Serious illness medical insurance

Serious illness medical insurance is a special medical insurance fund set up to protect the medical needs of urban workers for major diseases, which is used to pay the medical expenses (excluding out-of-pocket expenses) that the insured who participated in the basic medical insurance for urban workers exceeded the maximum payment limit of basic medical insurance (40,000 yuan) during the year. Every insured person who participates in the basic medical insurance pays the medical insurance premium for serious illness to the municipal and district social insurance bureaus every year in 48 yuan. Medical expenses exceeding the maximum payment limit of the basic medical pooling fund shall be reimbursed by the social security department for 85% below RMB 0-40,000, 90% below RMB 40,000-80,000 and 95% above RMB 80,000. The maximum payment limit for each medical year is 6.5438 yuan +0.5 million yuan.

First, the concept:

Units participating in medical insurance for serious illness must strictly follow the provisions of Beijing Municipality on Social Overall Planning of Medical Expenses for Serious Illness of Employees and Retirees of Local Urban Enterprises (Order No.6 of Beijing Municipal People's Government +65438) and relevant documents. This Ordinance aims to provide basic medical insurance for employees and retirees of enterprises in Bao Zheng when they are seriously ill.

Second, the scope of insurance:

These Provisions shall apply to local enterprises in cities, districts and counties within the administrative area of this Municipality (hereinafter referred to as enterprises) and their employees and retirees.

Three. Payment standard and payment time:

1. The unit (excluding foreign-invested enterprises) shall pay 6% of the average monthly salary of employees in this city in the previous year, and pay the overall medical expenses for serious illness on a monthly basis according to the number of employees in this unit.

2. Employees shall pay the medical insurance premium for serious illness on a monthly basis at 1% of the average monthly salary of employees in this Municipality in the previous year, which shall be withheld and remitted by the unit; 3. Units participating in medical insurance for serious illness as stipulated in the document of Beijing Labor Insurance [1998] 102 shall pay medical insurance premium for serious illness from 1 July, 998 1 day, and be established after1July, 998/day.

4. Last year, the average monthly salary of employees of foreign-invested enterprises in the city was 2.5%, and the overall medical expenses for serious illness were paid monthly according to the number of Chinese employees in the enterprise. Employees and retirees pay the overall medical expenses for serious illness on a monthly basis, accounting for 1% of the average monthly salary of employees in the city last year.

5. When the average monthly salary of enterprise employees is lower than 10% of the average monthly salary of employees in the whole city, 90% of the average monthly salary of employees in the whole city shall be taken as the base.

6 units must pay the medical insurance premium for serious illness in full monthly before the 30th of each month, without interruption.

Four, serious illness as a whole fund payment standards and reimbursement scope:

If the one-time hospitalization medical expenses of employees suffering from illness or non-work-related injuries or the accumulated part exceeding 2,000 yuan within 30 days (excluding the self-funded part and the personal burden part) fall within the scope of payment of the serious illness pooling fund, 90% of the part shall be paid by means of graded cumulative payment of1.2,000 yuan to 5,000 yuan;

85% for the part between 25,000 yuan and 1 1,000 yuan;

36,5438+80% of RMB 0,000 to RMB 30,000;

85% of the part of 43,000 yuan or more and 50,000 yuan or less;

Pay 90% for the part above 55,000 yuan.

The "above" mentioned in the preceding paragraph does not include this number, and "below" includes this number.

5. What medical expenses are not covered by reimbursement:

Medical expenses incurred under any of the following circumstances do not belong to a serious illness in medical insurance coverage:

1. See 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 regulations of the state and this Municipality, medical expenses should be taken care of.

6. How to reimburse medical expenses?

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

2. Examination and approval form for the allocation of serious illness medical expenses as a whole fund (III) (with official seal);

3. Correct discharge diagnosis (correct 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 sheet of hospitalization expenses (correct hospitalization reimbursement);

4. Special inspection, special treatment or use of expensive drugs shall issue an examination and approval form;

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

6. Referral treatment should provide a clear referral issued by the hospital's serious illness coordination office;

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 it will not be reimbursed after the time limit;

9. A one-time reimbursement system shall be implemented for serious illness medical expenses, and any omissions caused by enterprises, individuals and hospitals shall not be made up; 10. If the reimbursement materials are incomplete due to reasons of enterprises, individuals and hospitals, payment will be suspended.

Seven, how to transfer serious illness medical care?

For employees who have received medical insurance for serious illness, the social insurance agency will handle the transfer procedures in accordance with the relevant provisions of the Beijing Municipal Bureau of Labor and Social Security.

Eight, serious illness medical insurance medical management:

1. The designated hospital system shall be implemented for serious illness medical treatment. In the designated hospitals designated by social insurance agencies, units can choose two designated hospitals designated by the Municipal Labor Bureau and Health Bureau nearby in their business premises, including designated hospitals at or above the municipal level 1 home and district-level designated hospitals 1 home. If an employee goes to a designated hospital with a medical insurance card and really needs to be transferred for treatment, he shall go through the relevant transfer examination and approval procedures.

2. Employees who really need special examination and treatment (unit price 1000 yuan or more) or use expensive drugs must go through relevant examination and approval procedures.

3. Employees who participate in medical insurance for serious illness shall use prescriptions for serious illness as a whole when seeking medical treatment, and implement the scope of reimbursement for medical expenses and labor insurance drugs in Beijing and other relevant provisions on medical insurance and labor insurance stipulated by Beijing Municipal Labor Bureau. All "special drugs that need to be borne by other individuals" bear 20% of their expenses, and drugs that are not included in the "reimbursement scope" will not be reimbursed.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.