Saturday, 15 September 2018

సవతి పిల్లలు కి Employee Health Scheme వర్తిస్తుందా ?




G.O.MsNO.174, Dated: 01-11-2013 ప్రకారం సవతి పిల్లలు కూడా Employee Health Scheme ప్రయోజనాలు పొందవచ్చు.



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.

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
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,  pre- authorization 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.
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, 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 



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