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AP GO's | GO. 174-Health Cards to State Govt. Employees and Pensioners
Government of Andhra Pradesh
HEALTH MEDICAL AND FAMILY WELFARE
GO.MS.No.176; Date: 01/11/2013Health, Medical and Family Welfare - Employees Health Scheme - Providing Cashless medical treatment to the State Government Employees, Pensioners and their dependent family members - Notification of the 'Employees Health Scheme (EHS) - Orders — Issued.
Read the following
1 G.O.Ms.No.74, HM&FW (K1) Dept dated:15-03-2005.
2. G.O.Ms.No.180 HM&FW (K1) Dept dated 11-05-2006.
3. G.O.Ms.No.105 HM&FW(K1)Dept dated:09-04-2007.
4. G.O.Ms.No.397 HM&FW(K1)Dept, dated: 14-11-2008.
5. G.O.Ms.No.68 HM&FW (K1) Dept dated 28-03-2011.
6. G.O.Rt.No.5832 GA (Cabinet) Dept Dated:04-12-2010.
7. G.O. Rt No. 3401 GA (GPM&AR) Dept Dated:23-07-2012
8. G.O.Ms.No.184 HM&FW(M2) Dept, dated:14-08-2012.
9. G.O.Ms.No.186 HM&FW(M2) Dept, dated: 14-08-2012.
In the G.O. 1st read above, Government have issued modifications / amendments to the Andhra Pradesh Integrated Medical Attendance Rules, 1972, applicable to State Government employees and their dependents etc., for their treatment. In the G.O’s., 2nd to 5th read above, Government have issued further amendments / modifications / clarifications, from time to time, to the said rules. Having decided to provide comprehensive health care to all Government Employees, Pensioners, and their dependent family members, Government vide G.O. 8th read above, have approved the Employees Health Care Fund Scheme (EHF). In the G.O. 9th read above, Government have also issued operational guidelines for implementation of the Employees Health Care Fund Scheme to provide cashless treatment to all the Government employees, pensioners and their dependent family members. The Employees / Pensioners Associations made representations seeking certain modifications to the G.O.8th read above. The then Chief Secretary to Government convened a meeting with the representatives of the Employees / Pensioners Associations on 06-12-2012, and thereafter the matter was placed before the 'Group of Ministers' constituted in the G.O. 6th read above, for their consideration. The Group of Ministers have considered the recommendations of the then Chief Secretary to Government and recommended the implementation of 'Employees Health Scheme (EHS) and issue of Health Cards. The salient points of the recommendations were discussed by the Chief Secretary to Government with the representatives of the Employees / Pensioners Associations in the meeting held on 31-10-2013 and their views were considered.
Read More : GO.MS.No.175 — Operational Guidelines for Issue of Health Cards
2. Government after careful examination and in supersession of the orders issued in the G.O. 8th read above hereby issue the following orders notifying the 'Employees Health Scheme (EHS) and its implementation with immediate effect.
3. The Employees Health Scheme is formulated to provide cashless treatment to the employees and pensioners of the State Government and their dependent family members which will ipso facto replace the existing medical reimbursement system under APIMA Rules, 1972, with additional benefits such as post-operative care and treatment of chronic diseases which do not require hospitalization and treatment in empanelled hospitals.
The coverage under the scheme is as follows:-
4.1 Beneficiaries Covered
4.1.1 In the first Phase the following categories of beneficiaries will be covered.
a) Serving employees:1. All regular State Government employees. A State Government employee will have the meaning as defined under Fundamental Rules.
2. Provincialised employees of local bodies.
b) Retired employees:1. All Service Pensioners4.1.2. The following categories will not be covered under the scheme.
2. Family pensioners
3. Re-employed service pensioners
- a) Those who are covered under other insurance schemes such as CGHS, ESIS, Railways, RTC., Aarogya Bhadratha of Police Department and Aarogya Sahayatha of Prohibition & Excise Department;
- b) Law officers (Advocate General, State Prosecutors, State Counsels, Government Pleaders and Public Prosecutors);
- c) Casual and Daily paid workers;
- d) Biological parents if adopted parents exist;
- e) All independent children; and
- f) AIS officers and AIS pensioners.
4.1.3. The following family members are entitled to avail of the Employees Health Scheme.
- a) Dependent Parents (either adoptive or biological; but not both);
- b) One legally wedded wife in case of a male employee / service pensioner;
- c) Husband in case of a female employee / service pensioner;); and
- d) Dependents of family pensioners shall also be eligible as in the case of service pensioners.
4.1.4. DEPENDENCY HAS THE FOLLOWING MEANING
- a) In case of parents, those who are dependent on the employee for their livelihood;
- b) In case of unemployed daughters, those who are unmarried or widowed or divorced or deserted; and
- c) In case of unemployed sons, those who are below the age of 25 years.
- d) Disabled Children with a disability which renders them unfit for employment
4.2 BENEFITS COVERED
4.2.1. In-Patient Treatment:
- a) The scheme will provide inpatient treatment for the listed therapies under all specialties in the empanelled hospitals.
- b) Necessary follow-up treatments of surgical or medicalailments.
- c) EHS patient requiring IP treatment in an empanelled hospital will receive cashless services.
- d) Aarogyamithra belonging to AHCT in the empanelled hospital will guide and facilitate the movement of EHS patient from the time of registration till the time of discharge.
- e) The network hospital will earmark one of their staff as EHS liaison assistant to liaise with EHS patients.
4.2.2. Outpatient Treatment for identified chronic diseases:-
188.8.131.52 OP treatment for pre-defined long-term (chronic) diseases will be provided in notified hospitals. Orders on the modalities and provision of budget to the notified hospitals will be issued separately.4.3 FINANCIAL COVERAGE
- a). The employees, pensioners and their dependent family members will be eligible for a sum of Rs.2.00 lakhs (Rupees two lakhs only) per episode of illness with no limit on the number of episodes as existing in APIMA Rules, 1972. However, in the cases where the cost of treatment exceeds Rs.2.00 lakhs, cashless treatment will continue. No network hospital shall deny the treatment in such cases.
- b). The limit of Rs.2.00 lakhs will not apply in cases where predetermined package rates are above Rs.2.00 lakhs.
- c). Chief Executive Officer, Aarogyasri Health Care Trust will settle the claims which exceed Rs.2.00 lakhs, following the standard claims settlement process after obtaining the approval of the Technical Committee constituted by the Government.
Read More : GO.MS.No.176 - Notification and adoption of ‘Final Therapy Prices’
The empanelment and hospital payments is as follows.
5.1 Hospital Empanelment
- a. Guidelines for empanelment of hospitals within the State and outside, preauthorization and other modalities while implementing the scheme will be in conformity with the existing standard procedures being followed by AHCT. The list of empanelled hospitals will be made available in the official website www.ehf.gov.in
- b. Empanelled hospitals resorting to irregularities or misuse shall be blacklisted and entire amount recovered besides launching criminal action.
- c. Any irregularities or misuse committed by the beneficiaries coming to the notice of Government or AHCT will entail disciplinary action as per A.P. C.S. (CCA) Rules, 1991 and may attract penal action as per law.
5.2. Hospital Payments
- a. Payments under the scheme will be based on approved package prices.
- b. The period from the date of reporting to hospital to 10 days after the date of discharge from the hospital will be treated as part of the package.
- c. The package will include the entire range of investigations, medicines, implants, consumables, diet, post-operations / post-treatment complications and follow up care arising from the therapeutic intervention.
The financing arrangement for the Scheme is as follows.
6.1. 60% of total amount will be borne by Government and 40% by the employee / pensioner contribution.
6.2. The monthly contribution will be Rs.90/- (for Slab A consisting of employees with Pay Grades from I to IV, and Slab B consisting of employees with Pay Grades from V to XVII) and Rs.120/- (for Slab C consisting of employees with Pay Grades from XVIII to XXXII). The Pay Grades for the three Slabs under other Pay Scales, such as University Grants Commission Pay Scales, will be those equivalent to the corresponding Pay Grades under the State Government. The eligibility for Slab-A and Slab-B will be semi-private ward, and for Slab- C will be private ward. The contribution for service pensioners or family pensioners will be according to the present Pay Grade of the post from which the pensioner retired from service.
6.3. If both of the spouses are Government employees or Service Pensioners, contribution by any one of the spouses is sufficient. In such a case, the applicant shall give a declaration to the effect that the other spouse is a Government employee / Service Pensioner, duly indicating the Employee Code / Pensioner Code of the other spouse.
6.4. The expenditure in running the Scheme and Scheme experience will be reviewed at the end of six months and revision of contribution effected accordingly.
Read More : GO.MS.No.174 - Providing Cashless medical treatment to the State Government Employees, Pensioners and their dependent family members - Notification of the 'Employees Health Scheme (EHS)
7. IMPLEMENTATION MECHANISM:
The implementation Mechanism for the scheme is as follows.
7.1. Aarogyasri Health Care Trust will implement the Scheme under the supervision of Government of Andhra Pradesh.
7.2 A Steering Committee under the chairmanship of Chief Secretary to Government will review the implementation of the Scheme from time to time. The Steering Committee will meet as frequently as required, discuss, monitor and review the Scheme, benefit packages, grievances, quality of medical care including the modalities of an Employees Health Trust. The General Administration (Services & HRM) Department will issue orders forming the Steering Committee with 40% members from employees and pensioners associations, and 60% members from Government.
8. Chief Executive Officer, Aarogyasri Health Care Trust will incur expenditure for implementation of Employees Health Scheme (EHS) from existing funds of Aarogyasri Scheme and recoup as and when EHS budget is received.
9. Detailed operational guidelines required from time to time will be issued by Government (Health, Medical and Family Welfare Department) and made available in the website, and also detailed guidelines for outpatient treatment will be issued separately by Government (HM&FW Department).
10. The Secretary to Government (Services & HRM), General Administration Department; Secretary to Government IT&C Department; Commissioner, Civil Supplies; Chief Executive Officer, Aarogyasri Health Care Trust; Director of Treasuries and Accounts; District Collectors; Pay and Account Officers; and all Heads of Departments shall take necessary further action in the matter accordingly.
11. These orders will come into effect from 5th December, 2013.
12. This order issues with the concurrence of Finance (Expr.M&H.1) Department vide their U.O.No.360/A1/Expr.M&H.I/2013, Dated: 26/10/2013.