GENERAL INSTRUCTIONS FOR HOSPITALISATION

 

1.      “Package Rate" shall mean and include lump sum cost of inpatient treatment / day care / diagnostic procedure for which a CGHS beneficiary has been permitted by the 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) Anaesthesia 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.

 

§  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.

§  Treatment charges for new born baby are separately reimbursable in addition to delivery charges for mother.

§  The hospitals empanelled under CGHS shall not charge more than the package rates / rates.

 

2.      Package rates envisage up to 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.

 

3.      However, if the beneficiary has to stay in the hospital for his / her recovery for a period more than the period covered in package rate, in exceptional cases, supported by relevant medical records and certified as such by hospital, the additional reimbursement shall be limited to accommodation charges as per entitlement , investigations charges at approved rates, and doctors visit charges (not more than 2 visits per day per visit by specialists / consultants) and cost of medicines for additional stay).\

 

4.      No additional charge on account of extended period of stay shall be allowed if that extension is due to infection on the consequences of surgical procedure or due to any improper procedure and is not justified.

 

5.      CGHS beneficiaries are entitled to facilities of private, semi-private or general ward depending on their basic pay / pension.

 

6.      Entitlement of wards in private hospitals empanelled under CGHS (Based on basic pay in pay band):

 

S No

Ward Entitlement

Corresponding Basic pay drawn by the officer in
7th CPC per month

1

General Ward

Up to Rs. 47,600/-

2

Semi Private Ward

Rs. 47,601 to 63100/-

3

Private Ward

Rs. 63101 and above

 

 

7.      The package rates are for semi-private ward.

 

8.      It has now been decided that the CGHS beneficiaries taking treatment in the empanelled hospitals will be entitled for reimbursement /treatment on credit as per the package rates / rates. The package rates are for semi-private ward. If the beneficiary is entitled for general ward there will be a decrease of 10% in the rates; for private ward entitlement there will be an increase of 15%. However, the rates shall be same for investigation irrespective of entitlement, whether the patient is admitted or not and the test per se does not require admission to hospital.

 

9.      A hospital empanelled under CGHS, whose normal rates for treatment procedure / test are lower than the CGHS prescribed rates shall charge as per the rates charged by them for that procedure / treatment from a non-CGHS beneficiary and will furnish a certificate to the effect that the rates charged from CGHS beneficiaries are not more than the rates charged by them from non-CGHS beneficiaries.

 

 

10.  Private ward is defined as a hospital room where single patient is accommodated and which has an attached toilet (lavatory and bath). The room should have furnishings like wardrobe, dressing table, bed-side table, sofa set, carpet, etc. as well as a bed for attendant. The room has to be air-conditioned.

 

11.  Semi Private ward is defined as a hospital room where two to three patients are accommodated and which has attached toilet facilities and necessary furnishings.

 

 

12.  General ward is defined as halls that accommodate four to ten patients.

 

13.  Normally treatment in higher category of accommodation than the entitled category is not permissible. However, in case of an emergency when the entitled category accommodation is not available, admission in the immediate higher category may be allowed till the entitled category accommodation becomes available. However, if a particular hospital does not have the ward as per entitlement of beneficiary, then the hospital can only bill as per entitlement of the beneficiary even though the treatment was given in higher type of ward.

 

 

14.  In case of non-emergencies, the beneficiary shall have the option of availing specific treatment / investigation from any of the empanelled hospitals of his / her choice (provided the hospital is empanelled for that treatment procedure / test), after the same has been advised by CGHS Medical Officer/ Government Specialist and permission is obtained from the competent authority.

 

15.  The empanelled hospitals shall honour permission letter issued by competent authority and provide treatment / investigation facilities as specified in the permission letter.

 

 

16.  Hospitals shall provide credit facility to the following categories of CGHS beneficiaries (including dependant family members, whose names are entered on CGHS Card) on production of valid permission letter:

Members of Parliament; Pensioners of Central Government drawing pension from central estimates; former Vice-presidents, Former Governors and former Prime Ministers; Ex-Members of Parliament; Freedom Fighters; serving CGHS employees; serving employees of Ministry of Health & Family Welfare (including attached / subordinate offices under the Ministry of Health & Family Welfare); and such other categories of CGHS cardholders as notified by the Government.

 

17.  Bills should be submitted to the Office of the Rajya Sabha Secretariat/ Lok Sabha Secretariat in case of sitting Members of Parliament. Bills of Pensioners and other categories eligible for credit are to be sent to The Office of The Additional Director, CGHS, Bangalore, once in a month.

 

18.  The hospitals shall extend credit facility to the above categories of CGHS beneficiaries under emergency / with prior permission irrespective of the CGHS city where they are registered and send the bill to Additional Director, CGHS, Bangalore.

 

 

19.  Bills of serving employees of the Ministry of Health & Family Welfare and the employees if attached / subordinate offices under the Ministry of Health & Family Welfare will be sent to the concerned office.

 

20.  In case of emergencies empanelled hospitals shall not refuse admission nor demand payment from CGHS beneficiaries on production of valid CGHS card, issued by competent authority of any CGHS City.

 

 

21.  Reimbursement in case of pensioners, former Governors, former Vice Presidents, ex-MPs, Freedom Fighters, etc., is made by CGHS and by Rajya Sabha Secretariat / Lok Sabha Secretariat in case of sitting Members of Parliament and by concerned Ministry / Department/ Organisation in case of serving Govt. employees, serving employees and pensioners of autonomous bodies covered under CGHS.

 

22.  Serving Central Government employees and their dependent family members not covered by the CGHS will not be denied treatment at package rates if they approach the hospitals with a proper referral letter from the Ministry / Department in which they are working, after verifying the genuineness of the employee by production of his / her valid identity card issued by the appropriate authority.

 

 

23.  Serving Central Government employees and their dependent family members not covered by the CGHS will not be denied treatment at package rates if they approach the hospitals in emergency condition to the patient. The treatment will be given after verifying the genuineness of the employee by production of his / her valid identity card issued by the appropriate authority.

 

24.  During In-patient treatment of the CGHS beneficiary, the hospital will not ask the beneficiary or his / her attendant to purchase separately the medicines / sundries /or accessories from outside and will provide the treatment within the package rate, fixed by the CGHS which includes the cost of all the items.

 

 

25.  In case of treatment taken in emergency in any non-empanelled private hospitals, reimbursement shall be considered by competent authority at CGHS prescribed packages / rates only.

 

26.  If one or more minor procedures form part of a major treatment procedure, then package charges would be permissible for major procedure and only at 50% of charges for minor procedure.

 

27.  Any legal liability arising out of such services, responsibility solely rests on the hospital and shall be dealt with by the concerned empanelled hospital themselves.

 

The above list is not exhaustive and is subject to revision from time to time based on Government orders.