CGHS Clarification regarding Referral of beneficiaries to empaneled super specialty hospitals
Ministry of Health Order regarding CGHS
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."
CGEPHIS is Central Government Employees and Pensioners Health Insurance Scheme.
1. Name of the Scheme:
Central Government Employees and Pensioners Health Insurance Scheme.
2. Who Can Join ?
All Central Government Employees and Pensioners.
Compulsory to those who will join after the introduction of CGEPHIS. Existing employees and pensioners who are already CGHS beneficiaries have to opt out of CGHS.
3. Current Target
Approx 17 Lakhs Central government employees and 7 Lakhs pensioners.
4. Insurance Coverage for Treatment
a) In-patient benefits in which insurance scheme will pay all the expenses for the medical treatment in empanelled hospitals.
b) Coverage of Pre-existing diseases.
c) Pre & Post hospitalization benefit.
d) Domiciliary Hospitalization.
e) Day Care Procedures.
f) Maternity and Newborn Benefits.
5. Family Size
Serving/Retired Employees: Self, Spouse, Two dependent children and up to Two Dependent Parents. Any additional dependent member in addition to above can be covered under the Scheme by paying the fixed amount of premium.
6. Age Limit of Dependant Members
a) Son – 25 years or till starts earning.
b) Daughter – Till get married.
c) Sisters – Dependent unmarried /widowed / divorced/ abandoned / separated from their husband.
d) Daughter in law – Widowed irrespective of age limit.
e) Brothers – Up to the age of becoming a major.
f) Dependent Parents – As per condition of eligibility.
7. How to Identify Family ?
Beneficiaries shall be identified by a “Photo Smart Card” issued by the insurer to all beneficiaries which would have all personal details, medical history, policy limits etc. of the CGEPHIS members. .
8. What is the sum Assured for the Insurance Premium ?
Up to 5 Lakhs per family per year in any empanelled hospital.
9. What is the Buffer/ Corporate sum insured ?
Rs 25 Crore shall be provided by the insurer additionally if expense exceed Rs 5 Lakhs for the family.
10. Who are the Health Service Providers ?
Public and Private Health Providers which provide hospitalization and/or a Day Care Services would be eligible for inclusion under the
CGEPHIS.a) General Hospitals having 100 or more beds.
b) Specialty Hospitals.
c) Super Specialty Hospitals having more than 150 beds.
d) Cancer Hospitals.
11. Entitlements for various types of wards
SL NO
PAY DRAWN IN PAY BAND/ BASIC PENSION
ENTITLEMENT
1
Upto Rs. 13,950/-
General Ward
2
Rs. 13,960/- to 19,530/-
Semi-Private
Ward3
Rs. 19,540/- and above
Private Ward
12. Enrolment
The process is taken by the insurance company and shall issue a photo smart card to the CGEPHIS beneficiaries. The enrolment period in the first year shall be for 180 days in the case of retired employees and 60 days in case of serving employee.
13. Call Centre Service
The Insurer shall provide dedicated telephone services for the guidance and benefit of the CGEHIS beneficiaries whereby the Insured Persons shall receive guidance about various issues by dialing a National Toll free number exclusively for this scheme.
14. Nodal Ministry
The Ministry of Health & Family Welfare would be the Nodal Agency
for the implementation of CGEPHIS.
