Employees Health Scheme is formulated to provide cashless treatment to the employees, pensioners of the State Government and their dependent family members, which will ipso facto replace the existing medical reimbursement system, with additional benefits such as post-operative care and treatment of Chronic diseases, which do not require hospitalization and treatment in empanelled Hospitals.
IMPORTANT STAKEHOLDERS IN THE SCHEME
The Scheme is intended to benefit Serving employees and Retired employees of the state.
Aarogyasri Health Care Trust:
- Aarogyasri Health Care Trust will implement the Scheme under the supervision of State Government.
Network Hospitals - Service Providers:
A health care provider shall be a hospital or nursing home in Telangana established for indoor medical care and treatment of disease and injuries and should be registered under Telangana Private Allopathic Medical Establishments (Registration & Regulation) Act and Pre-Conception and Pre-Natal Diagnostic Techniques Act (Wherever Applicable).
Software Company - Technology Solutions:
A dedicated real-time online workflow system was designed by the Trust in order to bring dynamism and decentralization of work like Online processing of the cases starting from registration of case at network hospital, pre-authorization, treatment and other services at the hospital, discharge and post treatment follow-up, claim settlement, payment gateway, accounting system, TDS deductions, e-office solutions etc. The maintenance of the workflow is done round the clock.
- Serving Employees:
- All regular State Government Employees. A State Government Employee will have the meaning as defined under Fundamental Rules.
- Provincialized Employees of local bodies.
- Retired Employees:
- All service pensioners
- Family pensioners without dependents
- Re-employed Service Pensioners
Beneficiaries not covered:
- 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;
- Law officers (Advocate General, State Prosecutors, State Counsels, Government Pleaders and Public Prosecutors);
- Casual and Daily paid workers;
- Biological parents if adopted parents exist;
- All independent children; and
- AIS officers and AIS pensioners.
The following will constitute the family:
- Dependent Parents (either adoptive or biological, but not both).
- One legally wedded wife in case of a male employee/ service pensioner.
- Husband in case of a female employee/ service pensioner.
- Wholly dependent legitimate children (including step children and adopted children); and
- Dependents of family pensioners shall also be eligible as in the case of Service Pensioners.
- In case of parents, those who are dependent on the employee for their livelihood.
- In case of unemployed daughters, those who are unmarried or widowed or divorced or deserted.
- In case of unemployed sons, those who are below the age of 25 years
- Disabled children with a disability which renders them unfit for employment.
The eligible beneficiaries will be provided with health cards also called eligibility cards.
The procedure of verification of eligibility of beneficiary under the scheme shall be by online authentication of the Health Card details. The beneficiary shall provide either the eligibility card or the card number in case the card is unavailable. The staff at the kiosk in the Network Hospital shall verify the details online by accessing the database. Once the authentication is complete, the eligibility verification ends.
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.
- The scheme will provide Inpatient treatment for the listed therapies for identified diseases under all specialties in the empanelled hospitals. List of IP therapies
- Package includes the following services:
- End-to-end cashless service offered through a NWH from the time of reporting of a patient till ten days post discharge medication, including complications if any up to thirty (30) days post-discharge, for those patients who undergo a "listed therapy(ies);
- Free OP evaluation of patients for listed therapies who may not undergo IP treatment including consultation and investigations
Follow-up services are provided for a period of one year through fixed packages to the patients whoever requires long term follow-up therapy in order to get optimum benefit from the procedure and avoid complications. Follow-up package includes consultation, investigations, drugs etc., for one year for listed therapies. List of IP therapies
Outpatient Treatment for identified chronic diseases:
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.
The eligibility 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) will be semi-private ward, and for Slab- C (consisting of employees with Pay Grades from XVIII to XXXII) will be private ward.
- The total cost on implementation of Employees Health Scheme shall be borne by the Government and no contribution will be collected from the employees/pensioners. There shall be no upper limit on the financial coverage and the total cost of treatment of the patient for the enlisted therapies will be covered under the scheme..
- The total amount will be borne by Government and there is no contribution from employee / pensioner.
- 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.telangana.gov.in
Payments under the scheme will be based on approved package prices.
- Empanelled hospitals resorting to irregularities or misuse shall be blacklisted and entire amount recovered besides launching criminal action.