Can CGHS and AB-PMJAY Be Combined for Cataract Surgery With Multifocal Toric IOL Implantation?

Dear SESHASSYANAN ji,

Generally, CGHS and Ayushman Bharat PM-JAY cannot be combined to claim payment for the same cataract surgery without specific authorisation under the applicable scheme rules.

Cataract surgery may be covered under either scheme if the patient is eligible and the hospital and procedure meet the relevant requirements.

However, coverage of a multifocal toric intraocular lens (IOL) must be confirmed separately.

How do CGHS and Ayushman Bharat cover cataract surgery?

• CGHS: Cataract surgery is covered according to applicable CGHS rules and approved rates. The procedure rate may exclude the cost of the intraocular lens, so confirm the permitted lens category and reimbursement limit with the CGHS office and empanelled hospital.
• Ayushman Bharat PM-JAY: Cataract treatment is included in the scheme's package framework. However, the applicable package, lens specifications, beneficiary eligibility and hospital empanelment must be verified before treatment.
• Multifocal toric IOL: Do not assume that the full cost of this premium lens will be covered by either scheme. Ask the hospital to confirm in writing whether the lens is permitted under the applicable package and whether any additional payment is allowed.

Can both schemes pay for the same operation?

You should not assume that the two schemes can share the bill for one cataract procedure. Before booking surgery, contact your CGHS office and the hospital's Ayushman Mitra desk to confirm which scheme can be used and whether any combination of benefits is permitted under the applicable rules.

What should you confirm before the operation?

1. Confirm that the patient is eligible under the chosen scheme.
2. Check that the eye hospital is currently empanelled under that scheme.
3. Ask whether cataract surgery with a multifocal toric IOL is covered.
4. Request a written breakdown of the approved surgery charges, lens cost and any amount payable by the patient.
5. Obtain confirmation of the applicable scheme's approval before proceeding.

For official information, visit the CGHS website and the Ayushman Bharat hospital search portal.

Wishing you and your family good health always.
Warm regards,
Team HexaHealth