Employees Health Scheme rolled out finally with detailed financial and other packages

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The State government has finally rolled out a comprehensive Employees Health Scheme loaded with several facilities for employees, pensioners and their eligible dependents.

The guidelines framed by the Employees Healthcare Trust for effective operation of the scheme came into force from August 17. One of the major features of the scheme is the financial coverage, with the government announcing that the beneficiaries will be eligible for ₹3 lakh per episode of illness ‘with no limit on the number of episodes’.

The government took care to ensure that cashless treatment will continue in cases where the treatment costs exceed ₹3 lakh, directing the network hospitals not to deny treatment for them. “The limit of ₹3 lakh will not apply in cases where predetermined package rates are above ₹3 lakh,” according to the circular issued by the government.

Claims above ₹3 lakh and up to ₹10 lakh per treatment episode would be examined and approved by a sub-committee consisting of the technical committee along with three to four members of the board of trustees of the EHCT. Claims exceeding ₹10 lakh per treatment episode would be placed before the quorum of the board/trust in an emergency meeting convened either physically or through digital mode for appropriate decision.

The government directed the EHCT to constitute expert and executive committees for effective implementation of the EHS. The expert committee would review the implementation issues arising under the scheme, recommend technical improvements and the executive committee would discuss routine operational matters, coordinate with hospital associations and other stakeholders and place important policy matters before the board of trustees for the final decision.

The government said that the payments under the scheme will be based on the CGHS package rates notified in October 2025 and the package amounts should be regulated in cases where the government has notified ceiling or control prices for implants, stents, devices, drugs or consumables. All admissible payments should ordinarily be processed on a first-in, first-out (FIFO) basis subject to completion of medical and financial scrutiny, availability of funds and withholding of disputed or suspected claims. The approved package rates might be reviewed when CGHS rates are revised or when required on account of EHS experience subject to approval of the Board or the government.

The New Employees Health Scheme shall be financed through monthly beneficiary contributions recovered from serving employees, service pensioners and family pensioners, an equal matching contribution by the State government and such additional budgetary support as may be provided by the government from time to time.

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