CGHS revised rules: The guidelines for Central Government Health Scheme (CGHS) cardholders have been tweaked by the Centre in a bid to enhance healthcare facilities. The tweaked guidelines, issued in an Office Memorandum (OM) of the Union Ministry of Health on September 24, 2024, have been floated to streamline the referral process for consultations, treatments, and investigations at both government and empanelled private hospitals.
Key changes
Access to government hospitals: As per the tweaked rules, beneficiaries can now access services at all major government hospitals, including All India Institute of Medical Sciences (AIIMS) and Tata Memorial Hospital, without needing prior referral or endorsement. This includes consultations and treatment for procedures that are not listed.
Private hospital consultations: A single referral from a Central Government Health Scheme (CGHS) Wellness Centre will be valid for three months, allowing beneficiaries to consult up to three specialists. A maximum of six consultations is permitted during this period.
Investigations and procedures: Routine investigations and minor procedures do not require additional endorsements within the three-month referral period. For specialized tests costing over Rs 3,000, a referral will be necessary. Similarly, procedures requiring hospitalization will also need prior approval.
Age criteria adjusted: The age limit for accessing these services has been lowered from 75 to 70 years, expanding eligibility for more beneficiaries. These revisions are expected to enhance access to healthcare services and reduce bureaucratic hurdles for CGHS beneficiaries, making it easier for them to receive timely medical attention.
The policy simplifies the referral process for routine investigations and minor procedures by eliminating the need for additional endorsements within a three-month period. However, specialized tests costing over Rs 3,000 and procedures requiring hospitalisation will require prior approval through a referral.
Additionally, the adjustment of the age criteria from 75 to 70 years aims to broaden the beneficiary base, enabling more individuals to access these essential services. These changes are anticipated to streamline the healthcare delivery process for CGHS beneficiaries, facilitating prompt access to necessary medical care.
All government healthcare organizations (HCOs) are expected to follow the updated SOP for referrals and medical bill uploads to the TMS portal.