Health Ministry issues Guidelines to improve CGHS Medical Benefits to Govt Staff
In a move to enhance service quality and curb malpractices under the Central Government Health Scheme (CGHS), the Ministry of Health and Family Welfare has issued detailed guidelines to all CGHS-empaneled Healthcare Organizations (HCOs). The advisory, signed by Dr. Satheesh Y. H., Director of CGHS, outlines strict rules to ensure better compliance and improved experiences for beneficiaries. Non-compliance could lead to severe consequences, including blacklisting or de-empanelment.
The Central Government Health Scheme (CGHS) provides comprehensive healthcare services to Central Government employees, pensioners, and their dependents. It offers medical facilities through a wide network of wellness centers and empaneled hospitals, covering consultations, treatments, diagnostics, and medications, ensuring accessible and affordable healthcare.
Key Highlights of the Advisory
1. Service Provision: HCOs are prohibited from denying services to eligible CGHS beneficiaries. In cases of a patient’s death or if the patient is in a coma, the attendant’s signature and mobile number must be obtained on final bills for all services, including outpatient care, inpatient care, laboratory tests, and dialysis.
2. Mandatory Reporting: HCOs must report specific cases to the Additional Director’s office within 24 hours via email. These include:
- Non-referral cases.
- Emergency admissions or consultations.
- Direct admissions of beneficiaries aged 70 and above.
Failure to report will result in non-processing of approvals by the authorities.
3. Transparency in Bed Availability: HCOs must prominently display bed availability in wards and ICUs to assist visiting patients.
4. Ward Entitlement: Beneficiaries must receive treatment in their entitled ward category. Allocating a lower category is not permitted.
5. Prescription Standards: Prescriptions must be written in generic names and in capital letters. HCOs cannot insist on specific medicine brands.
6. Acceptance of CGHS Medicines: HCOs must accept medicines supplied by CGHS. If they decline, they must provide a purchase invoice for reimbursement purposes.
7. Implant and Device Costs: For implants priced above CGHS ceiling rates, beneficiaries must give informed consent, acknowledging that additional costs cannot be claimed from CGHS.
8. Information Display: HCOs must display the following prominently:
- CGHS city of empanelment.
- Charges as per CGHS-approved rates.
- Categories of beneficiaries eligible for credit, such as pensioners and ex-MPs.
- Contact details of the Nodal Officer and Additional Director CGHS.
Operational Directives
9. Nodal Officer Updates: Changes in the Nodal Officer’s details must be communicated immediately.
10. Data Entry and Photo Uploads: HCOs must ensure only the beneficiary’s phone number is entered into the portal. Geo-tagged photos of admitted patients must be uploaded daily, while same-day photos are required for OPD cases.
11. CGHS Help Desk: All HCOs must set up a CGHS Help Desk or Kiosk to assist beneficiaries.
12. Card Handling: HCOs are prohibited from collecting or retaining the physical CGHS card of any beneficiary.
13. Billing and Fraud Prevention: HCOs must adhere to CGHS-prescribed package rates and avoid overcharging. Fake billing or submission of forged documents will be treated as financial fraud, leading to legal action, including filing of an FIR.
Consequences for Violations
The ministry has warned that non-compliance with these guidelines will lead to de-empanelment, blacklisting, or other punitive actions under the Memorandum of Agreement (MoA).
Immediate Implementation
The circular has been shared with all CGHS-empaneled HCOs, government ministries, and stakeholders for immediate enforcement. The Health Ministry aims to ensure transparency and accountability in the healthcare services provided under CGHS.
