Employees Health Scheme rolled out finally with detailed financial and other packages
₹3 lakh limit for episode of illness but no ceiling on number of episodes
The State government has finally introduced a detailed Employees Health Scheme (EHS) offering significant benefits to employees, pensioners, and their eligible dependents. The scheme, governed by the Employees Healthcare Trust (EHCT), commenced operation on August 17. A key aspect of the scheme is the financial coverage, with beneficiaries entitled to ₹3 lakh per illness episode, with no limit on the number of episodes.
Despite this, the government ensured that cashless treatment would persist for cases where treatment costs surpass ₹3 lakh, prohibiting network hospitals from denying treatment. The ₹3 lakh limit would only be waived if predetermined package rates exceed ₹3 lakh. Claims between ₹3 lakh and ₹10 lakh per treatment episode will be reviewed and approved by a sub-committee comprising the technical committee and three to four members of the EHCT board. Episodes exceeding ₹10 lakh will be discussed in an emergency board meeting.
To implement the EHS effectively, the government instructed the EHCT to establish expert and executive committees. The expert committee will evaluate implementation issues and recommend technical improvements, while the executive committee will handle routine operations, coordinate with stakeholders, and forward critical policy matters to the board.
Payments under the scheme will follow the CGHS package rates notified in October 2025, with rate adjustments in cases where the government has set ceiling or control prices for medical items.
Admissible payments will generally be processed on a first-come, first-served basis, provided medical and financial scrutiny is completed, funds are available, and disputed or questionable claims are addressed. The scheme's funding will come from monthly contributions from serving employees, service pensioners, and family pensioners, along with equal matching contributions from the State government and additional budgetary support from the government as needed.
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