Hezhou City Critical Illness Medical Insurance Regulations, Hezhou City Critical Illness Medical Insurance Reimbursement Scope

Application conditions

Participants of medical insurance

Scope of reimbursement of critical illness medical insurance

Insured persons have one of the following circumstances , enjoy outpatient serious illness treatment:

1. Outpatient dialysis for chronic renal failure;

2. Outpatient anti-rejection drugs after organ transplantation that are included in the payment scope of medical insurance;

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3. Outpatient chemotherapy, interventional therapy, radiotherapy or radionuclide therapy for malignant tumors;

4. Hemophilia specialist outpatient treatment;

5. Specialized outpatient treatment for aplastic anemia;

6. Specialized outpatient treatment for thalassemia;

7. Specialized outpatient treatment for intracranial benign tumors

8 , other serious diseases, etc.

What are the situations in which serious illness medical insurance cannot reimburse?

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;

3. Injuries caused by traffic accidents;

4. Injuries caused by personal violations;

5. Food poisoning caused by liability accident;

6. Treatment due to suicide;

7. Injury caused by medical accident;

8 , according to the regulations of the state and this city, the medical expenses should be paid by oneself.

Processing materials

1. Employee's "Medical Insurance Card" and "Critical Illness Medical Insurance Payment Card";

2. Approval of allocation of critical illness medical expenses coordination fund Forms (three) (with official seal);

3. Clear discharge diagnosis (clear emergency rescue diagnosis should be issued for emergency rescue), "Settlement List of Hospitalization Medical Expenses for Coordinated Patients with Serious Illnesses", "Beijing Hospitalization "Special Receipt for Charges" and "Hospitalization Bill" (correct for hospitalization reimbursement);

4. Approval forms should be issued for special examinations, special treatments or the use of expensive drugs;

5. Outpatients must provide a positive diagnosis, a prescription for serious illness coordination, and a special receipt for outpatient fees in Beijing;

6. For transfer treatment, a transfer certificate issued by the hospital’s serious illness coordination office must be provided;

7. Other materials stipulated by the serious illness medical coordination.

8. The time limit for document reimbursement is within 60 days based on the last day of discharge or outpatient service. No reimbursement will be made after the deadline;

9. A one-time reimbursement system for serious illness medical expenses is implemented. Any omissions caused by individuals or hospitals will not be reimbursed;

10. If reimbursement materials are incomplete due to enterprises, individuals or hospitals, payment will be suspended.

Handling process

All seriously ill patients, once hospitalized, must send the medical certificate, basic medical insurance diagnosis and treatment manual and other materials to the medical insurance department of the hospital where they are staying for registration and review as soon as possible. So as not to affect the reimbursement of hospitalization medical expenses;

To apply for outpatient reimbursement for 23 diseases such as liver cirrhosis, insured residents must bring their basic medical insurance diagnosis and treatment manual and the materials required to declare the disease in May and November each year Each month, go to the medical insurance department of the specified designated hospital to fill in the relevant forms for preliminary review;

The designated hospital will submit the information of insured residents who have passed the preliminary review to each urban medical insurance agency for review.

Insured residents who pass the final review will be issued a "Taiyuan Basic Medical Insurance Outpatient Special Disease Medical Certificate" by each urban medical insurance agency, which will take effect after being stamped and will be available from July and January. Outpatient chronic disease treatment.

Reimbursement ratio standards

The actual payment ratio of critical illness insurance shall not be less than 50

In terms of the protection content of critical illness insurance for urban and rural residents, the "Opinions" pointed out that critical illness insurance The objects of protection are those insured by urban residents' medical insurance and the new rural cooperative medical insurance, and the scope of protection must be connected with the urban residents' medical insurance and the new rural cooperative medical insurance. Urban residents' medical insurance and new rural cooperative medical insurance should provide basic medical security in accordance with policy regulations. On this basis, critical illness insurance mainly protects the qualified medical expenses that need to be borne by the individual after compensation from urban residents' medical insurance and New Rural Cooperative Medical Insurance when the insured person suffers from a serious illness and incurs high medical expenses. In addition, the level of critical illness insurance protection is aimed at avoiding catastrophic household medical expenses for urban and rural residents. The compensation policy for critical illness insurance is reasonably determined, and the actual payment ratio is not less than 50%. The payment ratio is set according to the level of medical expenses. In principle, the higher the medical expenses, the higher the payment ratio. The higher the payout ratio.