A Landmark Judgment for Pensioners' Right to Life and Medical Reimbursement

 

 

CGHS AT A GLANCE.BLOGSPOT.COM /002/E 

    TREATMENT OF CANCER UNDER CGHS 

            Cancer is A disease resulting from uncontrolled growth and division of abnormal cells. Symptoms are highly variable and may include, persistent lump, weight loss and other unexplained changes in the body. Cancer may be Caused by gene mutations that may result from exposure to chemicals, carcinogens, radiation, and other causes. Treatment may include surgery, chemo or targeted therapy, radiotherapy and palliative care. Cancer causes 20% of all deaths. Every year 13 lakh new cases are detected Every year 8.5 lakh people die from cancer in India .70 –80% cancer is detected in the later stage. Early detection helps in complete cure of some cancers.

            In cancer awareness, different coloured ribbons represent different types of cancer (or related causes). Each colour is a symbol to raise awareness, show support for patients, and honor survivors or those who passed.       

        Early detection helps in complete cure of some cancers. As there are very few CGHS empanelled hospitals there is a provision for taking due approval for cancer treatment from a non-empanelled private hospital at CGHS rates. CGHS beneficiaries are permitted to get themselves treated from any of the 27 hospitals recognized by the Ministry of Health & Family Welfare under the National Cancer Control Programme that are funded by the Government of India . The list can be seen on CGHS website. 

      For pensioner CGHS beneficiaries, permission for treatment from non-empanelled hospitals at CGHS approved rates shall be considered by Additional Director, CGHS. No credit facility would be available, though for such a treatment. Pensioners have to make initial payment and seek reimbursement at approved rates later. In respect of serving central government employees such permission is considered by concerned Department/ Ministry.

        Powers are also delegated to the Additional Directors of CGHS of the concerned cities in respect of CGHS and to HOD/ Head of Office in respect of serving employees covered under CS(MA) Rules, 1944 for grant of permission for post-operative follow up treatment from the same Centre, where   permission has been granted earlier for Cancer treatment regarding post-operative follow up treatment.

        CGHS Rates for Cancer Surgery for hospitals empanelled under CGHS were revised w. e. f. 7/12/2015. 

 Summary:

• Summary of above circular is as below However beneficiaries are advised to go through original circular available on CGHS website.
• Revised CGHS Rates for Cancer Surgery (Effective from Date of Issue)
• The CGHS (Central Government Health Scheme) has revised the rates for cancer surgeries at empanelled hospitals:

Rates:

• Tata Memorial Hospital, Mumbai (2012) rates are adopted for NABH-accredited hospitals.
• Non-NABH hospitals will have 15% lower rates.
• Rates are based on Semi-Private Ward entitlement.
• 10% decrease for General Ward,
• 15% increase for Private Ward beneficiaries.

Hospital Stay Duration:

• Category I surgeries: 1–2 days
• Category II surgeries: 3–5 days (7–10 days for major thoracic/abdominal surgeries)
• Category III–VI surgeries: 12–14 days

Room Rent Charges:

• General Ward: ₹1000/day
• Semi-Private Ward: ₹2000/day
• Private Ward: ₹3000/day

Charges for Day care Procedures:

• One-day room rent applicable as per entitlement.

Chemotherapy:

• Procedure charges as per CGHS city-specific rates.
• Room rent, investigations, and medicines are reimbursable separately.
• Consultation and Investigation Fees:
• As per CGHS rates of the concerned city.

Implants/Stents/Grafts:

• Reimbursable in addition to surgery package, at CGHS-approved rates.
• Anesthesia, OT, and Surgery Charges (Semi-Private Entitlement):
• Anesthesia Fees: ₹2700 (Grade I) to ₹18,000 (Grade VI)
• Operation Theatre (OT) Charges: ₹1000 (Minor OT) to ₹20,000 (Major OT >4 hours)
• Surgery Charges: ₹5000 (Grade I) to ₹45,000 (Grade VI)

Billing Formula for Cancer Surgery:

• Room Rent + Anesthesia + OT Charges + Surgery Charges + Investigations + Medicines/Disposables
• (Rates adjusted by ±10% or ±15% depending on ward entitlement.)
• Other conditions from the Office Memorandum dated 1st October 2014 remain unchanged.

Issuance of Anti-Cancer Medicines in CGHS – Revised guidelines

• CGHS issued revised guidelines for issue of Anti-cancer medicines on 25th August 2023. Summary of same is as below. Please see circular on CGHS website mentioned for full details.
• The Competent Authority has approved revised guidelines for approving anti-cancer medicines for CGHS beneficiaries:

For Non-Imported, Offline Anti-Cancer Medicines:

• If the cost is less than ₹1,00,000 per chemotherapy cycle, approval can be granted by the Additional Director, CGHS, without STC (Standing Technical Committee) examination, for up to 3 cycles. STC examination may be done meanwhile.
• If the cost is between ₹1,00,000 and ₹1,50,000 per cycle, approval can be granted by the Director, CGHS, again without STC examination, for up to 3 cycles. STC examination may be carried out meanwhile.
• If the cost is more than ₹1,50,000 per cycle, the case must be placed before the STC of Experts for justification before seeking Competent Authority's approval.

 Continuation of Treatment:

• Once a particular drug has been approved based on STC’s recommendation, no further STC approval is needed for the continuation of the same treatment.
• For Imported Anti-Cancer Medicines: Existing guidelines remain unchanged:
• Medicine advised by Government Specialists/Empanelled Hospital Specialists must be placed before the STC of Experts.
• If justified, the approval of the Competent Authority and concurrence of IFD (Internal Finance Division) will be sought.
• After approval, procurement is done through the Embassy/High Commission of the concerned country.

 Treatment at  Tata Memorial Centre, Mumbai

Memorandum of Agreement has been signed between Tata Memorial Centre, Mumbai (and its subsidiary Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Khargahar, Navi Mumbai) and CGHS with a view to streamlining the procedures for undergoing treatment at Tata Memorial Centre, Mumbai. The procedure to be followed by CGHS beneficiaries for availing treatment at Tata Memorial Centre, Mumbai is as given below:

• All CGHS beneficiaries shall obtain a referral letter from a CGHS Wellness Centre in Mumbai/ Office of AD, CGHS in Mumbai for availing cancer treatment from Tata Memorial Centre, Mumbai.
• CGHS Wellness Centre shall refer the CGHS beneficiary with a proper authorization letter indicating the entitlement of the beneficiary for out/ in-patient treatment i.e., General Ward, Semi-Private Ward or Private ward, as the case may be, corresponding to the C, B, A of Tata rates respectively as authorized as per their entitlement. CGHS beneficiaries shall carry CGHS Card.
• The authorization letter shall be valid for one month and the CGHS authorization letter is inclusive for all the in-house treatment (Consultation, Investigation, Chemotherapy, Radiotherapy, Surgery etc.) during the validity period of one month. CGHS beneficiaries shall have to submit authorization letter in original along with two photo copies.
• The CGHS beneficiaries and their dependents who are referred to TATA Memorial Centre will be charged as per the rates in force and amended from time to time for various treatments as per TATA MEMORIAL CENTRE. Memos relating to drugs will be given to patient only as per policy of Tata Memorial Centre.
• All the medicines prescribed by Tata Memorial Centre’s doctors will be supplied to the patients by the Centre as per the procedure in force from time to time. In the event the medicines are not available in TMC’S dispensary, patients will have an option to procure from CGHS as per rules. In such circumstances Medical Superintendent, TMH, will certify that the medicine was not available in TMC dispensary and CGHS will provide the same to the patient.
• No priority/ preferential treatment will be accorded for the patients unless clinically indicated.
• Tata Memorial Centre shall provide treatment on credit basis to pensioner CGHS beneficiaries, etc., and to CGHS Staff as per the authorization letter and bills shall be sent to Additional Director, CGHS, Mumbai for payment as per terms and conditions of MOU. However, the credit facility shall not cover Bone Marrow Transplant cases, for which separate permission is required. Credit facility will not be extended to pensioners and CGHS staff who opt for treatment in a higher category than the one he/ she is entitled to. Serving CGHS Staff shall take permission letter from Addl. Director, CGHS of the city of residence and report to Add. Director, CGHS, Mumbai for further referral to TMC.
• Other serving employees report to CGHS, Mumbai with approval of their Ministry/ Department. Any consultation without the presence of the patient shall be charged by TMC at normal rates and no credit facility shall be provided. Serving CGHS beneficiaries shall make payment and claim reimbursement from concerned Ministry/ Department.

 Treatment at Chittaranjan National Cancer Institute (CNCI), Kolkata

OM No. 5l-588/CGHS/KOL/CNCL/2012/8449-98   Date: 23rd November 2022

• For treatment at Chittaranjan National Cancer Institute (CNCI), Kolkata, CGHS issued a circular on 23rd November 2022. Summary is as given below.
• Procedure for CGHS Beneficiaries:
• All CGHS beneficiaries must get a referral from a CGHS Wellness Centre using the NIC module.
• Mention in the "Remarks" column: "Referred to CNCI".
• Referral for Procedures and Investigations:
• All listed procedures and investigations related to cancer treatment require a referral letter from CGHS Wellness Centers at Kolkata / Siliguri / Jalpaiguri.

Permission for Unlisted Procedures:

• Pensioners and serving CGHS employees in Kolkata eligible for cashless treatment:
• Need to obtain permission from Office of Additional Director, CGHS Kolkata.
• Must have proper documentation forwarded by the Wellness Centre.
• Serving beneficiaries not in CGHS Kolkata:
• Need permission from their respective office/department, as per CGHS rules.

Rates Applicable:

• Treatment will be provided at CGHS Kolkata approved rates or CNCI rates, whichever is lower.
• For Cancer Surgery, guidelines of Office Order dated 7th September 2015 apply.
• Supply of Chemotherapy Medicines:
• Medicines prescribed by Oncologists will be provided by MSD, CGHS Kolkata.
• If any medicine is unavailable at MSD, CNCI can use the certificate issued by MSD/CGHS Wellness Centre to procure and administer the medicine.

Supply of Chemotherapy Medicines:

• Medicines prescribed by Oncologists will be provided by MSD, CGHS Kolkata.
•  If any medicine is unavailable at MSD, CNCI can use the certificate issued by MSD/CGHS Wellness Centre to procure and administer the medicine.

Emergency and Cashless Services:

• CNCI will admit CGHS beneficiaries on an emergency basis at CGHS rates according to their entitlement.

Credit Facility:

Pensioners

• CNCI must provide cashless (credit) treatment to Eligible CGHS pensioners.

Serving CGHS Kolkata staff.

• Bills should be sent to Additional Director, CGHS Kolkata for reimbursement.

Credit for Other Health Ministry Units:

• Staff from organizations like AIIPH, APHO, PHO, Institute of Serology, RHO under Ministry of Health & Family Welfare Receive credit benefits.
• Bills are sent to their respective offices for reimbursement.

Serving CGHS Beneficiaries (other Ministries):

• Need to pay first and claim reimbursement from their own ministry/department. 

Information: 

• For all information about CGHS , I have compiled and published a book “CGHS AT A GLANCE” an affordable and comprehensive guide on  CGHS. It is available on Amazon and Flipkart with a 5-star rating at an affordable price of ₹222.

                     

CGHS BENEFICIARIES WELFARTE ASSOCIATION OF INDIA (CBWAI)

All are requested to join by clicking on link https://tinyurl.com/bde9r8vb 

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Regards,

Chandra Kant Bapat