Central Government Health Schemes in India

The large volume of beneficiaries associated with this scheme makes it a unique one. This scheme comes with a range of benefits to provide comprehensive coverage to government employees/pensioners and their families. 

List of Central Government Health Schemes in India

The Central Government Health Scheme (CHGS) provides many Health Insurance Schemes listed below:

Eligibility Criteria for Availing Central Government Health Scheme

The eligibility criteria for availing the CGHS are as follows: 

1. All Central Government employees who are paid from the Central Civil Estimates (except for Railways and Delhi Administration), including their dependent family members who reside in the CGHS covered areas.  
2. Pensioners of Central Government (except pensioners belonging to the Railways and the Armed Forces) and their families.  
3. Central Government Pensioners who retire with Contributory Provident Fund benefits and their families  
4. Widows of Central Government pensioners who are eligible for family pension.  
5.  Delhi Police personnel and their families who reside in Delhi  
6. Railway Board employees  
7. Civilian employees of Defence who are paid from Defence Service Estimates  
8. Children who draw pension on the death of a Central Government employee including minor siblings of such a child.  
9. Ex-Governors and Lt. Governors and their families  
10. Ex-Vice Presidents and their families  
11. Central Government servants who are deputed to semi-government and autonomous bodies  that are financed by the Central Government or receive grants from it  
12. Central Government employees on deputation who are statutory or autonomous during the time of the deputation  
13. Military Officers who are on deputation to civil departments and who obtain emoluments from the Central Civil Estimates.  
14. Families of Governments servants who are transferred to a non-CGHS area for a maximum period of six months on deposit of the CGHS contribution (for the period of 6 months) in advance.  
15. Families of IAS Officers in the North-Eastern Cadre who continue to stay back in Delhi after the repatriation of the IAS Officer to the North-Eastern Cadre, as long as they continue to occupy Government accommodation in Delhi or New Delhi, on deposit of CGHS contribution in advance (one to three years). This is also applicable to the families of IAS Officers of the J&K Cadre  

1. Sitting Judges of Supreme Court and High Court of Delhi and former Judges of Supreme Court and High Courts.   
2. Members of Parliament and their families  
3. Ex-Members of Parliament  
4. Family members of Deceased Ex-Members of Parliament.   
5. Parliamentary Secretaries of the Central Government and their families.   
6. 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.  
7. Employees of Kendriya Vidyalaya Sangathan stationed at Delhi and NCR, Kolkata, Chennai, Hyderabad, Mumbai and Bengaluru.  
8. Employees of Ordnance Factory Board Headquarters, Kolkata, and Ordnance Equipment Factories Headquarters, Kanpur.  
9. Pensioners of Ordnance factories  
10. All India Service pensioners who retire while serving under the State at their option  
11. Freedom Fighters and members of their family who receive Central Pension under the Swatantrata Sainik Samman Pension Scheme  
12. Members of Staff Side of the National Council of the Joint Consultative Machinery  
13. Employees of semi-government and autonomous bodies who are allowed to join the CGH Scheme  
14. Accredited journalists with certificates from the Press Council of India stating membership of the Press Association, New Delhi (for OPD and at RML Hospital)  
15. Retired Divisional Accountants of the Indian Audit and Accounts Department and those whose pay and pension are borne by the State governments  
16. Absorbees of the PSU who had commuted 100 percent of their pension and have been restored one third portion of their pension after 15 years  
17. Absorbees of Statutory Bodies or Autonomous Bodies of the Central Government (including those who proceeded on deputation initially or were on deemed deputation and then absorbed), who are in receipt of Central Civil Pension  
18. Serving and retired Railway Audit Staff  
19. Serving and retired Divisional Accounts Officers and Divisional Accountants posted in the Office of Accountant Generals in States  
20. CISF personnel (and their families) and CAPF (Central Armed Police Forces) personnel posted in CGHS cities  

1. Employees of Supreme Court Legal Services Committee  
2. Employees of India Pharmacopoeia Commission and their families.  
3. Family and dependent members of a CGHS beneficiary who stays back in CGHS covered area after posting of the employee to N.E. region (including Sikkim), Andaman and Nicobar Lakshadweep or Ladakh region as well as CAPF personnel posted in Left Wing Extremist areas, on payment of annual CGHS contribution in advance.  
4. Defense Industrial Employees of Naval Dockyard Central Ordnance Depot and AFMSD in Mumbai. 

Enrollment Process for Central Government Health Scheme

The enrollment process under CGHS can be listed as follows: 

1. Eligible employees and pensioners must apply for this cover in order to get enrolled. 
2. The application can be made in the official websites (www.cghs.nic.in and www.cghs.gov.in) or by visiting the wellness centers. 
3. The provision of uploading supporting documents is currently not available on the website portals. After online enrollment, the applicant must get a printout of that application and submit it along with the supporting documents. 
4. Official CGHS wellness centers are open from 7.30 AM to 2.00 PM from Monday to Saturday. These centers will remain closed on all Central Government holidays. 
5. The filled up enrollment form must contain an individual photograph along with personal details such as proof of residence, proof of stay of dependents, age proof of dependents, etc. 
6. In addition to these documents, pensioners must also provide attested copies of their Pension Payment Order (PPO). If PPO is not available, provision PPO or last pay certificate must be submitted during enrollment. 
7. For availing medical benefits, the government has deemed parents, parents-in-law (in case of female employees), unmarried son till the age of 25 years, unmarried/divorced/separated daughters, and minor siblings are deemed as dependents if their overall income from all sources is less than Rs.9,000 + DA per month. 
8. Following the enrollment, CGHS beneficiaries will be issued a photo ID plastic card that contains all the relevant policy details including a unique beneficiary number. 
9. The card obtained after the enrollment process is valid till the date of retirement of the primary insured. 
10. In case of the death of the primary insured, the card will become invalid. Dependent family members have to apply for a fresh card upon drawing a pension. 
11. In case of the transfer of the employee to another department or another CGHS-covered area, the same card will continue. The department may inform the CGHS to make the necessary changes. 

Benefits of Central Government Health Scheme

Some of the benefits available for enrolled members under this scheme can be listed as follows: 

1. Inpatient treatment for all enrolled members at government and empanelled facilities 

1. Cashless treatment at empanelled hospitals and diagnostic centers 
2. Medical investigations conducted at government or empanelled diagnostic centers 
3. Specialist consultations at polyclinic or government hospitals 
4. Outpatient treatment (OPD) including expenses for medications 
5. Reimbursement for emergency medical treatments undertaken at government or private hospitals 
6. Expenses related to maternity, child health services, and family welfare 
7. Expenses incurred for external medical accessories such as hearing aids, appliances, artificial limbs, etc. 
8. Alternative treatment procedures such as Ayurveda, Homeopathy, Siddha, and Unani 

Member Contribution and Ward Allocation Under CGHS 

Obtaining a CGHS health insurance card is mandatory for all Central Government employees residing in CGHS covered areas. The following salary deductions in monthly salary will be applicable to employees enrolled in this scheme: 

Entitlement of Ward Based on Pay Band

Wards in private hospitals that are empaneled under the CGHS are offered on the basis of the basic pay drawn per month according to the 7th CPC. The ward entitlements are as given below: 

Claim Procedure for Central Government Health Scheme

Cashless treatment can be obtained in CGHS-empanelled hospitals across the country. These hospitals cannot deny admission to a CGHS beneficiary during the times of emergency. 

Treatment provided in these empanelled hospitals also include pre-operative investigations, two pre-operative consultations, two post-operative consultations, room charges, medicines, cost of implants (if required), etc. as per the CGHS package rates. The package rates for treatment and implants will remain standard as per the rates approved under the CGHS. 

Reimbursement can be obtained for treatments undertaken in non-empanelled hospitals and diagnostic centers. The claim has to be submitted to the concerned department of the employee and to the CMO of the CGHS Wellness Centre within a maximum of 6 months from the date of discharge from the hospital. 

For reimbursement claims, the beneficiary must submit relevant documents and proofs including policy certificate copy, discharge summary, medical bills and receipts, ambulance usage bills, etc. Once these documents are submitted, the Wellness Center will verify the details and provide the reimbursement. Status of a claim can be viewed in the CGHS computer module with the help of the claim number. 

Facilities Offered by Central Government Health Scheme

These are the facilities that can be availed under CGHS:  

1. Out Patient Department - OPD treatments including the issue of medicines   
2. Indoor treatments at government and empaneled hospitals    
3. Diagnostic tests at government and empaneled diagnostic centers.    
4. Specialist Consultation at government hospitals or polyclinics   
5. Medical consultation and dispensing of medicines in Ayurveda, Homeopathy, Unani and Siddha system of medicines (AYUSH)   
6. Cashless facility is available for treatments in empaneled hospitals and diagnostic centers   
7. Reimbursement of expenses for emergency treatments availed in government or private hospitals   
8. Reimbursement of expenses for the purchase of hearing aids, artificial limbs, etc., as specified   
9. Family Welfare, Maternity and Child Health Services. 

CGHS Card Types and Colour Codes

The colour scheme for the CGHS cards is as given below: 

Special Facilities – Individuals 80 and Above 

Beneficiaries aged 80 and above can enjoy the following facilities: 

1. Doctor consultation services can be availed at a wellness centre without having to stand in a queue. 
2. Medical claims will be settled on priority. 
3. Follow-up treatments will be provided by the same specialist who provided treatments earlier in a non-empanelled hospital. 

Issue of medicines - Guidelines

1. Medicines are required to be issued only according to the formulary available on the CGHS website and portal. 
2. If a medicine that is not present in the formulary needs to be issued, the same can be done supported by a valid prescription by the doctor at a wellness centre. The medicine, however, cannot be a food supplement, a banned drug, or a food item. 
3. In case a medicine of a brand other than the one prescribed has to be issued, the beneficiary will have to be educated about the same so that there are no confusions. 
4. In case the person suffers from a chronic disease, medicines required for up to 3 months may be provided. 
5. If a life-saving drug or an anti-cancer drug not approved by the DCGI for use in India has to be issued, the case is required to be dealt with by the Expert Committee chaired by the Special DG. 
6. If the beneficiary himself/herself cannot collect the medicine, a person with a valid ID card or an authorization letter can collect it on the beneficiary’s behalf.