West Bengal Health for All Employees and Pensioners Cashless Medical Treatment Scheme, 2014

GOVERNMENT OF WEST BENGAL
Finance Department
Nabanna, Howrah

No. 4476-F(MED) Kolkata, the 28th August, 2014.

NOTIFICATION

The Governor is pleased hereby to make, with immediate effect, the following scheme for the benefit of the State Government officers and employees, State Government pensioners including family pensioners, All India Service (AIS) officers, AIS pensioners including family pensioners, and their eligible family members for undergoing cashless medical treatment facility in enlisted hospitals up to a certain limit, namely:-

Scheme

1. Short title and commencement

(1) This scheme may be called the West Bengal Health for All Employees and Pensioners Cashless Medical Treatment Scheme, 2014.

(2) It shall come into force on such date, as the State Government may, by notification in the Official Gazette, appoint.

2. Application

(1) This scheme shall apply to all State Government employees, State Government pensioners including family pensioners and the beneficiaries who have opted for existing scheme in lieu of medical allowance. This scheme shall also apply to All India Service (AIS) officers and AIS pensioners of West Bengal who have opted for the existing scheme in terms of G.O. Nos. 9021-F(Med) and 9022-F(Med), dated the 16th September, 2011 and their beneficiaries.

3. Definitions

In this scheme, unless there is anything repugnant in the subject or context,-

(1) (a) “approved package rates” means such package rates as annexed to this Notification and as may be specified by the Government from time to time for various services, procedures and investigations required in connection with the medical attendance and treatment of an employee or pensioner or a beneficiary;

(b) “authority” shall mean the West Bengal Health Scheme Authority under the Finance Department, Government of West Bengal;

(c) “beneficiary” means a dependent member of the family of an employee or pensioner and includes-

(i) husband or wife, as the case may be;
(ii) parents whose monthly income does not exceed rupees three thousand five hundred.

Note – In case of pensioners, income from all sources including pension before commutation shall be considered as income and the dearness relief on pension shall not be considered as income;

(iii) children, including step-children, legally adopted children and unmarried daughter;
(iv) dependent widowed or divorced daughter(s);
(v) minor brother(s), minor sister(s);
(vi) dependent unmarried or widowed or divorced sister(s);

(d) “cashless card” means a card issued by the GAA for each of the beneficiary under this scheme on production of which the beneficiary will get treatment and medical attendance as an indoor patient in any HCO as per approved package rate without paying for the charges up to a maximum limit of rupees one lakh in each case;

(e) “existing scheme, 2008” means the West Bengal Health Scheme, 2008 and includes all subsequent orders issued to implement or clarify the existing scheme, 2008;

(f) “form” means a Form appended to this scheme;

(g) “Government” means the Government of West Bengal in the Finance Department;

(h) “Government Authorised Agency (GAA)” means an agency appointed by the Government for different regions or districts, as the case may be, for the purpose of –

(i) issuing cashless card to the beneficiaries;
(ii) authorising HCOs for providing cashless treatment as per approved package rate up to a maximum limit of rupees one lakh in each case;
(iii) accepting bill from the HCOs and authorising approval for payment of the HCOs;

(i) “Health Care Organisation (HCO)” means such hospital or nursing home or institution as may be recognised from time to time by the Government for the purpose of availing benefits of medical attendance and treatment under this scheme.

(j) “medical attendance” means attendance for professional advice and includes pathological, bacteriological, radiological or other methods of investigations for the purpose of diagnosis which are considered necessary by the attending physician and are carried out in a hospital or institution;

(k) “package rate” means the maximum rate for various treatments and includes lump sum cost of inpatient treatment or day care from the time of admission to the time of discharge including (but not limited to) –

(i) Registration charges,
(ii) Admission charges,
(iii) Accommodation charges including patient’s diet,
(iv) Operation charges,
(v) Injection charges,
(vi) Dressing charges,
(vii) Doctor/consultant visit charges,
(viii) ITU/ICU/ICCU charges,
(ix) Monitoring charges,
(x) Transfusion charges,
(xi) Anaesthesia charges,
(xii) Oxygen charges,
(xiii) Operation theatre charges,
(xiv) Procedural charges/surgeon’s fee,
(xv) Cost of surgical disposables and all sundries used during hospitalisation,
(xvi) Cost of medicines,
(xvii) Related routine and essential investigations,
(xviii) Physiotherapy charges etc; and
(xix) Nursing care and charges for its services but excluding expenses on telephone, tonics, toiletries, cosmetics etc.

Note – Each package shall start from the previous day of surgery and shall be of the following duration:-

(A) 12 days for specialised surgeries,
(B) 7-8 days for other major surgeries,
(C) 3-4 days for Laparoscopic/Endoscopic Surgeries/normal deliveries,
(D) 1 day for day care or minor (OPD) surgeries,

(1) “specified” means specified by order.
(2) Words and expressions used and not defined in this scheme but defined in the West Bengal Health Scheme, 2008, shall have the same meanings as respectively assigned to them in the existing scheme, 2008.

4. Procedures for obtaining cashless card under this scheme

(1) The Government shall appoint as many Government Authorised Agency (GAA) as it deem fit to implement this scheme.

(2) An employee or pensioner who is already enrolled under the existing scheme, 2008, may make an application-

(a) to the cadre controlling Department, in case an employee is a member of a constituted state service;
(b) to the head of the office, in case of any other employees;
(c) to the pension sanctioning authority, in case of pensioner/family pensioner, either in Form CS2 or Form CS3, as the case may be.

(3) Form CS2 shall be used by employees who are in-service and Form CS3 shall be used by pensioners.

(4) Form CS2 or Form CS3 shall be available at the portal of Medical Cell of the Finance Department, namely, .

(5) The application in specified form shall be duly filled up with all details along with the telephone no., email address etc., photocopy of the existing card.

(6) The cadre controlling Department or the head of the office or the pension sanctioning authority, as the case may be, shall forward those applications to the GAA, for issue of cashless cards to the beneficiaries.

5. Treatment and claim settlement procedure under this scheme

(1) This scheme shall be limited to indoor treatment or day care/minor (OPD) surgeries in approved HCOs as per approved package rate up to a maximum limit of rupees one lakh in each case.

Explanation – For removal of doubts, it is hereby declared that-

(1) The treatment and medical attendance which are not covered by this scheme shall continue to be covered by the existing scheme, 2008. The cost incurred on account of related medical attendance and treatment received in a hospital or an institution during the period upto 30(thirty) days prior to hospitalisation and 30 (thirty) days from the date of discharge, shall be reimbursed as per the provisions under the existing scheme, 2008.

(2) After the expiry of a period of six months from the date of coming into effect of this scheme, no advance shall be available for any treatment upto rupees one lakh for which approved package rate is available under this scheme.

(3) If the estimated treatment is for an amount of more than rupees one lakh, this scheme shall not be applicable and an advance of 80% (eighty per cent) of the estimated cost of treatment shall be available to the employees for undergoing treatment as per the provisions contained in the existing scheme, 2008.

(2) For availing benefit under this scheme, the beneficiary shall produce his health card under the existing scheme, 2008 and the cashless card under this scheme, to the HCO at the time of treatment or admission, as the case may be.

(3) If there is a package rate available under the scheme within rupees one lakh, treatment shall be done under this scheme.

(4) For the purpose of obtaining treatment under this scheme, the beneficiary or his relative shall fill up an application in Part A of Form CS1 and submit the same to the HCO with a photocopy each of both the cards.

(5) The HCO shall have to seek authorisation from the GAA in each case by duly filling up Part B of Form CS1 in accordance with the procedures mentioned in the website of the Finance Department, namely, .

(6) The GAA shall verify the particulars of the card holder from their data bank and also verify the requirement of the treatment as suggested by the HCO viz a viz the approved package rate under this scheme.

(7) The detailed guidelines shall be provided by the authority to the GAA in this respect from time to time.

(8) The GAA shall be required to send authorisation for treatment as per approved package rate within 3(three) days from the date of receipt of request from the HCO.

(9) A copy of the authorisation for treatment shall have to be sent to the card holder through his registered e-mail address and sms intimating the gist of the authorisation i.e code of the approved package(s) and the total amount approved for medical treatment as cashless under this scheme.

(10) The employee or pensioner or beneficiary as the case may be, shall be able to track the status of authorisation pending before the GAA in the website of the Government, namely, . in.

(11) The GAA shall maintain round the clock service including call centre facility for this scheme.

(12) In extreme emergency or life threatening situation, the HCO may treat the patient without waiting for receipt of the authorisation from the GAA.

Note – All emergency accident cases be brought under one common code as may be specified by the Government as a special case and a ceiling of rupees one lakh may be allowed for the treatment cost. If the cost of such type of treatment exceeds rupees one lakh, the amount in excess of rupees one lakh shall be reimbursed under the existing scheme, 2008.

(13) On receipt of authorisation from the GAA, the HCO shall perform the desired treatment as per the package rate and discharge the patient without claiming any payment from

(14) A bill showing total charges of treatment as per package rate shall be handed over to the concerned patient at the time of discharge under proper receipt. A copy of the said receipted bill shall be forwarded to the GAA by the HCO for settlement of cost of treatment as per approved package rate.

(15) The HCO shall claim the bill for treatment as per approved package rate to the GAA in the format, alongwith all supporting medical papers, prescriptions, cash memo etc., as may be specified by the Government within a period of one month of discharge of the patient and the GAA shall make an endorsement for payment of bill of the concerned HCO within one month from receipt of the bill.

Note – All sorts of clarification, confusion etc. shall be settled within the said period of one month from receipt of the bill by the GAA and if the GAA fails to make such authorisation for payment of the bill and forward the same to the authority, the authority may consider such bill as duly authorised by the GAA.

(16) On receipt of authorisation of payment from the GAA, the designated officer of the authority shall electronically transfer the authorised payment to the bank account of the HCO after deduction of necessary taxes as applicable, from the Government account and this transfer shall be effected within 7 (seven) working days from the receipt of authorisation from the GAA.

(17) The HCOs registered under the existing scheme, 2008 shall execute another agreement with the authority and the GAA for this scheme.

(18) Class 1, Class 2 and Class 3 categories of HCOs shall be authorised to charge maximum 100%, 80% and 70% of the approved package rates, respectively. The charges may vary depending upon the category of the beneficiary.

6. Duties and functions of HCOs

(1) HCOs classified as Class 1, Class 2 and Class 3 service provider under the existing scheme, 2008, shall be considered as such HCOs in this scheme.

(2) The HCOs shall be responsible for providing necessary medical attendance and treatment to the beneficiaries as per the approved package rate.

(3) No service charge over and above the approved package rate shall be charged by any HCO.

(4) If any HCO refuses to treat a beneficiary as per the approved package rate as provided under this scheme and insists for undergoing treatment by paying cash, the beneficiary shall, in writing, intimate the matter to the GAA and the direction of the GAA in this regard shall be binding on such HCO.

(5) In case of acute emergency, the HCO shall start treatment immediately without waiting for formal authorisation from the GAA and the GAA shall settle the matter with the HCO expeditiously after getting information.

(6) A report of service rendered in each month by HCOs shall be furnished to the authority under this scheme through e-mail.

7. Selection, duties and functions of Government Authorised Agency (GAA)

(1) The GAA shall be selected through competitive tender process and those organisations having experience and/or adequate manpower in the related field, shall be allowed to participate in the tender process.

(2) The GAA shall maintain adequate establishment for managing the scheme.

(3) The GAA shall have to employ adequate number of doctors, computer professionals, accountants etc. for this purpose.

(4) The GAA shall be paid fixed administrative costs, remuneration to be calculated on the basis of number of claims settled and annual performance bonus subject to deduction of taxes as applicable.

(5) The GAA shall be required to submit quarterly statement giving the details of bills received and endorsed during the quarter under report HCO wise, as well as annual statement as per specified performa through online procedure.

(6) The Finance Department may conduct test checks as and when necessary and the audit team may be deputed for this purpose and the GAA shall extend all sorts of cooperation for this purpose.

(7) The guidelines as may be provided by the Finance Department from time to time shall be binding on the GAA.

(8) The GAA shall prepare the cashless card as specified containing the name of the employee or pensioner or beneficiary and also the Beneficiary Identification Number and the GAA shall dispatch to the employee or pensioner concerned all the card(s) of his family member(s) by courier service.

(9) Colour of cashless card shall be different for the employees and the pensioners. The cards shall be marked as X, Y, Z depending on the category of the employee or pensioner concerned.

8. Powers of authority under this scheme

The authority shall have the following powers under this scheme

(1) If the GAA fails to make authorisation for payment of the bill and forward the same to the authority, the authority may consider such bill as duly authorised by the GAA.

(2) If the GAA informs the authority under this scheme that any HCO is continuously refusing treatment as per package rate under this scheme, such authority may, upon being satisfied after enquiry and after giving an opportunity of being heard, terminate contract with such HCO and may recommend to the concerned authority for cancellation of the licence under the West Bengal Clinical Establishment Act, 1950 and the rules made thereunder.

9. Operational guidelines, clarifications, etc.

(1) The Finance Department, in consultation with the Health and Family Welfare Department wherever necessary, shall issue operational guidelines, clarifications, etc. for implementation.

(2) If any difficulty arises in the course of implementation of the scheme, it shall be referred to the Finance Department and the decision of the Finance Department thereon shall be final and binding on all the HCOs, GAA and the beneficiaries.

APPROVED PACKAGE RATE FOR CASHLESS TREATMENT UNDER W.B. HEALTH FOR ALL EMPLOYEE AND PENSIONERS CASHLESS SCHEME, 2014

By order of the Governor,

Shri H.K Dwivedi
Principal Secretary to the
Government of West Bengal

No. 4476-F dated 28.08.2014, Source