non-CGHS areas who are getting Fixed Medical Allowance at the rate of Rs.300/- only per month to take care of their medical needs and have been demanding extension of CGHS or CS (MA) Rules to cover their OPD and Inpatient medical needs which is not feasible due to resource constraints. 

The Health Insurance Scheme seems to be a viable alternative. It will have additional implications, due to coverage of pensioners living in non-CGHS areas and not covered under any Government Scheme.

The proposal for inclusion of the Health Insurance Scheme for the Central Government employees and pensioners in the 12th Plan has been moved by the Ministry for consideration of the Steering Committee on Health in the Planning Commission. 

On receipt of approval of Planning Commission, the proposal would be placed before the Expenditure Finance Committee and finally before the Cabinet for approval of the scheme. No strict time frame can be given in this regard.

This information was given by the Union Minister for Health & Family Welfare Shri Ghulam Nabi Azad in reply to a Starred question in Lok Sabha on Friday, i.e. May 18, 2012.

Medical Facilities for inpatient treatment and post-operative follow-up treatment to CGHS Beneficiaries in Non-CGHS areas

Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New Delhi 110 108

No: S.11011/7/99-CGHS (P) Dated, the 27^th April, 2011

OFFICE MEMORANDUM

Subject: Medical Facilities for inpatient treatment and post-operative follow-up treatment to CGHS Beneficiaries in Non-CGHS areas.

The undersigned is directed to invite attention to the Office Memorandum of even number dated 30^th September, 1999, issued by the Ministry of Health & Family Welfare on the above subject and to state that keeping in view the difficulties being faced by the pensioner CGHS beneficiaries residing in non-CGHS covered areas, it has now been decided to liberalise the CGHS Rules with regard to pensioner CGHS beneficiaries and serving employees, as below, to enable them to avail medical facilities for in-patient treatment and post-operative follow-up treatment:

a) (i) CGHS pensioner beneficiaries (and their dependant and eligible family members), who are holding a valid CGHS Card and are residing in a non-CGHS areas shall be eligible to obtain treatment from Government hospitals (Central Government / State Government / Local self Government / hospitals recognised under Central Services (Medical Attendance) Rules, 1944 / hospitals and clinics empanelled under Ex-Servicemen Contributory Health Scheme (ECHS) and submit the medical reimbursement claim to the Additional Director / Joint Director of CGHS of the CMO in charge of CGHS Wellness Centre, where the CGHS is registered.

(ii) In case of non-emergency treatment from hospitals approved under Central Services (Medical Attendance) Rules, 1944 and Ex-Servicemen Contributory Health Scheme (ECHS), it is necessary to obtain prior approval from CMO in charge of concerned Wellness Centre where the CGHS card is registered.

(iii) In case of medical emergency, treatment may be obtained from any hospital and medical claim shall be submitted to Additional Director / Joint Director, CGHS of the concerned city through CMO in charge of the Wellness Centre, where the CGHS card is registered.

(iv) Reimbursement shall be limited to the CGHS rates of the city where the card is registered and as per the ceiling rates and ward entitlements or as per actuals, whichever is lower.

(v) CGHS pensioner beneficiaries / serving Central Government employees (and their dependant and eligible family members) and holding a valid CGHS Card and on a visit to non CGHS covered area may obtain treatment under emergency from Government hospitals (Central Government / State Government / Local self Government / hospitals recognised under Central Services (Medical Attendance) Rules, 1944 / hospitals and clinics empanelled under Ex-servicemen Contributory Health Scheme (ECHS) and the medical claim shall be submitted to Additional Director / Joint Director, CGHS of the concerned city through CMO in charge of the Wellness Centre, where the CGHS card is registered, in case of pensioners , etc., and to the concerned Ministry / Department / office in case of serving employees.

(vi) Reimbursement shall be limited to the CGHS rates of the city nearest to the place, where treatment is obtained and as per the ceiling rates and ward entitlements or as per actuals, whichever may be less.

b) (i) CGHS pensioner beneficiaries (and their dependant and eligible family members) , who are holding a valid CGHS Card and residing in a non-CGHS areas shall be eligible to obtain post operative follow-up treatment from Government hospitals (Central Government / State Government / Local self Government / hospitals approved under Central Services (Medical Attendance) Rules, 1944 / hospitals and clinics empanelled under Ex-servicemen Contributory Health Scheme (ECHS) in follow up cases of Renal Transplant surgery, Knee and Hip Joint Replacement, Cancer treatment , Neuro-surgery and cardiac surgery. However, prior permission is to be obtained from the CMO in charge of the concerned Wellness Centre, where the CGHS card is registered.

(ii) Permission shall be issued for 3 to 6 months at a time and may be extended based on medical requirement. Reimbursement for consultation, procedures and investigations shall be limited to CGHS rates of the city, where the card is registered and as per the ceiling rates and ward entitlements or as per actuals, whichever may be lower. OPD medicines shall be obtained from the concerned Wellness centre for a maximum period of 3 months at a time.

c) Wherever treatment is obtained from a hospitals approved under Central Services (Medical Attendance) Rules, 1944 / ECHS approved hospital, the beneficiaries (as in (a), (b) & (c) above) shall submit a certificate from the hospital that they have not charged more than the approved applicable hospitals approved under Central Services (Medical Attendance) Rules, 1944 / ECHS rates.

d) This Office Memorandum supersedes the earlier OM of even number dated 30th September 1999.

e) This arrangement is provisional and would be in place till such time the proposed Health Insurance Scheme for Central Government employees & pensioners is brought into effect.

f) These orders will come into effect from the date of issue.

[R.Ravi]

Director

CLARIFICATIONS REGARDING VALIDITY OF INDIVIDUAL PLASTIC CARDS AT ALL CGHS WELLNESS CENTRES IN THE COUNTRY

Government of India

Ministry of Health and Family Welfare

Department of Health & Family Welfare

Nirman Bhawan, Maulana Azad Road

New Delhi 110 108

No.Misc.6024/2007/CGHS (Hq)/CGHS(P) Dated March 16,2011

Office Memorandum

Subject: Clarifications regarding validity of individual Plastic Cards at all CGHS Wellness Centres in the Country.

The undersigned is directed to draw attention to the para E (6) of Office Memorandum of even number dated 30^th December, 2009, wherein it was mentioned that after computerization of all CGHS covered cities the plastic Cards will be valid in all CGHS cities in India and there will be no need for obtaining temporary attachment while on a visit to another CGHS City.

2. In response to representations received from CGHS beneficiaries seeking clarifications, it has now been decided to further clarify that:

"Now that computerization of all CGHS covered cities has been completed the plastic Cards are valid in all CGHS cities in India and there is no need for obtaining temporary attachment while on a visit to another CGHS City. Since, the data is available online CGHS beneficiaries are permitted to obtain medicines (including indented medicines) from any Wellness Centre located in the same city, where the card is registered or from any Wellness Centre located in any other CGHS city while on a visit (Official as well as personal)."

3. The other contents of the Office Memorandum of even number dated 30^thDecember 2009 remains unchanged.

Sd/-

(R RAVI)

Director

Tel:011-2306 3483

CGEPHIS - No time frame for introduction

Central Government Employees and Pensioners Health Insurance Scheme

The Central Government is contemplating introduction of a health insurance scheme for the central government employees and pensioners in consultation with other concerned Ministries/Departments. The proposal is to make this Scheme on voluntary cum contributory basis for serving employees & pensioners except for new joinees in respect of whom it is proposed to be on mandatory cum contributory basis. No time frame can be given at this stage for its introduction.

This information was given by Union Minister of Health & Family Welfare Sh. Ghulam Nabi Azad in reply to a question in the Lok Sabha today. (11.3.2011)

REIMBURSEMENT IN RELAXATION OF RULES IN EMERGENT CASES UNDER CGHS/CS(MA) RULES, 1944

NO.S.14025/2/2011-MS

Government of India

Ministry of Health and Family Welfare

313, 'D' Wing, Nirman Bhawan, New Delhi -110108

Email: so2ms-mohfw@nic.in

Dated: 11^th January,2011

OFFICE MEMORANDUM

Sub: Delegation of powers of Head of Department to Head of Office for settling permission cases and post facto approval to reimbursement in relaxation of rules in emergent cases under CGHS/CS (MA) Rules, 1944.

The undersigned is directed to invite reference to para (ii) of this Ministry's Office Memorandum NO.S.14012/9/75-MC (MS) dated 18.06.1982, as mentioned at point 4 under Appendix-VIII of CS (MA) Rules, 1944 relating to reimbursement in relaxation of rules in emergent cases, which stipulates that powers for settling permission cases and post facto approval should not be exercised by authorities lower than Heads of Departments.

2. The Ministry of Health and Family Welfare has examined the question of further delegation of powers to Head of Offices/officers at Under Secretary level, in such offices, which are not headed by officers equivalent to a Deputy Secretary, in the matter and it has been decided with the approval of the competent authority to delegate such powers in the following manner:-

"In case of medical reimbursement, delegation of power can be given to Under Secretaries in the Departments of Central Government declared as Heads of Offices subject to the condition that upto Rs. two thousand for taking treatment in OPD and upto Rs. Five thousand for taking treatment in IPD under CGHS/CS(MA) Rules, 1944. This delegation of powers can be exercised as per the prescribed rate list of nearest CGHS covered city or actual whichever is lower for CS (MA} beneficiaries and as per package rate for CGHS beneficiaries in CGHS cities."

3. This order is applicable to both CGHS and CS(MA) beneficiaries.

4. This Office Memorandum issues with the approval of Ministry of Finance vide 10 No 14(1)/E.IIA/2010 dated 06.07.2010.

S/d

(Sanjay Pant)

Under Secretary to the Government of India.

REFERRAL OF CGHS BENEFICIARIES TO EMPANELLED SUPER-SPECIALTY HOSPITALS

No.S.11011/23/2009-CGHS D.II/Hospital Cell (Part I)

Government of India

Ministry of Health & Family Welfare

Department of Health & Family Welfare

Maulana Azad Road, Nirman Bhawan

New Delhi 110 108 dated the 7^th February2011

OFFICE MEMORANDUM

Subject: Referral of CGHS beneficiaries to empanelled Super-Specialty Hospitals

With reference to the subject mentioned above, the undersigned is directed to state that several representations have been received from CGHS beneficiaries regarding problems faced by them in obtaining permission to undergo treatment at Super-Specialty hospitals. The matter has been reviewed and it has now been decided to simplify the procedure for obtaining treatment from CGHS empanelled super-specialty hospitals .Attention is drawn to Para 6.2 of office memorandum of even number dated 17^th August 2010 wherein it was stated that

"CGHS beneficiaries have, so far, been the option to get themselves treated in any hospital of their choice. However, in view of the increased outgo on getting treatment in super-specialty hospitals, it has now been decided that CGHS beneficiaries desirous of getting treated in super-specialty hospitals, in non-emergency conditions, prior approval of the concerned Additional Director, CGHS would have to be obtained".

The above mentioned procedure is modified to read as follows:

"CGHS beneficiaries have, so far, been the option to get themselves treated in any hospital of their choice. However, in view of the increased outgo on getting treatment in super-specialty hospitals, it has now been decided that CGHS beneficiaries desirous of getting treated in super-specialty hospitals, in non-emergency conditions, prior approval of the concerned Chief Medical Officer-in-Charge, of the CGHS Wellness Centre would have to be obtained."

Sd/-

(R. Ravi)

Director

REFERRAL OF CGHS BENEFICIARIES TO EMPANELLED SUPER-SPECIALTY HOSPITALS

No.S.11011/23/2009-CGHS D.II/Hospital Cell (Part I)

Government of India

Ministry of Health & Family Welfare

Department of Health & Family Welfare

Maulana Azad Road, Nirman Bhawan

New Delhi 110 108 dated the 7^th February2011

OFFICE MEMORANDUM

Subject: Referral of CGHS beneficiaries to empanelled Super-Specialty Hospitals

With reference to the subject mentioned above, the undersigned is directed to state that several representations have been received from CGHS beneficiaries regarding problems faced by them in obtaining permission to undergo treatment at Super-Specialty hospitals. The matter has been reviewed and it has now been decided to simplify the procedure for obtaining treatment from CGHS empanelled super-specialty hospitals .Attention is drawn to Para 6.2 of office memorandum of even number dated 17^th August 2010 wherein it was stated that

"CGHS beneficiaries have, so far, been the option to get themselves treated in any hospital of their choice. However, in view of the increased outgo on getting treatment in super-specialty hospitals, it has now been decided that CGHS beneficiaries desirous of getting treated in super-specialty hospitals, in non-emergency conditions, prior approval of the concerned Additional Director, CGHS would have to be obtained".

The above mentioned procedure is modified to read as follows:

"CGHS beneficiaries have, so far, been the option to get themselves treated in any hospital of their choice. However, in view of the increased outgo on getting treatment in super-specialty hospitals, it has now been decided that CGHS beneficiaries desirous of getting treated in super-specialty hospitals, in non-emergency conditions, prior approval of the concerned Chief Medical Officer-in-Charge, of the CGHS Wellness Centre would have to be obtained."

Sd/-

(R. Ravi)

Director

Issue of individual plastic cards to CGHS Pensioner Beneficiaries

The Department of Health issued fresh guidelines to the Pensioner beneficiaries vide its memo No. 6024/2007/CGHS (HQ)/CGHS (P) dt. 27.12.2010.

The order is furnished below:

FRESH EMPANELMENT OF PRIVATE HOSPITALS AND

REVISION OF ROOM RENT APPLICABLE UNDER CGHS

No: S.11011/23/2009-CGHS D.II/Hospital Cell (Part I)

Government of India

Ministry of Health & Family Welfare

Department of Health & Family Welfare

*************

Maulana Azad Road, Nirman Bhawan

New Delhi 110 108 dated the 16th November , 2010

O F F I C E M E M O R A N D U M

Subject: Fresh empanelment of private hospitals and revision of Room Rent

applicable under CGHS.

The undersigned is directed to state that CGHS had initiated action for fresh

empanelment of private hospitals under CGHS and also for the revision of package

rates (which were fixed in 2006-07), to be paid to hospitals, by floating tender for the

same. On the basis of the responses received package rates for various procedures

/ treatments have been arrived at and have been uploaded in the website of CGHS:

www.mohfw.nic.in\cghsnew\index.asp and can be downloaded.

2. "Package Rate" shall mean and include lump sum cost of inpatient treatment /day care / diagnostic procedure for which a CGHS beneficiary has been permitted bythe competent authority or for treatment under emergency from the time of admission to the time of discharge including (but not limited to) – (i) Registration charges, (ii)Admission charges, (iii) Accommodation charges including patients diet, (iv)Operation charges, (v) Injection charges, (vi) Dressing charges, (vii) Doctor /consultant visit charges, (viii) ICU / ICCU charges, (ix) Monitoring charges, (x)Transfusion charges, (xi) Anesthesia charges, (xii) Operation theatre charges, (xiii)Procedural charges / surgeon's fee, (xiv) Cost of surgical disposables and all sundries used during hospitalization, (xv) Cost of medicines, (xvi) Related routine and essential investigations, (xvii) Physiotherapy charges etc. (xviii) Nursing care and charges for its services.

(b) Cost of Implants / stents / grafts is reimbursable in addition to package rates as per CGHS ceiling rates for Implants / stents / grafts or as per actual, in case there

is no CGHS prescribed ceiling rates.

(c) Treatment charges for new born baby are separately reimbursable in addition to delivery chares for mother.

d) The hospitals empanelled under CGHS shall not charge more than the

package rates / rates.

2.2 Package rates envisage upto a maximum duration of indoor treatment as follows:

12 days for Specialised (Super Specialties) treatment;

7 days for other Major Surgeries;

3 days for Laparoscopic surgeries / normal deliveries; and

1 day for day care / Minor (OPD) surgeries.

2.3 However, there are certain procedures where there is no prescribed package

rate under CGHS. Similarly, there are medical emergencies where the treatment is

mainly conservative. The admissible amount in such cases is calculated item wise,

room rent, procedures, investigation , etc.,.

Therefore, it has now been decided to revise the rates applicable for room rent

(Accommodation Charges) for different categories of wards as given below:

General ward -Rs.1000/- per day

Semi-private ward -Rs. 2000/- per day

Private ward -Rs.3000/- per day

3. CGHS beneficiaries are entitled to facilities of private, semi-private or general

ward depending on their basic pay / pension. The entitlement is as follows:-

S. No
Basic Pay (without the inclusion of grade pay)
Entitlement

1.
Up to Rs. 13,950/-
General Ward

2.
Between Rs.13,951/ - and Rs.19,530/-
Semi-Private Ward

3.
Rs. 19,540/- and above
Private Ward

4.2 This issues with the concurrence of Internal Finance Division in the Ministry of

Health & Family Welfare, vide Dy. No: AS & FA / 3932 /2010 dated the 8th November

, 2010.

The revised rates will come into effect from the date of issue of this Office Memorandum.

A copy of this Office Memorandum along with rate list and a copy of MOA are

placed on the internet at http://mohfw.nic.in/cghsnew/index.asp.

[R Ravi]

Director

[Tel: 2306 3483]