The Nagaland Health Protection Society (NHPS) has issue clarification to certain aspects relating to a recent grievance raised by a beneficiary under the Chief Minister Health Insurance Scheme (Employees & Pensioners) [CMHIS (EP)] regarding charges incurred during a prolonged Neonatal Intensive Care Unit (N1CU) admission at an empanelled hospital. The beneficiary raised concerns regarding an additional amount of Rs.5,15,704 billed by the hospital for the course of treatment, where only Rs. 1,63,975 was processed and settled under the Scheme as the eligible claim amount.
In response to the matter, the NHPS has taken up the issue with the concerned empanelled hospital and has reiterated the following provisions under the CMHIS Scheme:
1. NICU and Newborn Care Packages: Under the existing CMHIS Health Benefit Packages, N1CU bed charges are covered in accordance with the approved package rates. In addition, the Scheme provides coverage for Paediatric Care for Newborns, wherever applicable, in accordance with the approved package guidelines. Additionally, the Scheme also provides separate add-on packages for oxygen, laboratory and diagnostic investigations.
2. Coverage of Medicines and Other Services: Medicines are reimbursable through the Open Billing mechanism where the claims for drugs are settled as per the NPPA ceiling or on actual cost of the drugs.
3. Consultation Charges: Consultation charges are included within the approved package rates and are not payable separately. Additional consultation charges are admissible only in cases of approved cross-consultations, where such add-on provisions are specifically provided for under the Scheme Guidelines.
4. Utilisation of Scheme Provisions: The NHPS has emphasised that all applicable package provisions, claims settlement and approval processes available under the CMHIS Scheme must be fully explored and appropriately utilised before concluding that any expenditure is not covered under the Scheme.
5. Cashless Treatment and Prohibition on Additional Charges: Under the CMHIS Scheme, no additional amount shall be recovered from a beneficiary except for non-payable items as per the IRDAI guidelines (e.g. diapers, toiletries etc) and for instances where the beneficiary voluntarily opts for a higher room entitlement or higher-value implants beyond the Scheme entitlement, as expressly permitted under the Scheme Guidelines. In all other circumstances, the Scheme mandates the provision of cashless treatment, and recovery of any outstanding amount from the beneficiary is not permissible.
6. Obligations under the Empanelment Agreement: The NHPS has further reminded the hospital that, at the time of empanelment, it executed a Memorandum of Understanding (MoU) with the State Health Authority, having accepted the approved package rates and the Scheme Guidelines. By virtue of this agreement, the hospital undertook to provide cashless treatment to all eligible AB PM-JAY/CMHIS beneficiaries strictly in accordance with the approved package rates and Scheme provisions.
Accordingly, the concerned empanelled hospital has been advised to process the claim strictly in accordance with die applicable CMHIS package provisions and the CMHIS Scheme Guidelines, and to refrain from recovering any amount from the beneficiary except in circumstances expressly permitted under the Scheme.
The Nagaland Health Protection Society (NHPS) remains committed to safeguarding the interests of beneficiaries and ensuring that all empanelled healthcare providers adhere to the Scheme Guidelines.
In the event of any concern or difficulty, NHPS kindly requests both beneficiaries and empanelled hospitals to contact the NHPS Team as the first point of contact. Early communication enables NHPS to work closely with all concerned parties to facilitate a timely and amicable resolution, helping to minimise inconvenience and avoid unnecessary escalation.
AB PM-JAY and CMHIS beneficiaries may reach the NHPS Toll-Free Helpline at 1800-202-3380 by call or WhatsApp to seek assistance or register a grievance.
(DIPR)