The Ministry of Health and Family Welfare (MoHFW) has introduced new guidelines for Central Government Health Scheme (CGHS) cardholders to improve healthcare accessibility.

The updated guidelines, issued in an Office Memorandum (OM) on September 24, 2024, aim to streamline the referral process for consultations, treatments, and investigations at both government and empanelled private hospitals.

In the OM, the MoHFW addressed numerous queries regarding the CGHS referral process, previously outlined in an OM dated June 28, 2024.

To clarify these concerns, a Standard Operating Procedure (SOP) has been developed, focusing on making the referral system more user-friendly for CGHS beneficiaries.

Key changes in CGHS referral process

Access to government hospitals: Beneficiaries can now directly access services at major government hospitals like AIIMS and Tata Memorial Hospital without the need for prior referral or endorsement.

This applies to both consultations and treatment for unlisted procedures.

Private hospital consultations: A single referral from a CGHS Wellness Centre will be valid for three months, allowing beneficiaries to consult up to three specialists.

Beneficiaries are permitted a maximum of six consultations within this period.

Investigations and procedures: Routine investigations and minor procedures no longer require additional endorsements within the three-month referral period. However, specialised tests costing over ₹3,000 or procedures needing hospitalisation will still require prior approval.

Lowered age criteria: The age limit for accessing these services has been reduced from 75 to 70 years.

The new guidelines and SOP aim to enhance the overall experience of CGHS cardholders by reducing bureaucratic hurdles and ensuring timely access to medical services.

All healthcare organizations (HCOs) are expected to follow the updated SOP for referrals and medical bill uploads to the TMS portal.