The much hyped Central Government Employees
Personal Health Insurance Scheme (CGEPHIS)which was proposed by Health Ministry
from the year 2009, as an alternate to presently existing Health related
Schemes for Central Government Employees such as CGHS, Medical Attendance Rules
etc, is still a non-starter for reasons known only to the Govt.
The following are the features of CGEPHIS :
Beneficiaries
- All
personnel of the Central Government including All India Service officers,
serving, newly recruited, retired and retiring and others who are covered
under the existing CGHS(Central Government Health Services) and
under CS (MA) [Central Services (Medical Attendance) Rules] Rules shall be
offered Health Insurance Scheme on voluntary or on compulsorily
basis . This could be:
- CGEPHIS
shall be compulsory to new Central Government Employees who would be
joining service after the introduction of the health Insurance Scheme.
- CGEPHIS
shall be compulsory to new Central Government retirees who would be
retiring from the service after the introduction of the Insurance Scheme.
- CGEPHIS
would be available on voluntary basis for the existing Central Government
Employees and pensioners serving in CGHS area/ covered by CGHS. In this
case such serving Central Government Employees and Central Government
existing Pensioners shall have to opt out of CGHS scheme. They will also
have the option of choosing both CGHS and Insurance policy. In such case
the total premium has to be born by the beneficiary.
- CGEPHIS
would also be available on voluntary basis for the existing serving
employees and pensioners in non-CGHS areas not covered by CGHS. In this
case such serving Central Government Employees and existing Pensioners
(who have opted for CGHS facility) shall have to opt out of CGHS scheme.
They will also have the option of choosing both CGHS and Insurance policy.
In such case the total premium has to be born by the beneficiary.
The proposals relating to sum assured/policy
limits, family size, age limit, Insurance coverage are as follows
Sums Insured / Policy Limits
The scheme shall provide coverage for meeting
all expenses relating to hospitalization of beneficiary members up to Rs. 500,000/-
per family per year subject to stated limits on cashless basis through smart
cards. The benefit shall be available to each and every member of the family on
floater basis i.e. the total reimbursement of Rs. 5 .00 lac can be availed by
one individual or all members of the family. The document also says the
Government has proposed to restrict the benefit in respect of Domiciliary
hospitalization and Maternity to Rs.50,000/- for each admission
Family Size / Age Limit
- Serving
Employees: Self, spouse, two dependent children and dependent parents (New
born shall be considered insured from day one).
- Retired
Employees: Self, spouse and one dependent child.
- Additional
dependent family member can be covered under the scheme by paying the
fixed percentage of premium per additional dependent family member. The
premium shall be borne by the beneficiary.
- All
beneficiaries shall be insured till survival.
- The
definition of dependent shall be as per guidelines issued by Central Government.
Insurance Coverage
In addition to the coverage afforded under a
standard medical insurance policy, the following shall also be covered under
CGEPHIS:
- Pre-existing
diseases
- Maternity
benefit
- Day-one
Coverage for all diseases
- New-born
babies
- Pre
and Post hospitalization cover of 30 days and 60 days respectively
- Domiciliary
Hospitalization
Now, as per the news flashed in the Indian
Express, Health Ministry taken up CGEPHIS proposal to terminate CGHS.
The health ministry has moved a proposal for
ending the Central Government Health Scheme (CGHS) in its
current form and moving to an insurance-based scheme — the
Central Government Employees and Pensioners Health
Insurance Scheme (CGEPHIS) — in an apparent attempt to cut costs.
Instead of the government directly
paying the medical bills of CGHS beneficiaries, the new scheme will
be implemented through insurance companies registered with the Insurance
Regulatory and Development Authority and selected through bidding.
Currently, under
CGHS, government employees pay Rs 6,000 annually as fixed medical
allowance (FMA). The new FMA for beneficiaries is yet to be calculated. While
the government’s actual financial commitment will depend on bids and the
new FMA, the ministry is working on a presumptive figure of Rs 14,000 per
family, which works out to approximately Rs 1,000 crore annually.
The scheme will cover medical
expenses up to Rs 5 lakh per family per year. Beyond that, the insurer will
have to get clearance from the nodal agency on a case to case basis.
An additional sum insured of Rs 10 crore in each of the four zones
will be provided by the insurer as buffer for such cases. The CGHS in its
present form does not have any annual cap, but each procedure has a prescribed
maximum limit for reimbursement. While a note for the Expenditure Finance
Committee (EFC) was circulated last year, a fresh proposal incorporating inputs
from various departments including the DoPT, erstwhile Planning Commission and
Ministry of Statistics and Programme Implementation has been sent to the
finance pision of the health ministry.
While existing employees can choose between
CGHS and CGEPHIS, the new scheme will be made compulsory for new
employees.
Sources in the health ministry said the
proposal dates back to 2011, when the committee of secretaries gave its
in-principle approval. The proposal was revived after the
NDA government took charge. Former Health Minister Dr Harsh Vardhan,
however, was opposed to the idea. According to sources, Vardhan was of the
opinion that the change would actually mean a higher burden on the exchequer.
The annual CGHS bill has increased in the past few years, rising from Rs 987.75
crore in 2008-09 to Rs 1755.62 crore in 2013-14. The average expenditure per
beneficiary adds up to Rs 4,787 (which means about Rs 23,000 for a
family of five) — Rs 11,955 for pensioners and Rs 2,096 for serving
employees.
The total number of CGHS beneficiaries is
36,67,765. Besides serving and retired government employees, this
includes former vice-presidents, former prime ministers, MPs and former MPs,
sitting and retired judges of the Supreme Court, PIB accredited journalists,
railway board employees, Delhi Police personnel in Delhi and employees and
pensioners of 60 autonomous/ statutory bodies.
Under CGEPHIS, the OPD needs will be met by
the FMA. While the CGHS covers only 25 cities, the new scheme will be
pan-India. This would automatically increase the financial commitment. All
diseases, including pre-existing ones, will be covered, and in case of
transplants, the expenses incurred for the donor or processing of cadaver organ
will also be covered. Interestingly, the Rashtriya Swasthya Bima Yojana, which
was run by the labour ministry so far, will be under the health ministry from
April 1, as it moves from an insurance-based scheme to a
trust-based scheme.
Source: The
Indian Express
