RGHS – AISRAJPEN

Introduction

Government of Rajasthan has been providing medical facilities to Hon’ble MLAs, Ex-MLAs and its State Government employees and pensioners through provisions under various Rules, Scheme and Medical Insurance Policies. State Autonomous bodies / Boards / Corporations are providing medical facilities through their own regulations. The main rules / schemes are as under:

The Rajasthan Legislative Assembly Members (Medical Facilities) Rules, 1964
Rajasthan Legislative Assembly Ex-Members and Family Pensioners (Medical Facilities) Rules, 2010
Rajasthan Civil Services (Medical Attendance) Rules, 2013
Rajasthan State Pensioners’ Medical Concession Scheme, 2014
Raj Mediclaim Policy

In addition to above, Ministers, All India Service Officers are also getting medical facilities under following rules:

The Rajasthan Ministers (Medical Attendance) Rules, 1961
All India Services (Medical Attendance) Rules, 1954

About the Scheme

All hospitals run by State Government, approved Hospitals and Public Private Partnership Hospitals will be eligible for providing medical facilities under this scheme as per norms and terms and conditions. In case of grave emergency, treatment will be allowed in Referral Hospitals after due reference from competent authority.

The Scheme is based on CGHS rates and provisions if otherwise not amended under this Scheme for the treatment taken in empaneled hospitals.

This Scheme will provide:

OPD Treatment
Cashless Facility for IPD/day care services.
Investigations at Government and Empaneled Diagnostic centers
Family Welfare, Maternity and Child Health Services.

RGHS: Fully Online and Automated system

Identified database for beneficiary status of family (Jan Aadhar)
Hospital Empanelment by HBEC (Apply and approve system) on RGHS web-portal: Online and transparent procedure
Pre-authorization at hospital level only
Online Payment System to Hospitals

Claim Settlement under RGHS

The claim settlement procedure will be on IT Platform of RGHS through the RGHS portal and the electronic medical record (EMR) of each beneficiary will be kept in RGHS card holder’s e-Wallet.

RGHS Coverage in case of CATASTROPHIC ILLNESS

Cases of Coronary Artery Surgery, Vascular Surgery, Hodgkin’s Disease, Acute Retention of urine more than 24 hrs., Acute Myocardial infarction, Acute Pneumonitis, Acute Respiratory Distress, Cancer, renal failure i.e. failure of both the kidney, Stroke,, Multiple Sclerosis, Meningitis, Major organ Transplants like Kidney ,Lungs, Pancreas, Heart, Liver or Bone Marrow, Accidents, Delivery, Tubal Pregnancy and related complication, swine flu, dengue fever, burst Appendicitis, Pancreatitis etc. can be covered under as cases of grave emergency.

Definitions in RGHS

RGHS means Rajasthan Government Health Scheme.
Coverage shall mean the types of persons to be eligible as the beneficiaries of the Scheme to health services provided under the Scheme, subject to the terms, conditions and limitations.
Cashless facility means a facility to make payment of treatment costs directly to the hospital in respect of treatment undertaken in an empanelled hospital to the extent as per this Scheme.
Catastrophic illness means severe illness requiring prolonged hospitalization for recovery. These illnesses involve high cost of treatment and make a person incapable from working and creating a financial hardship.
CGHS means “Central Government Health Scheme”.
RGHS Card means e-card issued to beneficiary of RGHS.
SABs means State Autonomous Bodies within the jurisdiction of Government of Rajasthan and it also includes Boards / Corporations etc. only for the purpose of this Scheme.
AYUSH Treatment means treatment under Ayurved, Unani, and Homeopathy systems under this Scheme.
Beneficiary shall mean a person who is eligible for coverage under RGHS and hold a valid RGHS card for the benefit.
Benefit shall mean the extent or degree of service the beneficiaries are entitled to receive as per the rules on the subject.
Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In-patient Care’ hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours.
Health Care Network Provider (HCNP) means Government and Empanelled / PPP Health Care units enlisted in this Scheme.
MOA shall mean Memorandum of Agreement and all Schedules, supplements, appendices, appendages and modifications thereof made in accordance with the terms of this Agreement.
Outdoor patient means treatment taken by the RGHS Card Holder as outdoor patient but it does not include day-care treatment.
Patient means RGHS Card holder including his/her family, who has fallen ill and to whom this Scheme apply.
Pre-existing disease means any disease prior to the inception of this Scheme.
Pre-hospitalization / Post hospitalization benefits means medical benefits upto 7 days pre-hospitalization and upto 30 days post hospitalization respectively which would cover all expenses related to the sickness for which hospitalization was done. The beneficiary shall avail this benefit on cashless basis.
Pre-authorization means process of identification of beneficiary on IT system of RGHS for the purpose of IPD/Day Care Treatment.
Bill Clearing Agency (BCA) shall mean an authority authorized by RGHS to process the medical reimbursement claims or to carry out medical audit.
Package Rates for allopathy treatment shall mean as per approved CGHS rates.
Pensioner means retired State Government employees and also employee of Panchayat Samiti and Zila Parishad who is granted pension under the Rajasthan Civil Services (Pension) Rules, 1996 or is retired on the Contributory Provident Fund benefits. Retired employees under NPS and retired employees of SABs / Board / Corporations etc., will also be included as pensioner only for the purpose of RGHS. The term “Pensioner” shall also include “Family Pensioner”.
TPA means Third party Administrator as a part of bill clearing agency engaged for the purpose of pre-authorization and claim processing services for eligible family)
Treatment means administration of medicines / surgery / surgical facilities / vaccinations to cure, control and prevent any disease. Inclusion and exclusion under “Treatment” as per point No. 4 of this Scheme,

Beneficiaries and Scheme Coverage

Beneficiary Category	Rules / Scheme presently applicable	RGHS Coverage
Ministers	Medical facilities as per The Rajasthan Ministers (Medical Attendance) Rules, 1961	Coverage as per Rules Applicable
Members of Rajasthan Legislative Assembly	Medical facilities as per The Rajasthan Legislative Assembly Members (Medical Facilities) Rules, 1964	Coverage as per Rules Applicable
Ex-Members of Rajasthan Legislative Assembly	Medical facilities as per Rajasthan Legislative Assembly Ex-Members and Family Pensioners (Medical Facilities)Rules, 2010	Coverage as per Rules Applicable
Serving AIS Officers	Medical facilities as per All India Services (Medical Attendance) Rules, 1954 and also various orders issued by DOP in this regard.	Coverage as per Rules Applicable
Retired AIS		Coverage as per Rules Applicable
Serving State Government employees	Medical facilities as per RCS(MA) Rules, 2013	Coverage as per Rules Applicable
Pensioners and family pensioners under RCS (Pension) Rules, 1996	Medical facility as per Rajasthan State Pensioners Medical Concession Scheme, 2014	Coverage as per Rules Applicable
Serving employees of State Autonomous Bodies (SAB) including Boards, Corporation etc. who were appointed prior to 01.01.2004	As per applicable Scheme of concerned Board / corporation etc.	Cashless IPD/ DAY Care, OPD (Upto Rs.20,000), Medical Care facilities as per CGHS rates or other rates as decide by competent authority. •Treatment up to 5 lacs per family on floater basis. •Additional expenses relating to catastrophic illness up to Rs 5 lacs per family. •Travelling allowance for journeys undertaken for medical treatment as applicable TA Rules. •Ambulance Charges.
Serving employees of State Autonomous Bodies (SAB) including Boards, Corporation etc. who were appointed on or after 01.01.2004	Presently under Raj Mediclaim Scheme.	•Cashless IPD/ DAY Care, OPD (Upto Rs.20,000), Medical Care facilities as per CGHS rates or other rates as decide by competent authority. •Treatment up to 5 lacs per family on floater basis. •Additional expenses relating to catastrophic illness up to Rs 5 lacs per family. •Travelling allowance for journeys undertaken for medical treatment as applicable TA Rules. •Ambulance Charges.
Pensioners of State Autonomous Bodies (SAB) including Boards, Corporation etc. who were appointed prior to 01.01.2004	As per applicable Scheme of concerned Board / corporation etc.	•Cashless IPD/ DAY Care, OPD (Upto Rs.20,000), Medical Care facilities as per CGHS rates or other rates as decide by competent authority. •Treatment up to 5 lacs per family on floater basis. •Additional expenses relating to catastrophic illness up to Rs 5 lacs per family. •Travelling allowance for journeys undertaken for medical treatment as applicable TA Rules. •Ambulance Charges.
Pensioners of State Autonomous Bodies (SAB) including Boards, Corporation etc. who were appointed on or after 01.01.2004	No medical facilities.	• Cashless IPD/ DAY Care, OPD (Upto Rs.20,000), Medical Care facilities as per CGHS rates or other rates as decide by competent authority. • Treatment up to 5 lacs per family on floater basis. • Additional expenses relating to catastrophic illness up to Rs 5 lacs per family. • Travelling allowance for journeys undertaken for medical treatment as applicable TA Rules. • Ambulance Charges.