CGHS rate changes explained: How 2025 reforms affect your healthcare costs

Scheme for central government employees expands eligibility criteria and makes cashless treatment easier

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The Central Government Health Scheme (CGHS) recently announced steps to make various services cashless and more accessible for over 1 million central government employees and pensioners. The scheme’s rates, eligibility criteria and rules will change from October 13.

Need for reform

 

CGHS beneficiaries were often forced to pay from their own pockets and wait months for refunds as outdated package rates meant hospitals hesitated to provide services without upfront payments. Pressure from employee unions, patient groups, and policy reviews prompted the government to fix the problem.

Base rate in CGHS

 

The base rate is the standard package rate set by CGHS for a medical procedure. It serves as a benchmark for calculating charges across hospitals, factoring in differences such as location and accreditation. Rates for hospitals are adjusted relative to this base rate.

 

If the base rate for a gallbladder surgery is Rs 33,000 in a hospital accredited to the National Accreditation Board for Hospitals & Healthcare Providers (NABH), then:

 

A non-NABH hospital may charge 15 per cent less: Rs 28,050. (NABH sets standards for CGHS healthcare and patient safety)

 

In a Tier-II city, the rate will be 19 per cent lower than the base rate: Rs 26,730.

 

In a Tier-III city, it will be 20 per cent lower: Rs 26,400.

 

The revised rates aim to ensure that fees are fair and tailored to local costs.

Changes in CGHS package rates

Rates have been revised for around 2,000 medical procedures to balance affordability for patients with sustainability for hospitals. The rates will vary based on city category and hospital accreditation:

• Tier-II cities: 19 per cent lower than the base rate
• Tier-III cities: 20 per cent lower than the base rate
• NABH-accredited hospitals: Base rate
• Non-NABH hospitals: 15 per cent lower than the base rate
• Super-specialty hospitals (200+ beds): 15 per cent higher than base rate

Inclusivity and expanded benefits

A significant change in the 2025 CGHS rules is expanded eligibility. Dependents who are transgender, including children and siblings of central government employees and pensioners, are now covered, regardless of age. They must be financially dependent and hold a valid certification under the Transgender Persons (Protection of Rights) Act, 2019.

 

This step reflects a broader push towards inclusivity in public healthcare.

Other notable updates include:

1. Strengthened the CGHS online portal and mobile app for quicker access to services.

 

2. Addition of more private hospitals to the CGHS panel.

 

3. An online referral system for faster approvals.

 

4. Real-time tracking of drug availability.

 

5. Special helpdesks for senior citizens.

   

Eligibility and enrolment

 

CGHS covers:

 

All central government employees (except certain railway and Delhi Administration employees) and their families.

 

Central government pensioners (excluding certain railway and armed forces pensioners).

 

Residents of designated CGHS cities, currently covering 80 cities nationwide.

Enrolment

 

Employees: Submit the required forms and family photos to your department.

 

Pensioners: Apply at the city’s Additional Director’s office or download forms from cghs.gov.in.

 

Provisional CGHS cards can be issued with a Last Pay Certificate if a Pension Payment Order is pending.

Where to check new rates

 

Updated package rates and procedure codes will be available on the official CGHS website under Circulars/Notifications.

 

These reforms mark a substantial step towards modernising the scheme, easing access to medical care, and improving the experience of millions of CGHS beneficiaries.