CGHS

Central Government Health Scheme (CGHS)

[1] Overview [2] Eligibility to join CGHS [3] Accrual of CGHS benefits [4] Registration to CGHS/Plastic Card [5] Contributions [6] Hospital accommodation/Free diet [7] Procedure of referral to recognised hospitals [8] Medical Advance [9] Final Claim [10] Miscellaneous

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[1] Overview

1.1    The Central Government Health Scheme (CGHS) is a contributory health scheme for serving or retired central government employees who are paid from Civil Estimates (other than Railways employee & under Delhi administration) and their dependent family members. The scheme was started in 1954 in Delhi.

1.2    Central Government Health Scheme (CGHS) is providing comprehensive medical care to the Central Government employees and pensioners enrolled under the scheme.

1.3    CGHS caters to the healthcare needs of eligible beneficiaries covering all four pillars of democratic set up in India namely- (i) Legislature, (ii) Judiciary, (iii) Executive and (iv) Press.

1.4    CGHS is the model Health care facility provider for Central Government employees & Pensioners and is unique of its kind due to the large volume of beneficiary base and open ended generous approach of providing health care.

1.5    Currently, the scheme is operational in 72 cities through 329 allopathic wellness centres and 86 AYUSH centres. The CGHS serves 12.09 lakh primary card holders and 35.72 lakh beneficiaries, out of which around 17 lakh beneficiaries belong to Delhi-NCR.

1.6     CGHS provides health care through following systems of Medicine –

(a) Allopathic

(b) Homoeopathic

(c) Indian system of medicine – (i) Ayurveda (ii) Unani (iii) Siddha and (iv) Yoga

[2] Eligibility to join CGHS

2.1    Eligibility to join CGHS facilities is discussed in successive para herein after.

2.2    All Central Government employees paid from the Central Civil Estimates (except Railways and Delhi Administration), including their dependant family members residing in CGHS covered areas.

2.3    Pensioners of Central Government (except pensioners belonging to Railways and the Armed Forces) and their families.

2.4    Central Government Pensioners retiring with Contributory Provident Fund benefits and their families.

2.5    Widows of Central Government pensioners, in receipt of family pension.

2.6    Delhi Police personnel and their families, in Delhi only.

2.7    Railway Board employees.

2.8    Civilian employees of Defence paid from Defence Service Estimates.

2.9    Child drawing pension on death of a Central Government employee including minor brothers and sisters of such child.

2.10    Ex-Governors and Lt. Governors and their families.

2.11    Ex-Vice Presidents and their families.

2.12    Central Government servants who are deputed to semi-government and autonomous bodies receiving substantial grant from, or financed by the Central Government.

2.13    Central Govt. employees on deputation to statutory or autonomous during the period of deputation.

2.14    Military Officers while on deputation to civil departments and getting their emoluments from Central Civil Estimates.

2.15    Families of Governments servants transferred to a non-CGHS area, for a maximum period of six months on deposit of CGHS contribution (for the period of 6 months) in advance.

2.16    Families of IAS Officers on North-Eastern Cadre, who continue to stay back in Delhi even after repatriation of the IAS Officer to the North-Eastern Cadre, provided that they continue to occupy Government accommodation in Delhi or New Delhi, on deposit of CGHS contribution in advance (one to three years). The same also applies to families of IAS Officers of J&K Cadre.

2.17    Parliamentary Secretaries of the Central Government and their families.

2.18    Members of Parliament and their families.

2.19    Ex-Members of Parliament.

2.20    Sitting Judges of Supreme Court and High Court of Delhi and former Judges of Supreme Court and High Courts.

2.21    Work Charged and Industrial Staff working in establishments run by various Ministries or Departments of Central Government, immediately from the date of their joining the service.

2.22    Employees of Kendriya Vidyalays Sangathan stationed at Delhi and NCR, Kolkata, Chennai, Hyderabad, Mumbai and Bengaluru.

2.23    Employees of Ordnance Factory Board Headquarters, Kolkata and Ordnance Equipment Factories Headquarters, Kanpur.

2.24    All India Service pensioners who retire while serving under the State at their option.

2.25    Freedom Fighters and members of their family receiving Central Pension under the Swatantrata Sainik Samman Pension Scheme.

2.26    Family members of the Deceased Ex-Members of Parliament.

2.27    Pensioners of Ordnance factories.

2.28    Members of Staff Side of the National Council of the Joint Consultative Machinery, even though not serving as Central Government employees.

2.29    Persons employed in semi-government and autonomous bodies who are permitted to join the CGH Scheme.

2.30    An Accredited Journalist who produces a certificate from the Press Council of India stating that he is a member of the Press Association, New Delhi (for OPD and at RML Hospital).

2.31    Retired Divisional Accountants of the Indian Audit and Accounts Department and those whose pay and pension are entirely borne by the State governments.

2.32    PSU absorbees who had commuted 100 percent of their pension and have been restored one third portion of their pension after 15 years.

2.33    Absorbees of Statutory Bodies or Autonomous Bodies of Central Govt. (including those who proceeded on deputation initially or were on deemed deputation and then absorbed), who are in receipt of Central Civil Pension.

2.34    Serving and retired Railway Audit Staff.

2.35    Serving and retired Divisional Accounts Officers and Divisional Accountants posted in the Office of Accountant Generals in States.

2.36    CISF personnel (and their families) and CAPF (Central Armed Police Forces) personnel posted in CGHS cities.

2.37    Employees of Supreme Court Legal Services Committee.

2.38    Employees of India Pharmacopoeia Commission, and their families.

2.39    Family and dependent members of a Central Govt. employee (a CGHS beneficiary) who stay back in CGHS covered area after posting of the employee to N.E. region (including Sikkim), Andaman and Nicobar Lakshadweep or Ladakh region and CAPF personnel posted in Left Wing Extremist areas, on payment of annual CGHS contribution in advance.

2.40    Defence Industrial Employees of Naval Dockyard Central Ordnance Depot and AFMSD, in Mumbai.

2.41    Eligibility Criterion: Residence alone (and not the Headquarters) is the criterion for determining eligibility of a Central Government servant for availing medical facilities under the Central Government Health Scheme. Thus, Central Government employees and their family members etc. residing in any of the notified cities are covered under the Scheme.

2.42    Central Government servant should reside in the area covered by the CGHS scheme. This condition is not mandatory for Pensioners. Pensioners can get their names registered with any of the dispensaries, whether they were residing in that city or not.

[3] Accrual of CGHS benefits

3.1    The benefits of CGHS accrue from the date on which the Government servant applies for a CGHS card.

3.2    CGHS is is a compulsory scheme for all Central Government employees residing within the areas covered by CGHS dispensaries.

3.3    As soon as a person joins Central Government service and intimates his residential address which is within a CGHS covered area, CGHS contribution at the appropriate rate should be recovered whether the CGHS card is issued or not.

3.4    In case of Para 4.3, in such cases, the offices concerned should ensure that the employee/Government servant applies for a card and if he is not applying despite intimation, suitable action should be taken [MoHFW OM dtd: 15/06/2004].

3.5    A Government servant who is covered under this CGHS scheme and whose spouse is employed in Defence or Railway Services, State Government or Corporations or Bodies financed partly or wholly by the Central Government or State Government, Local Bodies and Private Organizations which provide medical facilities can opt out of the Scheme and avail of the medical facilities provided by the employer of the spouse.

3.6    If a Government Servant or a member of his/her family covered under CGHS falls ill at a place not covered under CGHS, treatment shall be admissible under CS(MA) Rules.

3.7    Permanently disabled unmarried sons (both physical and mental/schizophrenia illness) who are financially depended on CGH
S beneficiary and residing with CGHS beneficiary and suffering from 40% or more of disabilities are eligible to avail CGHS facilities. After every 5 (Five) years, the CGHS beneficiary should furnish a disability certificate issued by the appropriate authority to CGHS [MoHFW OM dtd: 02/08/10, 03/09/10, 04/11/10, 26/05/11 & 07/05/2018].

3.8    Permanently disabled unmarried brothers who are financially dependent on and residing with the principal CGHS Cardholder and suffering from 40% or more of disabilities are also eligible to avail CGHS facilities subject to fulfilment of other conditions [MoHFW OM dtd: 25/07/2013].

3.9    Minor children of widowed/separated daughters who are residing with and dependent upon CGHS beneficiary are also eligible for medical facilities w.e.f. 19/01/2012 up to the age of 18 years. Once he becomes major, such facilities shall be deemed to be seized [MoHFW OM dtd: 19/01/2012].

[4] Registration to CGHS/Plastic Card

4.1    All the CGHS beneficiaries and their dependants are now provided with photo ID plastic cards individually with unique beneficiary ID number which need to be produced at each service point to avail the facilities.

4.2    Procedure to get a CGHS Card: Eligible serving employees/Pensioners/Family Pensioners require to apply in the prescribed form through online portal (available on CGHS web portal www.cghs.nic.in and website www.cghs.gov.in and also in the wellness centres). The form should be completely filled up with individual photographs pasted as specified in the form.

4.3    Documents required (For serving employee): Following documents are required by serving Government servant. List is given below:

(a) Proof of residence.
(b) Proof of stay of dependents.
(c) Proof of age of son.
(d) In case of differently abled dependent son above 25 years, disability certificate from competent authority as specified.

4.4    Documents required (For Pensioners/Family Pensioners): In addition list of documents mentioned at Para 5.3 above, following documents are required:

(i) Surrender certificate of CGHS Card (only if CGHS Card was issued during Service Period).
(ii) Attested copies of PPO/Provisional PPO/Last Pay Certificate (in case PPO is not readily available immediately after retirement.).
(iii) Demand Draft in the name of “PAO CGHS New Delhi”.
The amount of Demand Draft will be for contribution due to be paid as discussed in Para 6 as the case may be.

4.5    Channel of submission: In case of serving employees, the application is to be submitted through the department after due endorsement. In case of Pensioners, the application with enclosures are to be submitted to the concerned Addl. Director of the city (CGHS covered city viz. Jabalpur, Nagpur etc.).

4.6    Application with enclosures (Discussed in Para 5.3 & 5.4) and Demand Draft (DD) are to be forwarded to the CGHS through the office of the employee.

4.7    Provision for making pensioner CGHS card while in Service: A serving employee can apply for a pensioner CGHS Card along with his pension papers. The pensioner Card will be issued on the day of retirement subject to the condition that it is applied for at least six weeks before retirement/superannuation date and will get activated from next day.

4.8    Process of Online Application for CGHS Card: The card can be applied online by visiting CGHS web portal www.cghs.nic.in or CGHS website www.cghs.gov.in.

However, at present, provision for uploading the supporting documents is not available. Hence, after online submission of the application, the applicant is required to take a print out of the application and submit it with supporting documents (duly endorsed by the Head of the Department/Office in case of serving employees) in the office of the Additional Director HQ in Delhi or Additional Director in other cities.

4.9    As soon as the Application for CGHS card is accepted at the CGHS Card Section, an acknowledgment letter is issued to the applicant mentioning the card number and the Ben ID of all family members. The plastic cards are available after one month of the application at the parent wellness centre of the card holder.

In the meantime, the acknowledgment letter can be used to avail the facilities from the Wellness centre.

4.10    Addition/Deletion of names in CGHS Cards: Addition or deletion of names in CGHS cards can be done easy as and when required. The process is discussed as follows:

(a) On the death of the main card holder, the card becomes invalid and fresh card is required to be applied for by the spouse after he/she starts drawing the family pension. Old CGHS card and a Death Certificate need to be attached with the application.

(b) A serving Government servant on marriage or on the birth of his/ her child may get the names of spouse/child added to the card after submitting the form for addition duly endorsed by his department.

(c)    After the death of spouse and death/marriage/employment of a son/daughter/dependent it is the responsibility of main card holder to inform CGHS for necessary deletion of the card.

4.11  Validity of the CGHS Card: (a) The service card will be valid till the date of retirement if otherwise the employee is eligible.

(b) In case of yearly contribution pensioner cards, in order to continue validity, contribution is to be made prior to completion of the continuing year.

(c) In case of transfer of serving employee to a non CGHS covered area the service card will be valid for the family members up to six months after transfer provided that CGHS contribution for 6 months is made beforehand.

(d) CGHS card is valid in all CGHS cities for treatment/investigation/Hospitalization. There is no need for transit permit to get treatment in another CGHS city except for receiving high value medicines classified as “lifesaving”/restricted supply medicines for which temporary attachment to a wellness centre is required.

4.12    Transfer of CGHS Cards: (i) In case of serving CGHS beneficiary transferred from one department /ministry to another in the same city, the same CGHS card will continue. The new department/ministry will duly inform CGHS so that necessary changes can be made in the database of the employee.

(ii) In case of transfer of a serving CGHS beneficiary from one CGHS covered city to another, again the same CGHS card will continue. The employee will submit an application along with the transfer orders, to the Addl. Director of his/her present CGHS city for transfer of card to new city of posting. The card will be transferred online to his new city of posting. Thereafter, on joining in new city, he will submit an application with supporting documents to the Addl. Director of that CGHS city to validate his card.

4.13    Pensioners residing outside CGHS covered area can opt for a regular CGHS Card or an IPD (Indoor treatment) CGHS Card with fixed medical Allowance in lieu of OPD treatment) from the nearby CGHS city. IPD card holders will not be eligible for OPD treatment & issue of medicines from CGHS Wellness Centres.

4.14    Self-printing of CGHS Card (Para 5.24 – 5.15): A beneficiary can also self-print his/her and his/her dependents cards online through Beneficiary login. This e-CGHS Card is equivalent to the Plastic Card. After downloading the card in PDF format beneficiary can take a colour print out and get it laminated for further use.

4.15    The beneficiary can print his/her or family members card using following steps

(a) Visit CGHS portal cghs.nic.in

(b) Click Beneficiary Login

(c) Enter your Ben ID, password and sign in

(d) Click Print card for the beneficiary whose card needs to be printed

(e) Enter the onetime password sent on your registered mobile

(f) Click Print CGHS Card

(g) A message appears on the screen requesting to take a coloured print out and get the card laminated. Click OK

(h) Download or open the eCGHS card in PDF format

(i) Print the eCGHS card using control P command.

4.16    A beneficiary may use an eCGHS card for availing health care facilities. The credentials of the beneficiaries can be verified by the HCOs through the computer database using the beneficiary ID number, if required.

4.17    Safe custody of the CGHS Cards is the responsibility of the beneficiary and in case of loss of the card beneficiary is required to inform the police and CGHS authorities.

4.18    Duplicate CGHS card can be obtained against lost card by applying for the same to the concerned Additional Director along with a copy of FIR and will be charged Rs. 50/-

4.19    A retired/superannuated Government servant who does not join CGHS immediately after retirement/superannuation has to pay Rs. 30/-, if he subsequently desires to get himself/herself registered with CGHS and apply for CGHS card.

4.20    Compassionate appointees holding Family Pensioner CGHS card can apply for serving CGHS card as per their present higher entitlement, subject to certain conditions [MoHFW OM dtd: 19/09/2016].

[5] Contributions

5.1    Serving Government Servant: Since, CGHS is a scheme based on contribution. Serving Government servant required to subscribe to get the facility of this scheme. Government defined certain monthly subscription fee corresponding to Pay Leval (As per 7^th CPC) w.e.f. 1^st February 2017 and the same are tabulated below:

5.2    The monthly subscription amount is deducted from monthly salary of the Government servant through Regular Pay Bill. Such deduction is made during the period of duty, suspension period and leave (other than EOL) not exceeding 4 (Four) months. If leave exceeding 4 (Four) months, the Government Servant has the option not to pay the contribution in which case, the facility of CGHS shall be terminated.

5.3    If any Government servant promoted/granted NFSG with retrospective date, the amount of subscription shall be changed w.e.f. the issue of such order only.

5.4    Pensioners/Family Pensioners: In case of Pensioners or Family Pensioners, there are two ways to join CGHS – (i) Annual subscription basis (Calendar year) & (ii) Life-time subscription basis.

5.5    (i) Annual subscription is based on the subscription table mentioned at Para. 5.1 above. Annual CGHS subscription is collected up to the month of December next year if an employee superannuated/retired in the middle of the year.

Example: Date of Superannuation/Retirement = 31/05/2020. Pay Level = 6. Date of subscription to CGHS = 01/06/2020. His initial annual membership will be collected up to 31/12/2021 @ Rs. 450 P.M. = 450 x 19 = 8550/-. Beyond 31/12/2021, it will be charged from January to December.

5.6    (ii) The lifetime membership registration in CGHS is based on a very simple calculation.  Pensioners have to pay the subscription (according to pay level as per 7th CPC) amount for 10 (Ten) years (120 months) as one-time payment for a lifetime membership.

Example: If a pensioner retired in the pay level of 6 and he wants to join in the scheme of CGHS for a lifetime membership. To obtain the CGHS card, he has to pay the amount for 120 months of subscription. A total of Rs. 54,000 (120 x 450=54000).

5.7    One-time subscription amount for life time registration to GCHS member card is tabulated below:

5.8    Registration of Pensioners to CGHS: All Government servants who are entitled to avail the facility of CGHS whether they were availing such facility before retirement/superannuation are eligible for CGHS facility after retirement/superannuation. It is not necessary that the Pensioner/Family Pensioner should be living in the areas covered under CGHS Scheme.

5.9    Family pensioners can avail CGHS only for the dependent of the deceased CGHS beneficiary [MoHFW OM dtd: 26/05/1999].

5.10    Pensioners/Family Pensioners have the option to get their names registered with any of the dispensaries in available CGHS covered cities. These days it is applied through online.

[6] Hospital accommodation/Free diet

6.1    As per Ministry of Health & Family Welfare OM No. S.11011/11/2016- CGHS (P)/EHS dtd: 09/01/2017, pay limit for entitlement of Hospital accommodation/Nursing home facilities and Free diet are as follows:

6.2    Nursing Home facilities in Government/State Government/Municipal Hospitals available for those drawing Pay/Pension/Family pension Rs. 47,600 p.m. and above.

6.3    Free diet entitlements:

[7] Procedure of referral to recognised hospitals

7.1    The beneficiaries (including pensioners) have option of availing specialised treatment at CGHS recognised hospitals of his/her choice after a Specialist of CGHS/Government hospital recommends for the same. No advance permission is required in case of emergency.

7.2    After the recommendations, the procedure for obtaining Administrative approval are as follows:

(a) Permission letter is always required to be issued before the patient visits the CGHS hospitals/Higher CGHS hospitals or wellness centre.

(b) Documents required: (i) Xerox of valid CGHS token card. (ii) A request letter from the beneficiary indicating the choice of hospital. (iii) Xerox of prescription from Government Hospital Specialist/CGHS specialist.

7.3    In case of pensioners, for treatment in another city when such facilities are not available in the same city, Head of the CGHS may grant permission on the specific advice of the Specialist. T.A. may be limited to referral hospitals available in the nearest city for the shortest route.

7.4    Expenditure to be reimbursed by the CGHS Directorate, would be restricted to the package deal rates/rates approved by the Government. Excess expenditure, if any, would be borne by the beneficiary.

7.5    If no CGHS rate is prescribed/fixed for any treatment, the Head of the Department/CGHS of the city may grant up to Rs. 20,000 as per recommendation of the Government specialist limited to AIIMS rate. If no AIIMS rate is prescribed, then the actual expenditure will be reimbursed.

[8] Medical Advance

8.1    For indoor treatment: 90% Medical advance of the approved CGHS package rates on receipt of estimate.

8.2    For outdoor treatment: Advance is limited to 90% of the total estimated expenditure, if total estimate of expenditure including tests/investigation is more than Rs. 10,000/-.

8.3    The advance to be released within 10 days of receipt of the request for advance by the Administrative Department/Ministry/Office [MoHFW OM dtd: 17/10/2016].

[9] Final Claim

9.1    For serving Government servants: Please refer Para – 15 of CM(MA).

9.2    For Pensioners/Family Pensioners: CGHS wellness centre which issued CGHS card to the Pensioner/Family Pensioners works same as the department/office works for a serving Government servant.

9.3    Pensioners/Family Pensioners require to submit their final claim to the CMO in-charge of the CGHS wellness Centre, where the CGHS Card is enrolled. CMO in-charge issues Serial Number and sends the claim papers to the office of the Additional Director, CGHS for processing. After the approval of the Additional Director, the bill for payment shall be sent to the Pay and Accounts Officer for payment to the beneficiary. The payment shall be completed within 30 days of submission of the medical final claim.

[10] Miscellaneous

10.1    CGHS beneficiaries above the age of 80 years have special provisions – (a) No need to stand in a queue. (b) CGHS Doctors shall enquire by phone, at least one in a month to enquire about their wellbeing/make home visit if residing within 5 km of CGHS wellness centre. (c) Speedy settlement of medical claims out of turn.

10.2    for NPS candidates: Minimum years of qualifying service for eligibility of CGHS membership after retirement is 10 (Ten) years.

10.3    No minimum qualifying years of service for availing CGHS facilities in case of death/disability.

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