Insured participating in medical insurance

Reimbursement scope of serious illness medical insurance

The insured person in any of the following circumstances, enjoy serious illness outpatient treatment:

1, chronic renal failure outpatient dialysis;

2, into the scope of medical insurance payment of organ transplant outpatient anti-rejection drugs;

3, malignant tumor outpatient chemotherapy, interventional therapy, radiotherapy or radionuclide therapy;

4, hemophilia specialist outpatient treatment;

5, aplastic anemia specialist outpatient treatment;

6, thalassemia specialist outpatient treatment;

7, intracranial benign tumor specialist outpatient treatment

8. Other serious diseases, etc.

What are the situations in which medical insurance for critical illness cannot be reimbursed?

1, seeing a doctor in a non-designated hospital without approval (except for emergency rescue);

2. Suffering from occupational diseases, work-related injuries or recurrence of old injuries;

3. Injuries caused by traffic accidents;

4. Injuries caused by my illegal acts;

5. Food poisoning caused by accidents;

6. receiving treatment for suicide;

7. Injuries caused by medical accidents;

8, according to the provisions of the state and the city should take care of medical expenses.

Handling materials

1. Employee medical insurance card and serious illness medical insurance payment card;

2, serious illness medical expenses fund appropriation approval form (three copies) (with official seal);

3. Correct discharge diagnosis (emergency rescue diagnosis should be issued for emergency rescue), settlement list of overall hospitalization medical expenses of seriously ill patients, special receipt of hospitalization expenses in Beijing, and settlement list of hospitalization expenses (hospitalization reimbursement shall be subject to correct proof);

4, special inspection, special treatment or use of expensive drugs should issue an approval form;

5. Outpatients need to issue prescriptions for correct diagnosis and serious illness and special receipts for outpatient charges in Beijing;

6, referral treatment should be provided by the hospital serious illness co-ordination office issued a clear referral;

7, other materials as stipulated in the overall medical care for serious illness.

8. The time limit for reimbursement of documents shall be based on the last day within 60 days of discharge or outpatient service, and will not be reimbursed after the time limit;

9, a one-time reimbursement system for serious illness medical expenses, where the omission caused by enterprises and individuals, the hospital will not repay;

10. If the reimbursement materials are incomplete due to reasons of enterprises, individuals and hospitals, payment will be suspended.

Treatment process

Once hospitalized, all patients with serious diseases must send the medical certificate, my basic medical insurance diagnosis and treatment manual and other materials to the medical insurance department of the hospital where they are located for registration and verification, so as not to affect the reimbursement of hospitalization medical expenses;

To apply for outpatient reimbursement for 23 diseases such as liver cirrhosis, the insured residents should go to the medical insurance department of the designated hospital to fill in the relevant forms in May and June 165438+ 10 every year for preliminary examination.

Designated hospitals will report the information of insured residents who have passed the preliminary examination to the urban medical insurance agency for review.

The insured residents who finally pass the examination and approval shall be organized by the urban medical insurance agency to issue the Medical Certificate of Specific Diseases in the Basic Medical Insurance Outpatient Department of Taiyuan City, which will take effect after being sealed, and they will enjoy the treatment of chronic diseases in the outpatient department from July and June of 5438+ 10.

Reimbursement proportion standard

The actual payment ratio of serious illness insurance is not less than 50%.

In terms of the coverage of major illness insurance for urban and rural residents, the Opinions pointed out that the coverage of major illness insurance is urban residents' medical insurance and the new rural cooperative medical system, and the coverage should be connected with urban residents' medical insurance and the new rural cooperative medical system. The medical insurance for urban residents and the new rural cooperative medical system should provide basic medical security according to the policy. On this basis, the major illness insurance mainly guarantees the eligible medical expenses of urban residents compensated by medical insurance and the new rural cooperative medical system when the insured (co-insured) is seriously ill and the medical expenses are high. In addition, the level of serious illness insurance is aimed at avoiding catastrophic medical expenses for urban and rural residents, and the compensation policy for serious illness insurance is reasonably determined, and the actual payment ratio is not less than 50%; The proportion of payment is determined according to the level of medical expenses. In principle, the higher the medical expenses, the higher the payment ratio.