Uttarakhand State Government Health Scheme

Scheme Introduction: A Brief Overview

The Uttarakhand State Government Health Scheme (SGHS) provides healthcare benefits to eligible Uttarakhand State Government employees, pensioners and their dependent family members. The scheme has been running since 1 January 2021 and works on a contributory basis. Eligible beneficiaries can access cashless inpatient treatment at SGHS empanelled hospitals, while eligible OPD expenses can be reimbursed at applicable Central Government Health Scheme (CGHS) rates. The scheme aims to reduce the financial burden of medical treatment and improve access to healthcare for government employees and pensioners.

Under SGHS, eligible beneficiaries can receive medical treatment through empanelled government and private hospitals. The scheme also provides reimbursement for eligible OPD treatment, including consultation, diagnostic and radiology services and medicines. Treatment at non-empanelled hospitals can also qualify for reimbursement subject to the applicable SGHS rules. The State Health Authority material states that the scheme provides medical treatment without an annual family ceiling.

The scheme covers eligible dependent family members along with employees and pensioners. The SGHS rules include dependent spouses, dependent sons and daughters up to 25 years, certain dependent daughters without an age limit, dependent parents and dependent children with the required disability certification. Employees and pensioners of eligible autonomous bodies, corporations, authorities, universities and grant-aided institutions can also come under SGHS where their institution adopts the scheme.

SGHS operates on a contributory basis, with the applicable contribution deducted from the salary or pension according to the prescribed pay level. Beneficiaries receive hospital bed entitlement according to their applicable pay level. Employees under the New Pension Scheme can obtain the SGHS card after completing 10 years of service, with an option to obtain a lifetime Golden Card by paying the required 10 year contribution in a lump sum. Together, state government employees and pensioners make up over 2.5 lakh beneficiaries under the scheme.

Uttarakhand also benefits from the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the central government health assurance scheme, along with the state's Atal Ayushman Uttarakhand Yojana. PM-JAY provides health coverage to eligible families for secondary and tertiary hospitalisation, while Atal Ayushman Uttarakhand Yojana extends health coverage to eligible families in the state. The Uttarakhand State Government Health Scheme (SGHS) serves a different beneficiary group by specifically covering eligible State Government employees, pensioners and their dependants.

Beneficiaries can complete SGHS related formalities through their concerned department and DDO. Aadhaar and Employee Code or GRD Number are required for KYC, while eligible family members must be added and approved in the SGHS system. After approval, beneficiaries can obtain the SGHS Golden Card through authorised centres or empanelled hospitals with the help of an Ayushman Mitra. For medical reimbursement, beneficiaries must submit the prescribed medical records, bills and certificates through their concerned office within the applicable time limit.

Scheme Benefits

The Uttarakhand State Government Health Scheme provides medical treatment and reimbursement benefits to eligible government employees, pensioners and their eligible dependants. The major benefits include:

• Beneficiaries can receive cashless IPD treatment at SGHS empanelled hospitals.
• The scheme provides medical treatment with no annual family ceiling, unlike the ₹5 lakh limit that applies under Atal Ayushman Uttarakhand Yojana.
• Cashless IPD treatment also extends to listed hospitals outside Uttarakhand through the National Health Authority's hospital portability network.
• No referral is required for treatment at listed private hospitals within Uttarakhand.
• A referral is required only for treatment at non-listed hospitals outside the state, and this requirement is waived in an emergency.
• Treatment at non-empanelled hospitals can be reimbursed at applicable CGHS rates, subject to SGHS rules.
• Where CGHS rates are not fixed for a particular treatment, reimbursement is made at AIIMS rates, and where neither rate is available, the actual treatment cost is reimbursed in full as a rarest of rare case.
• An advance payment of up to 75% of the hospital's estimate is allowed for emergency treatment at a non-empanelled hospital.
• Eligible beneficiaries can claim reimbursement for OPD treatment at applicable CGHS rates.
• OPD reimbursement covers consultation, diagnostic and radiology services, and medicines.
• Registered diagnostic centres and pharmacies provide free OPD diagnostics and medicines to employees and pensioners.
• Eligible dependants of employees and pensioners can receive medical treatment under the scheme.
• Ayush treatment expenses can be reimbursed at applicable CGHS rates under the SGHS provisions.
• Beneficiaries receive different hospital bed categories according to their applicable pay level.
• Employees under the National Pension Scheme can receive a lifetime Golden Card by paying a lump sum contribution after completing a minimum of 10 years of service, and pensioners under the Old Pension Scheme have a similar lifetime card option.
• Medical reimbursement claims can be submitted through the concerned department and processed through the SGHS system.

SGHS Contribution

Uttarakhand State Government Health Scheme is a contributory scheme. The monthly contribution is deducted from the salary or pension according to the applicable pay level under the 7th Pay Commission.

• Level 1 to 5: ₹250 per month
• Level 6: ₹450 per month
• Level 7 to 11: ₹650 per month
• Level 12 and above: ₹1,000 per month

Eligible beneficiaries who need to make their contribution online can use the SGHS portal. The contribution payment process involves selecting the applicable month or period, generating a transaction ID and completing the payment through the available payment gateway.

Eligibility Requirements

Employees, pensioners and eligible dependent family members can receive benefits under the Uttarakhand State Government Health Scheme (SGHS) subject to the applicable scheme conditions. The main eligibility requirements are:

• Serving employees of the Uttarakhand State Government are eligible for coverage under SGHS.
• Retired State Government employees and pensioners are eligible beneficiaries under the scheme.
• The spouse of an employee or pensioner can qualify as a dependent when dependent on the employee or pensioner.
• Dependent sons and daughters can remain covered up to 25 years of age, subject to the applicable dependency conditions.
• Unmarried, divorced, deserted or widowed dependent daughters can remain covered without an age limit, subject to the applicable dependency conditions.
• Dependent parents of a government employee can receive coverage under SGHS.
• A dependent son or daughter with a mental or physical disability can qualify when the required 40% disability certificate issued by the Medical Board is available.
• Employees and pensioners of eligible autonomous bodies, corporations, authorities, universities and grant-aided institutions can be covered when their respective parent institution formally adopts the SGHS.
• Employees covered under the New Pension Scheme can obtain the SGHS card after completing 10 years of service and making the required contribution. They can also obtain a lifetime Golden Card by paying the contribution for 10 years in a lump sum, subject to the applicable SGHS provisions.

Persons Not Covered or Opting Out of SGHS

• Beneficiaries who have opted out of SGHS are not covered under the scheme from the applicable opt-out date.
• Pensioners and family pensioners who exercised the permitted opt-out option can have their medical reimbursement claims processed under the applicable earlier reimbursement provisions.
• Where an employee, pensioner or family member is covered under another applicable government health scheme, the relevant SGHS rules regarding coverage and opting out will apply.

Required Documents

Beneficiaries should keep the required identity, employment, family and medical documents ready for SGHS registration, Golden Card services and medical reimbursement. The exact documents may vary depending on whether the beneficiary is applying for the card or submitting a reimbursement claim.

Documents Required for SGHS Golden Card

• Aadhaar Card for KYC verification.
• Employee Code or GRD Number of the employee or pensioner.
• Family and dependant details approved through the concerned DDO, wherever applicable.
• Relevant pension or retirement records for pensioners, wherever applicable.

Documents Required for Medical Reimbursement

• Mandatory medical certificate containing the patient's name, disease, treatment period and treatment expenses.
• Medical certificate signed and stamped by the treating doctor and countersigned by the Medical Superintendent or authorised doctor.
• Original medical bills and vouchers for the treatment period.
• Detailed bill and final summary bill certified by the treating doctor.
• Original bills and vouchers bearing the signature and seal of the treating doctor.
• Case summary, discharge summary, death summary or other relevant medical records, as applicable.
• Documents establishing the eligibility of a dependant, wherever the claim relates to a dependant.
• Referral documents for treatment outside Uttarakhand, wherever referral is required under SGHS rules.
• Other documents prescribed by the concerned department or authority during claim processing.

Beneficiaries should submit the reimbursement records through their concerned department or office. The SGHS rules require the relevant medical records and bills to be submitted within 6 months after completion of treatment.

Steps to Apply

Eligible employees and pensioners can complete SGHS enrolment and beneficiary-related formalities through their concerned department and the SGHS system. The following steps explain the general process based on the available SGHS documents.

• Serving employees can apply for the Golden Card through their office's Drawing and Disbursing Officer, who prepares the card with staff support.
• Pensioners can apply for the Golden Card through their concerned treasury officer.
• Employees and pensioners can also get the Golden Card made at any Common Service Centre or at a listed government or private hospital through an Aarogya Mitra.
• Applicants need to submit their employee code or GRD number along with an Aadhaar card for KYC verification while applying for the card.
• Applicants need to pay a card fee of ₹30 per card at the time of application.
• Dependants get added to the Golden Card once the family details are submitted and approved by the concerned Drawing and Disbursing Officer.
• Beneficiaries can pay their monthly SGHS contribution online by logging in to the State Health Authority portal with their employee ID or pension code, selecting the SGHS menu, choosing the contribution option, entering the month range, and completing the payment through the available card or net banking options.
• Beneficiaries can undergo cashless inpatient treatment directly at an SGHS empanelled hospital by presenting their Golden Card.
• For OPD reimbursement, obtain the required medical records, bills and certificates and submit the claim through the concerned department/office.
• Beneficiaries need to submit their reimbursement claim, along with all supporting documents, to their concerned Office Head or Department Head within 6 months of completing treatment.
• The DDO accepts and forwards eligible reimbursement claims through the prescribed SGHS/IFMS process to the State Health Authority for processing.

Important Rules for SGHS Claims

Beneficiaries should follow the prescribed documentation requirements carefully because incomplete or improperly certified records can affect claim processing.

• Submit the original medical bills and vouchers for the treatment period.
• Bills relating to a period outside the approved treatment period are not admissible.
• Photocopies of the required original vouchers are not accepted for reimbursement.
• The mandatory medical certificate should contain the patient's name, disease, treatment period and treatment expenses.
• The treating doctor should sign and stamp the mandatory medical certificate with their name and designation.
• The required certificate should also be countersigned by the Medical Superintendent or authorised doctor.
• The detailed bill and final summary bill should be certified by the treating doctor.
• Attach the case summary, discharge summary or death summary, wherever applicable.
• Any correction or overwriting in a mandatory certificate should be properly authenticated.
• Eligible dependant claims must satisfy the applicable SGHS dependant conditions.

How to Pay SGHS Contribution Online

Beneficiaries who need to pay their SGHS contribution online can use the SGHS portal. The payment process requires the Employee ID or Pension Code and allows the beneficiary to select the applicable contribution period before making the payment.

1. Open the SGHS portal and log in using your Employee ID or Pension Code.
2. Go to the SGHS section.
3. Select the Contribution option.
4. Select the required month or contribution period.
5. Generate the Transaction ID for the selected contribution period.
6. Select Make Payment and proceed to the available payment gateway.
7. Complete the online payment using the available payment option.
8. Keep the payment receipt and Transaction ID for future reference.
9. After payment, check the contribution status through SGHS > Report > Contribution Status.

If an online payment has been made but the contribution is not reflected in the SGHS system, the beneficiary should keep the payment receipt and transaction ID and contact the designated SGHS support channel.

Treatment Outside Uttarakhand

SGHS beneficiaries can receive treatment outside Uttarakhand subject to the applicable referral and verification rules. Beneficiaries should follow the prescribed procedure before taking treatment outside the state, except in emergency situations.

• A referral from a government hospital is generally required for treatment outside Uttarakhand.
• The referral requirement does not apply in an emergency.
• An employee posted or working outside Uttarakhand does not need to return to the state to obtain the required referral.
• For treatment taken in another state, the reimbursement claim must undergo the applicable verification and countersignature process.

Medical Reimbursement Rules & Time Limit

SGHS beneficiaries can claim reimbursement for eligible medical expenses by submitting the required records through their concerned department or office. The scheme prescribes a specific time limit and documentation requirements for processing these claims.

• The reimbursement claim should be submitted within 6 months after completion of treatment.
• The beneficiary should submit the claim through the concerned department or office instead of directly submitting it to the countersigning officer.
• The DDO processes and forwards eligible claims through the prescribed SGHS/IFMS system.
• OPD reimbursement is provided at applicable CGHS rates.
• Medical reimbursement claims are verified and processed by the designated authorities according to the applicable claim amount.

Relevant Links

• Uttarakhand State Government Health Scheme (SGHS)
• Uttarakhand State Government Health Scheme Guidelines
• SGHS government orders and notifications
• State Government Health Scheme List of Hospitals
• SGHS claim status
• State Health Authority Portal
• Department of Medical Health and Family Welfare, Uttarakhand

Contact Information

• State Health Authority, Uttarakhand
  • Helpline: 155368
  • Toll free: 1800-1805368
  • DDO helpline: 8899890000
  • Email: [email protected]
• Department of Medical Health and Family Welfare, Uttarakhand
  • Phone: 0135-2608763
  • Email: [email protected]