A new health benefit rule has been introduced for central government employees. The geographical condition that earlier restricted access to the Central Government Health Scheme (CGHS) has been removed. It will give employees posted or living outside the scheme’s coverage area a new option to seek medical coverage.
The Ministry of Health and Family Welfare has changed the eligibility rules for the CGHS coverage and made the new provisions effective immediately. The change is relevant for employees who live or work outside the prescribed CGHS area and those posted in places where CGHS facilities are not available.
Under the earlier system, serving central government employees generally needed to live or work within 5 kilometres of a CGHS Wellness Centre to qualify for the scheme. Employees posted outside CGHS-covered locations were generally served under the Central Services (Medical Attendance) Rules, 1944, or CS(MA) Rules. The government had earlier stated that the CS(MA) Rules applied to serving central government employees residing in areas not covered by CGHS.
The change in the geographical condition for eligibility means an eligible employee will no longer lose the option of joining CGHS simply because the place of residence or posting falls beyond that distance.
Who can now opt for CGHS?
Serving central government employees covered under CS(MA) Rules can now benefit from the change if they live or work outside the CGHS geographical area.
Such employees will get a one-time option to shift to CGHS. They will have to meet the other eligibility requirements and pay the prescribed CGHS contribution or subscription.
The decision also applies to the eligible dependants of the employee. Once the employee chooses CGHS, the same medical coverage will apply to the eligible dependants covered under the scheme.
The government has made the choice a one-time decision. An employee who opts for the CGHS cannot later switch back to the CS(MA) Rules simply because the medical coverage no longer suits their needs.
This distinction is important because the CGHS and the CS(MA) serve different groups of central government employees.
The CGHS is medical scheme for serving and retired central government employees and their families, while CS(MA) Rules have traditionally provided medical attendance to serving employees in non-CGHS areas.
Already on CGHS? Here’s what changes
Employees who live or work in an area covered by CGHS will continue to follow the CGHS system. The new option is aimed at employees who were outside the geographical coverage and were therefore using CS(MA) facilities.
An employee cannot choose CGHS for one family member and the CS(MA) Rules for another eligible dependant. The medical coverage selected by the main beneficiary will apply to the eligible dependants as well.
The government has also made it clear that a person cannot claim medical benefits under both systems at the same time. Employees opting for the CGHS will have to provide a written undertaking confirming that they and their eligible dependants will not claim benefits under both schemes simultaneously.
If a beneficiary receives benefits from both systems improperly, the amount involved can be recovered under the applicable rules.
The new provisions also affect travel-related claims. If an employee receives treatment or medicines under the CGHS, he or she cannot claim TA/DA for the same medical benefit under the applicable provisions.
Medical benefits available under CGHS
The CGHS provides several medical services to its beneficiaries. Under the scheme, employees and their families can get OPD treatment and medicines, specialist consultations, hospitalisation, medical tests and other approved healthcare services.
It also provides certain cashless treatment facilities to eligible pensioners and other identified beneficiaries at empanelled hospitals and diagnostic centres.
Other approved benefits include reimbursement in specified emergency cases and facilities relating to hearing aids, artificial limbs and other medical appliances.
Employees who were previously outside the CGHS geographical area can now opt for the scheme if they meet the other eligibility conditions and pay the required contribution.
One choice for the employee and family
Employees covered under CS(MA) Rules can choose CGHS only once. Once they make the choice, it will be final and they cannot switch back later.
The government has also warned beneficiaries to provide complete and accurate information while applying for or using CGHS facilities. Suppression of information, incorrect details or misleading information can lead to disciplinary action. Any benefit obtained through incorrect information can also be recovered.
The rule change comes ahead of the implementation of the 8th Pay Commission, although the CGHS decision itself deals with medical coverage and eligibility rather than salary revision.
