GOVERNMENT OF ANDHRA PRADESH
ABSTRACT
Health, 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.
HEALTH, MEDICAL AND FAMILY WELFARE (M2) DEPARTMENT
G.O.Ms.No.174 Dated: 01-11-2013
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.
-:oOo:-
ORDER:
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.
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.
Contd. P. 2.,
-2-
4. COVERAGE:
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 Pensioners
2. Family pensioners
3. Re-employed service pensioners
4.1.2. The following categories will not be covered under the scheme.
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
Contd. P. 3.
-3-
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 medical
ailments.
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:-
4.2.2.1 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.
5. HOSPITALS:
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.
Contd. P. 4.
-4-
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.
6. FINANCING: 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.
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,
Contd. P. 5.
-5-
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.
(BY ORDER AND IN THE NAME OF THE GOVERNOR OF ANDHRA PRADESH)
Dr. P.K. MOHANTY
CHIEF SECRETARY TO GOVERNMENT
To,
The Principal Secretary to Government, General Administration (Services & HRM),
Department.
The Secretary to Government, Information Technology & Communications Department.
The Commissioner, Civil Supplies, AP.,Hyderabad.
The Commissioner of Printing, Stationary & Stores (Printing Wing), A.P, Hyderabad
(with a request to furnish 500 copies of the G.O. to Government .
The Chief Executive Officer, Aarogyasri Health Care Trust, Hyderabad.
All the District Collectors
All Heads of Department
Copy to:
All the Special Chief Secretaries to Government / Prl. Secretaries/ Secretaries in
Secretariat. Hyderabad.
All the employees and pensioners associations through GA (Services Welfare)
Department, Secretariat, Hyderabad.
Accountant General (A&E), AP., Hyderabad.
The Pay and Account Officers
The Director of Treasuries and Accounts, AP., Hyderabad
The Commissioner of Information and Public Relations, Hyderabad
PS to Principal Secretary to Governor.
The Finance (Expr.M&H-1) Dept.
All concerned through the Chief Executive Officer, Aarogyasri Health Care Trust,
Hyderabad.
S.F./S.Cs.
// FORWARDED :: BY ORDER //
SECTION OFFICER
