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Table of Contents
NAME OF THE SCHEME 3
STRUCTURE OF CGEPHIS 4
Sums Insured / Policy Limits 4
Expected Number of beneficiary families 4
Scheme Floater Sum Insured 5
Family Size / Age Limit 5
Insurance Coverage 5
EXPRESSION OF INTEREST: APPLICANT’S PROFILE 5
Contact Details 5
Experience in Health Insurance 6
Resource Group 6
INPUTS SOUGHT FROM THE APPLICANTS 7
Enrolment of beneficiaries 7
Free OPD Consultation 8
Capacity Building 8
Smart cards 8
Grievance Redressal 8
Web-based MIS 9
IEC Plans 9
OPD Coverage Limit 9
Management of OPD Corpus 9
Central Government Health Scheme (CGHS) is a scheme for providing health care to serving Central Government employees and their dependant family members. Over the years, the scheme has been extended to cover central government pensioners, their dependant family members and certain other categories like members of parliament and ex-members of parliament, freedom fighters etc. Employees of some select autonomous bodies as also PIB accredited journalists have also been extended CGHS facilities on cost-to-cost basis in Delhi.
Central Government Health Scheme is available in 25 cities [Delhi (including Noida, Gurgaon, Faridabad, and Ghaziabad), Ahemdabad, Allahabad, Bangalore, Bhopal, Bhubaneshwar, Chandigarh, Chennai, Dehradun, Guwahati, Hyderabad, Jabalpur, Jaipur, Jammu, Kanpur, Kolkata, Lucknow, Meerut, Mumbai, Nagpur, Patna, Pune, Ranchi, Shillong and Thiruvanthapuram]. Central Government Employees living outside the CGHS areas are entitled to reimbursement for medical attendance and treatment under the Central Services (Medical Attendance) Rules [CS(MA) Rules]. Pensioners of the Central Government are not covered under these rules. At present, Central Government Pensioners living in non-CGHS areas are paid a sum of Rs. 100 p.m. for meeting their medical expenditure. Consequently, there has been a long standing demand from Central Govt. pensioners residing in non CGHS areas for medical services at par with those available to Central Govt. pensioners in CGHS areas. The VIth Pay Commission has recommended the introduction of a health insurance scheme in lieu of the CGHS.
Government of India, therefore, proposes to provide inpatient health care services to their all personnel of the Central Government including All India Service officers, serving and retired, and others who are covered under the existing CGHS (Central Government Health Services) and under CS (MA) Rules [Central services (Medical attendance) Rules] through a Health Insurance Scheme catering to their health care requirements. The proposed scheme shall be on voluntary basis for current set of employees & pensioners but compulsory for future employees & pensioners. The existing CGHS beneficiaries will have an option to avail CGHS facilities for OPD requirements and the insurance scheme for inpatient treatment.
With the introduction of health insurance scheme, the Central Government Employee (existing/ retired) will have the choice to select the best available health facilities for meeting their health care and can get best available treatment in areas in the close proximity.
Ministry of Health & Family Welfare, Government of India invites Expressions of Interest from Insurers and Health Insurance consultants for the proposed scheme.
NAME OF THE SCHEME
The name of the proposed scheme is Central Government Employees & Pensioners Health Insurance Scheme (CGEPHIS).
All personnel of the Central Government including All India Service officers, serving, newly recruited, retired and retiring and others who are covered under the existing CGHS(Central Government Health Services) and under CS (MA) [Central Services (Medical Attendance) Rules] Rules shall be offered Health Insurance Scheme on voluntary or on compulsorily basis . This could be:
1. CGEPHIS shall be compulsory to new Central Government Employees who would be joining service after the introduction of the health Insurance Scheme.
2. CGEPHIS shall be compulsory to new Central Government retirees who would be retiring from the service after the introduction of the Insurance Scheme.
3. CGEPHIS would be available on voluntary basis for the existing Central Government Employees and pensioners serving in CGHS area/ covered by CGHS. In this case such serving Central Government Employees and Central Government existing Pensioners shall have to opt out of CGHS scheme. They will also have the option of choosing both CGHS and Insurance policy. In such case the total premium has to be born by the beneficiary.
4. CGEPHIS would also be available on voluntary basis for the existing serving employees and pensioners in non-CGHS areas not covered by CGHS. In this case such serving Central Government Employees and existing Pensioners (who have opted for CGHS facility) shall have to opt out of CGHS scheme. They will also have the option of choosing both CGHS and Insurance policy. In such case the total premium has to be born by the beneficiary.
STRUCTURE OF CGEPHIS
Sums Insured / Policy Limits
The scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs. 500,000/- per family per year subject to stated limits on cashless basis through smart cards. The benefit shall be available to each and every member of the family on floater basis i.e. the total reimbursement of Rs. 5 .00 lac can be availed by one individual or all members of the family. The sub-limits mentioned herein form part of the overall annual, family limit.
Head Sub-limit (Rs. / per admission)
Domiciliary hospitalization 50,000
Maternity benefit 50,000
Expected Number of beneficiary families
It is expected that a minimum of 2, 00,000 families shall join CGEPHIS in the 1st year but the Government proposes to invite bids for the following numbers with varying guaranteed numbers.
Number of families Minimum Guaranteed Number of families
2,00,000 to 3,00,000 2,00,000
3,00,001 to 5,00,000 3,00,000
Scheme Floater Sum Insured
An additional sum of Rs. 15 crore shall be provided as Buffer / corporate floater to take care of hospitalization expenses of a family (per illness or annual) exceed the original sum insured of Rs 5.00 lac. In all such cases an additional amount up to Rs. 5.00 lac per family shall be provided from the Scheme Floater, on the recommendation of the committee set up by the Central government/ Nodal agency.
Family Size / Age Limit
1. Serving Employees: Self, spouse, two dependent children and dependent parents (New born shall be considered insured from day one).
2. Retired Employees: Self, spouse and one dependent child.
3. Additional dependent family member can be covered under the scheme by paying the fixed percentage of premium per additional dependent family member. The premium shall be borne by the beneficiary.
4. All beneficiaries shall be insured till survival.
5. The definition of dependent shall be as per guidelines issued by Central Government.
In addition to the coverage afforded under a standard medical insurance policy, the following shall also be covered under CGEPHIS:
1. Pre-existing diseases
2. Maternity benefit
3. Day-one Coverage for all diseases
4. New-born babies
5. Pre and Post hospitalization cover of 30 days and 60 days respectively
6. Domiciliary Hospitalization
EXPRESSION OF INTEREST: APPLICANT’S PROFILE
Name of the organization
Insurer or Health Insurance Consultant
Phone (with STD code)
Fax (with STD code)
Contact person’s name
Contact person’s mobile phone
Contact person’s e-mail ID
Experience in Health Insurance
Please give details of five, government-sponsored major health insurance schemes which you have, individually or as an organization, been associated with as insurers or as health insurance consultants.
S.No Sponsoring Ministry / State Name of the Scheme Insured persons Families Insured (number)
Please give details of resource persons currently in your employ who would be responsible for CGEPHIS activities
S.No Name Qualifications Experience in Insurance industry Area of Specialization
INPUTS SOUGHT FROM THE APPLICANTS
(Based on the aforementioned background and indicative policy structure, inputs are sought from the applicants on the issues as follows. It is expected that the applicants will give inputs based on their experience of other large health insurance schemes and learnings there from. Please slot your response in the boxes under each heading).
Enrolment of beneficiaries
Since it will be an enrollment driven scheme, especially for the retired personnel, details are sought about the end-to-end enrollment process, documentation, logistics, government intervention, plans to reach out to the beneficiaries and finally delivery of smart cards. This should take into account multiple locations and sizeable number of beneficiaries and, therefore, the timelines. (Please give your views in the box)
Mapping of insured population with the healthcare infrastructure, service indicators, processes, documentation for all three scenarios need to be elaborated i.e., planned hospitalisation, emergency hospitalisation and admissions in non-panel hospitals. (Please give your views in the box)
Free OPD Consultation
Views are sought on the industry’s ability to organize free OPD consultation inn designated hospitals / nursing homes on panel, free of any charge, in certain designated locations. (Please give your views in the box)
A scheme of this magnitude may require that the government plays the crucial roles in creating awareness about the scheme, its benefits, procedures, documentation and service levels to the beneficiaries as regards enrollment and claims. This would require building of capacities within the government at multiple locations through multiple fora by training the facilitators representing the government to ensure seamless implementation and delivery. Please state your plans and activities to this end. (Please give your views in the box)
Single Smart Card for all beneficiaries would be required; carrying all personal details, biometric data, medical history, policy limits etc. to the CGEPHIS members. Please elaborate all related issues like smart card specifications, logistics plans , OTC issuance of cards , district-based card-kiosks , POS machine installations & other hardware at the hospitals’ end, connectivity , transfer of data, payment mechanism etc. across the country. (Please give your views in the box)
A structured and layered grievance redressal mechanism needs to be in place to attend to the beneficiaries’ issues regarding enrollments, cards, claims and service standards. This mechanism is to be accessible at district / state / centre levels. Please give your observations as regards the structure, processes and timelines involving grievance redressal. (Please give your views in the box)
This is one of the most critical aspects of the scheme. A web-based, real-time MIS is to be created which will track, on one hand, the status of each beneficiary as regards his enrollment details, smart cards and claims preferred by him. On the other hand, it should give a wide combination of statistics to the government enabling government to monitor various macros. Besides country-wide, the data should be available for each district and state. Please elaborate on the structure and technical specification of the same. (Please give your views in the box)
Drilled-down Info/Education/Communication requiring the beneficiaries to understand the scheme, especially at the Non-CGHS locations & for the retirees in both CGHS & Non-CGHS locations. This should include awareness about the scheme, facilities and “How-to-access-facilities”. A combination of vehicles such as newspapers / pamphlets / radio / TV / public announcements / website of the Insurer, riding piggy-back on govt. machinery, health camps etc. could be used. Please state appropriate plans. (Please give your views in the box)
OPD Coverage Limit
It’s being contemplated to provide OPD coverage of Rs.10, 000 per family per annum through panel hospitals only. We seek your views on practicality of this cover from the point of view of service capabilities of the insurance industry as well as the attendant cost of this cover. Please give your inputs as well as an indicative premium for this cover. (Please give your views in the box)
Indicative Premium Rate per family per annum: Rs.
Management of OPD Corpus
Over and above the OPD coverage of Rs. 10,000 per family per annum, it is contemplated to take care of the additional OPD expenses of a family through an OPD corpus. This corpus shall be fully funded by the Government but managed by the insurers. Views are sought on the structure, servicing methodology, tie-up with hospitals, concessional charges for treatment, funds-flow, documentation and audit of such a corpus. (Please give your views in the box)
Coverage of AIDS
Coverage of expenses towards treatment of Aids may also be sought by the Government which generally happens to be a exclusion in a standard medical insurance policy. (Please give your views in the box)
The scheme proposes to include a general health check up for all beneficiaries at least once a year. Please detail elements of health check-up, process , service network etc. ( Please give your views in the box)
Medical Equipments etc.
Under the CGHS, medical equipments like oxygen concentrators, hearing aids, C Pap Machines, IOLs for Cataract Surgeries etc. are also provided. Should these be provided under the proposed health insurance scheme? ( Please give your views in the box)
The CGHS provides for certain dental procedures while such procedures are not covered under most health insurance policies currently available in the market. Should the proposed insurance scheme also include dental procedures? ( Please give your views in the box)
CGEPHIS aims to be a comprehensive insurance scheme. It is , therefore, imperative that all exclusions , standard or otherwise , be known to the Government in ahead of implementation so that there are no surprises. Please list out the exclusions which the insurance industry cannot help but impose. (Please give your views in the box)
Period of Insurance Contract
The period of insurance shall be annual but the Govt proposes to enter into a long-term contract with insurers. Fully appreciating the pricing issues facing renewals of medical policies , the Government is open to the idea of introducing a renewal pricing mechanism which shall be based on burning cost. Views are sought for a 3-year contract with provision for correction of renewal price by way of loading on premium rate. (Please give your views in the box)
Applicants are requested to indicate premium rate per family for a sum insured of Rs.5.0 lacs per family per annum, including the Scheme Floater sum insured. It is clarified that the premium rate so advised by the applicants shall be purely for building a reasonable estimate of the scheme costs and not for any other purpose. (Please give your views in the box)
Minimum Guaranteed Number of families Indicative premium per family per annum
ELIGIBLE HEALTH INSURERS AND OR HEALTH INSURANCE CONSULTANTS MAY SEND IN THEIR EXPRESSION OF INTEREST IN THE GIVEN FORMAT BY E-MAIL TO “email@example.com” HARD COPIES, DULY ATTESTTED BY AN AUTHORISED SIGNATORY MAY BE SENT TO MR VINEET CHAWDHRY, JOINT SECRETARY, MINISTRY OF HEALTH & FAMILY WELFARE, ROOM NO 147-A, A-WING, NIRMAN BHAVAN, MAULANA AZAD ROAD, NEW DELHI. EXPRESSIONS OF INTEREST NOT SUBMITTED ELECTRONICALLY WOULD NOT BE CONSIDERED.