1. Scope of reimbursement of major illness insurance 1. Malignant tumor treatment: including malignant tumor chemotherapy (including endocrine-specific anti-tumor therapy), malignant tumor radiotherapy, isotope anti-tumor therapy, interventional anti-tumor therapy and traditional Chinese medicine anti-tumor therapy.
2. Outpatient hemodialysis and peritoneal dialysis treatment for severe uremia.
3. Anti-rejection treatment after kidney transplantation.
4. Treatment of serious mental illnesses: schizophrenia, depression (moderate and severe), mania, obsessive-compulsive disorder, mental retardation accompanied by mental disorders, epilepsy associated with mental disorders, and paranoid psychosis.
It should be noted that the following situations are not covered by the reimbursement scope of critical illness insurance: 1. Seeking treatment in non-designated hospitals without approval (except for emergency rescue); 2. Suffering from occupational diseases, work-related injuries or relapse of old work-related injuries;
Injuries caused by accidents (it is recommended to purchase commercial accident insurance); 3. Injuries caused by personal violations; 4. Food poisoning caused by liability accidents; 5. Treatment due to suicide (except for mental illness); 6. Due to medical accidents
Causing injuries; 7. According to the regulations of the state and this city, the medical expenses should be paid by oneself (it is recommended to purchase commercial supplementary medical insurance).
2. Major illness medical insurance reimbursement ratio 1. Minimum payment line: 20,000 yuan.
If the amount exceeds 20,000 yuan, it can be reimbursed through critical illness insurance.
2. Above the deductible line, the reimbursement ratio of critical illness insurance is: 1) 20,000 yuan to 50,000 yuan: 50% of critical illness insurance is reimbursed; 2) 50,000 yuan to 100,000 yuan: 60% of critical illness insurance is reimbursed; 3) 10
For more than RMB 10,000: 70% will be reimbursed by major illness insurance.
3. Annual reimbursement cap: 300,000.
3. Critical illness medical insurance reimbursement process 1. Materials required for critical illness medical insurance reimbursement: 1) ID card of the insured person; 2) Medical guarantee or medical insurance card of the insured person; 3) Original and copy of the medical expense settlement list.
2. Critical illness medical insurance reimbursement process 1) Insured persons need to bring the above materials to the medical insurance department of the local designated hospital to fill out relevant forms for preliminary review; 2) The designated hospital will submit the information of insured residents who have passed the preliminary review to each urban medical insurance agency for review; 3)
The insured residents who pass the final review will be organized by various urban medical insurance agencies to issue critical illness medical insurance reimbursements.
4. The reimbursement period for serious illness insurance is up to two years from the date of first diagnosis or recurrence of malignant tumors, of which Chinese herbal medicine treatment for malignant tumors can be enjoyed for 5 years.
Compared with previous years, what are the changes in the new policy of critical illness medical insurance? The changes are mainly reflected in the following aspects: 1. Lowering the minimum payment standard: the minimum payment standard has been reduced from 20,000 yuan to 18,000 yuan.
2. Increase the reimbursement ratio: The payment ratio of adult residents, children and college students who participate in the first-tier payment is increased from 60% to 65%; the payment ratio of adult residents who participate in the second-tier payment is increased from 50% to 55%.
3. Increase the over-limit subsidy: Employees’ medical insurance participants will be reimbursed at 90%; residents’ medical insurance participants, adult residents, children and college students who pay in the first level will be reimbursed at 80%, and adult residents who will pay in the second level will be reimbursed at 70%.
4. Increase in large-amount subsidies: Employees’ medical insurance participants will be reimbursed at 75%; adult residents, children and college students who pay in the first level will be reimbursed at 60%; adult residents who will pay in the second level will be reimbursed at 50%.
5. Free vaccination for children: Children over 4 years old are eligible for the second dose of chickenpox vaccine free of charge.
Legal basis: Article 28 of the "Social Insurance Law of the People's Republic of China" that meets the basic medical insurance drug catalog, diagnosis and treatment items, medical service facility standards, and emergency and rescue medical expenses shall be deducted from the basic medical insurance fund in accordance with national regulations.
Pay.
Article 29 The part of the medical expenses of the insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance agency and the medical institution and pharmaceutical business unit.
The social insurance administrative department and the health administrative department should establish a settlement system for medical expenses in other places to facilitate insured persons to enjoy basic medical insurance benefits.