The government has issued comprehensive clarification regarding existing CGHS guidelines through an Office Memorandum dated 11 August 2026 following a request from the Union Public Service Commission (UPSC). According to the memorandum, certain issues relating to reimbursement of medical claims have frequently been noticed in this office during scrutiny/processing of claims due to lack of clarity in the existing CGHS guidelines/instructions. The UPSC had flagged recurring issues while scrutinising medical reimbursement claims, prompting the need for these clarifications to provide greater clarity to beneficiaries and government offices handling such claims.
The clarified guidelines establish specific requirements for medical procedures and investigations. Tests costing up to ₹3,000 should generally be done at the same hospital where primary consultation was availed. For investigations costing up to ₹3,000 each, the investigation/test must be undertaken at the same hospital/HCO where primary consultation has been taken. If beneficiaries want to get tests/investigations done from any other CGHS empanelled hospital/HCO/Diagnostic Centre, they must obtain prior referral/endorsement from CGHS Wellness Centre. For investigations costing more than ₹3,000, a CGHS referral is required including major diagnostic investigations such as CT scans, MRI scans and PET scans. As per Business Standard, the basic rule is that follow-up treatment should remain with the hospital where the beneficiary had the initial consultation, with beneficiaries not assuming that a test prescribed at one hospital can automatically be carried out at another facility.
The guidelines specify additional requirements for specialized medical procedures. Referral/endorsement from CGHS shall be required for special investigations like CT Scan, MRI Scan, PET Scan and any other investigation costing over ₹3,000. Each consultation will be considered valid for a period of 7 days, provided it pertains to the same specialty. Eye consultation fees include refraction, tonometry and fundus examination, with the consultation fee covering these procedures and they should not be charged separately. The current CGHS memorandum of agreement with empanelled hospitals also specifies that an OPD consultation is valid for seven days within the same specialty. Business Standard reports that the CGHS has separately clarified what is covered under the eye consultation fee, including refraction, tonometry and fundus examination procedures.
The Ministry of Health & Family Welfare has substantially revised CGHS financial powers through an Office Memorandum dated 25 June 2026. The financial power has been increased from ₹7 lakh to ₹15 lakh, with the Additional Secretary & Director General, CGHS now able to approve reimbursement claims up to ₹50 lakh. This enhancement is expected to significantly reduce the number of cases referred to the Ministry, thereby speeding up reimbursement. Reimbursement will remain restricted to CGHS package rates or actual expenditure, whichever is lower, with cases exceeding ₹50 lakh still requiring Ministry approval. Business Standard notes that the clarifications are particularly relevant for pensioners and serving employees because medical reimbursement claims can be affected by procedural requirements, even when the underlying treatment itself is covered under CGHS.
The revised delegation introduces several practical changes for beneficiaries. The Additional Director of the concerned CGHS City or Zone has been empowered to grant permission or ex-post facto approval for elective treatment or investigations carried out in non-empanelled hospitals. This provision benefits pensioners who often undergo treatment in nearby hospitals not included in the CGHS empanelled list. The health ministry has also integrated the CGHS web portal with the Bhavishya portal to streamline the retirement process for government employees. The clarification also covers investigations or procedures that are not part of the listed CGHS services - if a specialist recommends an unlisted investigation, the beneficiary must obtain prior permission from the concerned department or office before proceeding. The revised powers are applicable to CGHS pensioners, serving CGHS employees and other eligible CGHS beneficiaries, with the Ministry emphasizing that delegated powers should be exercised on a case-to-case basis without creating automatic entitlements.
