Policy letter on cashless treatment scheme in emergency (CTSE) in empanelled hospitals for retired employees and their dependent family members
GOVERNMENT OF INDIA
MINISTRY OF RAILWAYS
No.2014/H/28/1/smart Card/Part A
All Indian Railways
All production Units, NAIR & RDSO
Sub: Policy letter on cashless treatment scheme in emergency (CTSE) in empanelled hospitals for retired employees and their dependent family members.
Railway provides comprehensive health care facilities to its beneficiaries through its health institutions along with referrals to recognized hospitals whenever necessary. The beneficiaries, among others, include retired employees and their dependent family members. Large no. of retired beneficiaries live in the newly developed suburbs of various cities throughout India. These parts of the city are often far away from the established Railway Health Institutions. In this scenario the RELHS beneficiaries coming to Railway Health Institution in routine is acceptable, however in emergency situations, precious time is lost in travel to the railway hospital.
To overcome this problem, Railway Board has decided to roll out a “Cashless treatment scheme in empanelled hospitals for retired employees and their dependent family members in emergency situations” (CTSE). The empanelled hospital shall give necessary treatment in emergencies (defined in the draft agreement or DA) and raise the bill directly to Railway authorities; provided the identity and eligibility of the patient is established as CTSE beneficiary and emergency is certified by designated Railway Medical Authority (RMA). To implement this scheme on the ground, a system will have to be developed with provisions which are summarized as follows:-
(i) It should be possible for the retired employee/dependant family member to establish their identity and eligibility under the scheme, reasonably beyond doubt to the private/referral hospital.
(ii) The hospital should be able to communicate to the local Railway medical authorities sufficient medical data through internet/phone to establish the emergency, to get an authorization to treat the patient on railway account.
(iii) The bills raised by hospitals should be as per the mutually agreed rates.
(iv) This scheme should work seamlessly on pan India basis, i.e any retired beneficiary retiring from anywhere, settling in any city or moving from place to place, should be able to get emergency medical facility anywhere in India, in any of the recognized hospitals without the need of formal referral from the local railway medical authorities.
Note: To gain experience and smoothen out the possible hiccups, initially the scheme shall be launched in four metro cities; Delhi Urban Agglomeration (UA) or Delhi NCR,Mumbai (UA), Kolkata (UA) and Chennai (UA) as a pilot scheme for one year. The term ‘Urban Agglomerate’ includes the metro city and its suburbs, not necessarily restricting to municipal limits of the metro concerned.
To achieve the above objectives, it has been decided to issue such RELHS beneficiaries (retired employees and their dependent eligible family members, registered in these four cities at present) who are willing to become member of the new scheme, individual ‘CTSE plastic photo Identity Care’ (CTSE Card). This new CTSE card and scheme will have the following features:-
(a) the new CTSE card should have relevant demographic detail of the beneficiary i.e. name, date of birth, date of retirement of the ex-employee, photograph, address, PPO number, last pay drawn, designation at the time of retirement, Office from which retired, health unit/hospital at which RELHS card is registered, relation to the ex-employee etc. Since identification of beneficiary can be established quickly in real time by Aadhar No., it should also have Aadhar no. of the beneficiary. Accordingly, RELHS beneficiaries wishing to join CTSE shall be required to provide Aadhar Number as in absence of Aadhar Number establishing identity may consume precious time. To protect confidentiality of the beneficiary only certain part of this entire information (to the extent required) shall be printed in language. The remaining part shall be available in barcode/QR code which will be printed on the card.
(b) The hospital should be able to communicate with the Railway authorities on real time basis. M/s UTIITSL has been authorized to develop a website to facilitate this. Address of the website shall be communicated in due course.
(c) The new CTSE card shall be valid throughout the country and the website shall also be accessible from every part of the country.
(d) The list of referral hospital shall be available on website and should be updated regularly by zonal railways and should be visible to all beneficiaries.
(e) It is also to be noted here that CTSE is a new and additional scheme; even without the new CTSE Identity card, all the existing facilities will continue to be available to the RELHS beneficiaries as before.
(f) The prerequisite to join CTSE shall be the membership of RELHS. For this purpose the option to join RELHS now, for the already retired employees, is again thrown open. Such retired employees will have to complete all the formalities and deposit required fees with concerned personnel department office.
The outline of the CTSE scheme is as follows:-
The website will be maintained by the M/s UTIITSL, which will be operational round the clock, throughout the year. The website will have various modules:
(i) List of recognized hospitals, Zone, State, City and area wise, along with information on the services/specialties for which the hospital is recognized. Medical Department, at every zonal HQ shall provide the list of recognized hospital within their jurisdiction to the agency maintaining the site online.
(ii) The authorized persons from the Railway administration shall be able to log on to the site with unique id and password and perform various functions like updating the list of hospitals, type of treatments for which the hospital is recognised, authorize treatment, correspond with M/S UTIITSL and communicate with hospitals etc.
(iii) The recognized hospitals will also be having access to the site with a unique id and password to establish the identity and eligibility of the patient reporting to them, communicate with the Railway medical authorities, correspond with M/S UTIITSL, raise bills etc.
(iv) M/S UTIITSL shall enter into an MoU with Unique identification Authority of India (UIDAI). At the backend the website shall verify the identity of the patient by matching the biometrics (primarily fingerprint only and retinal scan if and when required) with the biometrics stored at the UID website through Aadhar no.
(v) The basic date, with Aadhar number being the key and the unique CTSE registration noc., of all beneficiaries, shall be stored at the website, Ideally, the initial identification of the beneficiary at the time of presenting to the hospital should be through comparison of the patient’s fingerprints (at the hospital’s finger print reader) to the UIDAI website biometric parameters itself. However, though there may be times when this is not possible, in such cases also the hospital can start the treatment. However, it will be the duty of the hospital to establish the identity of the patient through the biometrics (as described above) or otherwise before discharge. In absence of this verification, it will not be considered authorized treatment by Railways. In these cases it will be incumbent upon hospital to prove the emergency and get authorization of Medical Emergency from RMA.
(vi) In every case, the hospital will take the fingerprint of the patient treated in the case sheet, so that random checks may be conducted by Railway, whenever required.
(vii) The data base of the beneficiaries shall be provided to M/S UTIITSL by the personnel Department. IT is envisaged that all the Sr.DPOs shall be updating the date base at ARPAN and the data base at M/S UTIITSL shall be updated and matched daily (or at a frequency as decided by railway) with ARPAN, at a fixed time, online. The updating of the data base of ARPAN shall be done by railway with help of M/S UTIITSL as spelled out in detail in ‘Online and offline mode of CTSE ID card Application and issue.’
(viii) M/S UTIITSL shall maintain the website on a 24 hour basis for at least the next 5 years, with above mentioned functions, extendable on usual terms and conditions. The software, source code, etc. shall be the property of railways.
(ix) M/S UTIITSL may have to make a few modifications when the system starts working as per the experience gained from the working of the system.
How to implement the CTSE Scheme along with responsibilities of various departments
a. M/s UTIITSL will develop an application to enable RELHS beneficiary to apply for new CTSE Care at the website. Advertisements will be issued in the national, regional and local newspapers by NR,WR,CR,ER,SER,SR Metro Railway and ICF advising all RELHS beneficiaries registered in the four metro cities (UA) to apply online for CTSE. – Action by personnel Department.
Note: For the benefit of those RELHS beneficiaries who are not comfortable with the online form, an offline process of obtaining the card has also been designed, please see the annexes.
b. After filling up the form, the print out of the completed form will be submitted by the retired Railway employee to the concerned personnel Department (Division/Zone/PU/Other Units) along with Self attested photocopy of Aadhar Card, RELHS Card, PPO and any other documentary proof on the claims made in application form. The fee, to join CTSE per family (Comprising of all eligible members as per RELHS Card) shall be as follows:
Those entitled to Pvt Ward – Rs.50,000/- (fifty thousand)
Those entitled to Semi-Pvt Ward – Rs.25,000/- (twenty five thousand)
Those entitled to General Ward – Rs.10,000/- (ten thousand)
Ward entitlement is dependent upon last salary drawn and shall be displayed at the website while filling the form. – Action by personnel Department.
Note: All the existing facilities are even otherwise available to the RELHS beneficiaries. However to avail cashless treatment in recognized hospital (the new facility) they will have to get the new CTSE Card. personnel Department shall enter into an MOU with M/S UTIITSL for issuing the plastic CTSE card. One card to each beneficiary will be issued on payment of Rs.200/- Additional cards (in case of loss, mutilation etc.) Can be issued after payment of Rs.200/- by the beneficiary. The CTSE card shall also serve the purpose of RELHS identity card, for these beneficiaries, however the vice verse will not be true.
The amounts received (one time CTSE Joining fee and CTSE card cost) shall be credited to sundry earning. detailed head no.657 as below:
657 other Unclassified receipts
657 Receipts on account of recovery towards cost of cashless card and one time recovery for subscription under CTSE
c. The personnel Department will authenticate the bonafide of the beneficiaries (from the RELHS Card etc.) New/additional information as mentioned in application form, duly verified by personnel department would also get incorporated in the data base for each and every application (within a reasonable time frame). Personnel Department shall duly authenticate application and authenticate application and authorize M/S UTIITSL to make “CTSE photo-identity Card” which will be issued to the beneficiary. M/S UTIITSL shall use the updated database at ARPAN/UTI website for printing the new CTSE card. This way there will be 1005 conformity between the data base and the new CTSE Card. – Action by personnel Department and W Railway in respect of ARPAN
Note: Since ther are different practices in different zones for maintaining the service records every zone will devise its own methodology for verification of the application forms. For smooth implementation of the scheme it would be advisable to issue a joint procedure order duly signed by CPO, Fa&CAO,CMD and PHOD/CHOD of concerned Department (wherever other Departments maintain their employees’s service records separately); the requirements for manpower and other resources may be taken care of in the JPO.
d.after commencement of the scheme, the newly retired personnel intending to settle in the four metros can apply to become member of CTSE in addition to RELHS. personnel department shall issue CTSE cards to them with the help of M/S UTIITSL (till the time scheme is extended to the other regions this shall be restricted to those retiring persons who are settling in four metros (UA). – Action by personnel Department
Note: The points given herein above at (a) to (d), will take care of both the groups of retirees; those who have already retired and those who will be retiring in future. In any case the exercise of issuing the CTSE cards shall be a continuous one. Those persons who are not comfortable with online application shall be able to obtain CTSE card by complete offline mode. Detailed process flows are attached as Annexes.
e. Medical Department of zonal railways will empanel private hospitals (located in its geographical limits) recognized by CGHS at the same rates (CGHS empanelled hospitals which are not lying in the jurisdiction of any Zone/PU shall be empanelled by the zone which has jurisdiction in some part of that district/state). Model MoA to be followed, is attached along with this letter as Draft Agreement (DA). The MoA has been vetted by the Finance directorate and Legal Directorate of Railway Board and as such there is no need to get it vetted again at Zonal/Divisional level. The concerned MD/CMS/CMO can enter into MoA with the CGHS empanelled hospital located, within jurisdiction of the hospital, with concurrence of the associate finance. If there is no CGHS empanelled hospital at a place and a need is felt for an empanelled hospital, then Railways will recognise suitable hospital(s) as per the already existing procedure. All the zonal HQs will be communicating the list of empanelled hospitals online to M/s UTIITSL who are maintaining the site on real time basis. Initially only the CGHS recognized hospital shall be empanelled by Railway, but eventually the objective is to have at least one suitable hospital empanelled by railway in every district. The list of civil districts distributed amongst railway divisions for the purpose shall be distributed separately later. – Action by Medical Department.
Note: All the CGHS empanelled Hospitals shall be approached by concerned CMS/MD and if willing every hospital in CGHS list, providing emergency treatment, shall be empanelled by Railway. There shall be 2 annexes with the prescribed MoA. First annexure will be the relevant city specific CGHS rate list and the second set of Annexes will be the different process flows attached with this letter as annexes.
f. Every year 5% cases of every hospital shall be audited. – Action by Medical Department
g. Each empanelled hospital will be allotted to a particular Railway Health Institution which is nearest/suitable as decided by the divisional/zonal authorities. For every administrative function e.g. authorization of emergency, bill submission, bill payment etc. The empanelled hospital will have to communicate with that particulay Railway Health Institution or the concerned CMS/MD/CMO office only. the CMS/MD/CMO/ACMs-in-charge will have to make a roster so that at least one medical officer is always available to authorize treatment at each empanelled hospital daily. – Action by medical Department.
Note: In earlier system, hospital recognition used to be for the treatment of patients of that particular division/unit only. In this new scheme, any railway patient belonging to any zone/unit may be treated at any recognized hospital but the bill shall be processed by the local medical and account department only. If need be, a debit note shall be raised later by this local unit on to the concerned zone/PU.
h. A CTSE beneficiary in an emergency situation can go to any of the nearby private empanelled hospital (list accessible at the M/S UTIITSL website). At time of admission in private hospital the beneficiary will have to make a deposit at following rate;
Those who are entitled to Private Ward – Rs. 10,000/-
Those who are entitled to semi-private ward – Rs.5,000/-
Those who are entitled to General Ward – Rs.2,000/-
If the medical condition turns out to be an emergency then the hospital shall refund the deposited amount (to the CTSE beneficiary) within 48 hrs of authorization otherwise this deposit shall be adjusted towards the bill payment of the treatment/investigations undertaken till the time emergency authorization is declined by Railway, In such cases, where condition is not found to be an emergency, the balance part of payment (after adjustment of initial deposit by the beneficiary) shall be borne by Railway, only till the time emergency was declined. – Action by Medical Department
i. Information about any railway patient admitted to an empanelled hospital will be communicated by the empanelled hospital to the Railway Health Institution which signed the MoA (described in detail in process flows attached to this document). Authorization for treatment will be given by Railway Health Institution (through its designated Railway medical officers) based on clinical parameters communicated by the hospital within 24 hrs. The communication will be normally through the website/SMS, however if the situation demands other means of communication may also be employed. – Action by Medical Department
j. If the authorization is not forthcoming from the designated doctor within 24 hours period then at the end of 24hr period the concerned MD/CMS/CMO shall automatically receive an alert, to make a decision and communicate it to hospital. Likewise there will be an automatic alert to the concerned CMD at 36 hrs and AGM at 47 hour period. if Railway fails to respond within 48 hrs, then that case shall be considered an emergency and the cost of entire treatment shall be borne by Railway. List of all cases, in which no decision could be made about emergency within 48 hrs period, despite private hospital submitting all the details, shall be put up to GM every month.
k. If emergency authorization is declined the patient shall be apprised through sms by the system and the patient will be transported to Railway Hospital by the empanelled hospital in its own ambulance or the patient may be asked to report to Railway hospital for treatment at convenient hour. The Railway will bear the expenses till the emergency authorization is declined by a positive act. If the patient or his/her representative refuses Railway Medical Services and opts to continue treatment in the non-railway facility the cost of such treatment will be borne by the patient or his/her representative without any further reimbursement from Railway. In line with provisions of MoA signed between MoHFW and CGHS empanelled hospitals, such bills by the hospital shall however be at CGHS rates as per terms and condition of Railway MoA with the hospital and payments will be made by the patient or his representative. Railway Beneficiaries shall be required to give an undertaking to this effect at the time of applying for CTSE Card and for such balance treatment Railway will not be liable for payment in any way and the entire liability will be borne by the patient or his/her representative. – Action by Medical and personnel Department.
The hospital shall raise the bill online to M/S UTIITSL (within 7 days of discharge of the patient) which will exercise checks and get it corrected from concerned hospital, if required. Thereafter a physical copy of the corrected bill shall be submitted by the hospital to Mis UTIITSL. – Action by Medical Department
m. M/S UTIITSL shall process the bill as per the extant rules and applicable rates as per MoA, and thereafter submit it to MD/CMS/CMO office both online and offline (within 15 days of submission of corrected bills by the hospital).
n. After approval of MD/CMS/CMO the office shall submit the bill to associate accounts Department (within 15 days of submission of corrected bills by M/s UTIITSL). Account Department will pass the bills and make the payment to the hospital and M/S UTIITSL (within 15 days of submission of approved bills). M/S UTIITSL fee is 2% of the amount of the bill raised by the hospital subject to a minimum of Rs.12.50 and a maximum of Rs.750) plus Rs.1/- for the SMS service. The M/s UTIITSL fee is not in addition to the hospital bill, rather this amount shall be debited to the heads as per the note below. The 2% fee of M/s UTIITSlL has been fixed at the same level as CGHS is paying them, this may go upward or lower revision as per the CGHS action in this regard and such changes shall be advised by Railway Board. – Action by Accounts Department on Zones and Health Directorate of Railway Board
Note: The process flow charts in various situations and backend are attached as annexes 1.1 to 1.7. Detailed accounting head, under minor head 200 and subhead 240, have been modified/created for debiting the cost as follows:
200 Medical Services (existing)
240 payment to non-railway hospitals, reimbursement of medical expenses and miscellaneous
241 Reimbursement to serving railway officials for emergency medical treatment and assistance at non-railway institutions/hospitals. (Non-referred cases where beneficiary pays first and then claim reimbursement later) 242 Reimbursement to retired railway officials for emergency medical treatment and assistance at non-railway institutions/hospitals. (Non-referred cases where beneficiary pays first and then claim reimbursement later.)
243 payment to non-railway institutions/hospitals for medical treatment of serving railway official in cases referred by Railway Medical Dept. (referred cases.)
244 payment to non-railway institutions/hospitals for medical treatment of retired railway officials in cases referred by railway medical dept. (Referred cases).
245 payment to non-Railway institutions/hospitals for treatment of retired railway subscribers to cashless treatment scheme in emergency (CTSE) declared as emergency by RMA.
246 Payment to non-Railway institutions/hospitals for medical treatment of retired railway subscriber to cashless treatment scheme (CTSE) in cases which are not declared as emergency.
247 payment of fess to outsourced mediating agency (M/s UTIITSL) under cashless Emergency Treatment Scheme. 248 cost of TB treatment in sanatoria.
249 other expenses.
o. In case the patient belongs to some other railway zone, then the debit shall be raised to the concerned zone at a later stage as per the extant codal provisions, but the bill shall be passed by the local accounts only. – Action by Accounts Department
The whole exercise will require creation of additional infrastructure like space, computers, printers, scanners, other associated equipments, furniture etc to be created in offices responsible for running the schemes that is health units, hospital Sr DPO office, Sr DFM office. This requirement needs to be worked out by the respective branch officers. As far as purchase of new PCs, printers etc. is concerned, the same is left to the discretion of the DRM and this requirement would be over and above the normal powers given to DRM for purchase of new PCs.
FA & CAO, CMD and CPO of these 8 zonal Railways/PU (NR,WR,CR,ER,SER, Metro railway, SR and ICF) may nominate one deputy FA & CAO, deputy CMD and one deputy CPO as nodal officers of these units to implement the cashless treatment scheme and for authorization of various activities for CTSE scheme.
An effort has been made to foresee all the situations and give solutions to them. However, a new work of this magnitude will throw up new challenges as we go along. Those challenges will have to be met with the underlying philosophy that this scheme is to give social security to one of the most vulnerable group of society. i.e the elderly group of people who had served Railways in their youth, hence, innovative solutions may have to be found many a times. Having said this, it is also imperative to state that enough safeguards and precautions are always exercised to ensure that the provisions of the scheme are not misused.
M/s UTIITSL shall be conducting coaching cum interactive sessions for the empanelled hospital staff and the railway staff of medical, personnel and accounts Department to familiarize them with the working of the website and different procedures to be followed (the period of one year of pilot scheme start only after the website starts working and not from the date of issue of this letter.) All the zones/PUs are advised to nominate and get their staff members, who will be working for implementation of the scheme, trained in these sessions. the Railway shall be implementing this scheme in coordination with M/S UTIISL, hence it is desirable that the concerned officials should be in touch with the local M/S UTIITSL officials so that any problem that crop up can be sorted out swiftly. A list of contact persons of M/S UTIITSL will be circulated in due course of time.
These documents are very comprehensive and contain a lot of information it may be read in its entirety, for proper understanding of the scheme. In case of any difficulty/clarification the respective directorate (Viz, Health, Finance or personnel) Official may be contacted at a convenient time.
This letter is issued with approval of Railway Board. The draft agreement attached with this letter is also vetted by the finance and legal directorate of the Railway Board. This issues with the concurrence of Finance Directorate of the Board.