No: S.11011/23/2009-CGHS D.II/Hospital Cell (Part I)
Government of India
Ministry of Health & Family Welfare
Department of Health & Family Welfare
*************
Maulana Azad Road, Nirman Bhawan
New Delhi 110 108 dated the 17th August, 2010
OFFICE MEMORANDUM
Subject: Fresh empanelment of private hospitals and revision of package rates applicable under CGHS, Delhi.
The undersigned is directed to state that CGHS had initiated action for fresh empanelment of private hospitals under CGHS, Delhi (which covers areas in Delhi, Faridabad, Gurgaon, Ghaziabad and NOIDA) and also for the revision of package rates (which were fixed in 2006), to be paid to hospitals, by floating tender for the same. On the basis of the responses received rates for various procedures / treatments have been arrived at and have been uploaded in the website of CGHS: www.mohfw.nic.in\cghsnew\index.asp and can be downloaded.
2. In order that CGHS beneficiaries get treatment from well maintained and run hospitals, it has been decided to have differential rates of reimbursements, as per details given in the enclosed rates list. The principle followed for the differential package rates being:
(i) where L-1 rates were arrived at on the basis of rates quoted by non-NABH accredited hospitals / super-speciality hospitals, NABH accredited hospitals will be entitled to reimbursement of certain percentage of additional amount over and above the L-1 rates;
(ii) where L- 1 rates were arrived at on the basis of rates quoted by NABH accredited hospitals, then non-NABH accredited hospitals would be entitled to an amount lower by certain percentage than the reimbursement made to NABH accredited hospitals at L-1 rates; and
(iii) Rates for super-speciality hospitals have been identified separately and notified in the rate list put on the website of the CGHS. Super-speciality hospitals covered under this category are:
- (1) Cardiology & Cardio-thoracic surgery
- (2) Joint replacement surgery made under orthopaedics
- (3) Nephrology & Urology including renal transplantation;
- (4) Endocrinology;
- (5) Neurosurgery;
- (6) Gastro-enterology & GI surgery; and
- (7) Oncology
3.1 “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) Anesthesia 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.
(b) 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.
(c) Treatment charges for new born baby are separately reimbursable in addition to delivery chares for mother.
d) The hospitals empanelled under CGHS shall not charge more than the package rates / rates.
3.2 Package rates envisage upto 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.
3.3 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).
3.4 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.
4.1 CGHS beneficiaries are entitled to facilities of private, semi-private or general ward depending on their basic pay / pension. The entitlement is as follows:
| S. No | Basic Pay (without the inclusion of grade pay) | Entitlement |
| 1 | Upto Rs. 13,950/- | General Ward |
| 2 | Between Rs.13,951/- and Rs.19,530/- | Semi-Private Ward |
| 3 | Rs. 19,540/- and above | Private Ward |
4.2 The package rates for semi-private ward.
4.3 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.
4.4 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.
5.1 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.
5.2 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.
5.3 General ward is defined as halls that accommodate four to ten patients.
5.4 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.
6.1 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 I other Government Specialist I CMO in-charge and permission is obtained from the competent authority.
6.2 CGHS beneficiaries have, so far, been given the option to get themselves treated in any hospital of their choice. However, in view of the increased outgo on getting treatment in super-speciality hospitals, it has now been decided that CGHS beneficiaries desirous of getting treated in super-speciality hospitals, in non-emergency conditions, prior approval of the concerned Additional Director, CGHS would have to be obtained.
6.3 Permission for treatment, other than those covered by para 6.2 above, is granted by CMO in-charge / Additional Director / Joint Director, CGHS in case of pensioners, former Governors, former Vice-Presidents, ex-MPs, Freedom Fighters, etc., and by Rajya Sabha / Lok Sabha Secretariat as the case may be in case of sitting Members of Parliament, concerned Ministry / Department / Organisation in case of serving Government employees, serving employees and pensioners of autonomous bodies covered under CGHS.
7. The empanelled hospitals shall honour permission letter issued by competent authority and provide treatment / investigation facilities as specified in the permission letter.
8.1 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.
8.2 Bills should be submitted to the Office of the Rajya Sabha Secretariat / Lok Sabha Secretariat in case of sitting Members of Parliament and to Additional Director, CGHS (Hqrs), Delhi, in case of other beneficiaries enlisted above, once in a month.
8.3 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 (Hqrs), Delhi.
8.4 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 directly to the office / officer which / who referred the patients to the hospitals.
8.5 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.
8.6 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.
8.7 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 identify card issued by the appropriate authority.
8.8 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 given after verifying the genuineness of the employee by production of his / her valid identify card issued by the appropriate authority.
9 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 / equipment 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.
10 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.
11 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.
12 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.
13 This Office Memorandum supercedes all earlier instructions relating to empanelment of hospitals for specialised and general purpose treatment and investigations for Delhi, Faridabad, Ghaziabad, Gurgaon and NOIDA areas.
14 This issues with the concurrence of Internal Finance Division in the Ministry of Health & Family Welfare, vide Dy. No: AS & FA / 2457/2010 dated the 16th August, 2010.
15 The revised rates will come into effect from 1st September, 2010.
16 A copy of this Office Memorandum along with rate list and a copy of MOA are placed on the internet at http://mohfw.nic.in/cghsnew/index.asp.
[R.Ravi]
Director