What are the special critical diseases covered by medical insurance, and what special diseases are c

Including: malignant tumors, acute myocardial infarction, sequelae of stroke, major organ transplantation or hematopoietic stem cell transplantation, coronary artery bypass grafting (or coronary artery bypass grafting), end-stage renal disease (or chronic renal failure uremia stage), multiple limb loss, benign brain tumor, chronic liver failure decompensation, encephalitis sequelae or meningitis sequelae, etc.

1. Malignant tumors.

Refers to the uncontrolled progressive growth and spread of malignant cells, infiltrating and destroying surrounding normal tissues, and can be menstrual blood. Diseases in which the tubes, lymphatic vessels, and body cavities spread to other parts of the body. The diagnosis is confirmed by pathological examination.

The clinical diagnosis falls under the category of malignancies under the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10).

2. Acute myocardial infarction.

Refers to partial myocardial necrosis caused by insufficient blood supply to the corresponding area due to coronary artery occlusion. At least three of the following conditions must be met:

1) Typical clinical manifestations, such as acute chest pain;

2) recent ECG changes suggestive of acute myocardial infarction;

3) diagnostically elevated cardiac enzymes or troponin, or dynamic changes consistent with acute myocardial infarction;

4) 90 days after the onset of the disease, the left ventricular function was confirmed to be reduced, such as the left ventricular ejection fraction was less than 50%.

3. Sequelae of stroke.

It refers to cerebral vascular hemorrhage, embolism or infarction caused by sudden lesions of cerebral blood vessels, and leads to permanent dysfunction of the nervous system. Permanent dysfunction of the nervous system, defined as one or more of the following disorders remaining 180 days after the diagnosis of the disease:

1) Complete loss of function of one or more limbs;

2) complete loss of language ability or ability to chew and swallow;

3) Complete loss of the ability to live independently, unable to perform three or more of the six basic activities of daily living independently.

4. Major organ transplantation or hematopoietic stem cell transplantation.

Major organ transplantation refers to an allogeneic transplant of the kidney, liver, heart or lungs due to organ failure.

5. Coronary artery bypass grafting (or coronary artery bypass grafting).

Refers to the most severe coronary heart disease, and the operation of coronary artery bypass grafting with thoracotomy was actually performed. Coronary artery stenting, cardiac catheterization balloon dilation, laser radiofrequency technology and other non-thoracotomy interventional procedures and laparoscopic surgeries are not covered.

Legal analysis: According to the regulations, there are the following 19 special diseases in the medical insurance: tuberculosis, childhood autism, complete growth hormone deficiency, malignant tumors, chronic heart failure, chronic respiratory failure, chronic renal failure, chronic liver failure, severe Alzheimer's disease, Parkinson's disease, chronic aplastic limb abrasion, chronic viral hepatitis, hemophilia, systemic lupus erythematosus, cerebrovascular accident, hypertension, diabetes, severe mental disorders, Anti-abrasion rejection after tissue and organ transplantation**, etc.

Legal basis: "Regulations on the Administration of Medical Institutions" Article 35 Medical establishments shall handle the special diagnosis and treatment of patients with infectious diseases, mental illness, occupational diseases, etc., in accordance with the provisions of relevant national laws and regulations.

Critical illnesses covered by medical insurance include the following:

1. Childhood leukemia;

2. Congenital heart disease;

3. End-stage renal disease;

4. Breast cancer;

5. Cervical cancer;

6. Severe mental illness;

7. Drug-resistant tuberculosis;

8. AIDS chance infection;

9. Hemophilia;

10. Chronic myeloid leukemia;

11. Cleft lip and palate;

12. Lung cancer;

13. Esophageal cancer;

14. Gastric cancer;

15. Type I diabetes mellitus;

16. Hyperthyroidism;

17. Acute myocardial infarction;

18. Cerebral infarction;

19. Colon cancer;

20. Rectal cancer.

Medical insurance generally refers to basic medical insurance, which is a social insurance system established to compensate workers for economic losses caused by the risk of disease. Through the employer and individual payment, the establishment of medical insurance**, after the insured person is sick and incurs medical expenses, the medical insurance institution will give him a certain amount of economic compensation.

The establishment and implementation of the basic medical insurance system gathers the economic strength of the unit and the members of the society, coupled with the first funding, which can enable the sick members of the society to obtain the necessary material help from the society, reduce the burden of medical expenses, and prevent the sick members of the society from "becoming poor due to illness".

Medical insurance, in the traditional sense, refers to the management of medical insurance by a specific organization or institution, through mandatory policies and regulations or voluntary contracts, in a certain area of a certain group of insured people**.

Medical insurance has the basic characteristics of social insurance, such as compulsory, mutual aid and sociality. Therefore, the medical insurance system is usually enforced by national legislation, and the establishment of a first-class system, the cost is jointly paid by the employer and the individual, and the medical insurance premium is paid by the medical insurance institution to solve the medical risk caused by the illness or injury of the worker.

Legal basis] Detailed Rules for the Implementation of the Social Insurance Law of the People's Republic of China

Eighth insured persons in the agreement of the medical expenses incurred in the medical institutions, in line with the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards, in accordance with the provisions of the State from the basic medical insurance **.

If the insured person really needs emergency treatment or rescue, he or she can seek medical treatment in a non-agreed medical institution; The scope of drugs that must be used for rescue purposes may be appropriately relaxed. The specific management measures for medical services for emergency and rescue of insured persons shall be formulated by the overall planning area according to the actual local situation.

Although the medical insurance for serious illnesses does not clearly stipulate the types of diseases, more than 20 major diseases of NCMS have reference significance, including: childhood leukemia, congenital heart disease, end-stage renal disease, breast cancer, cervical cancer, severe mental illness, drug-resistant tuberculosis, AIDS infection, hemophilia, chronic myeloid leukemia, cleft lip and palate, lung cancer, esophageal cancer, gastric cancer, type I diabetes, hyperthyroidism, acute myocardial infarction, cerebral infarction, colon cancer, and rectal cancer. The first batch of 20 diseases has been clearly included in the scope of serious illness medical insurance.

After the hospitalization expenses incurred by rural residents and urban residents are compensated by the basic medical insurance, 73% of the medical expenses borne by individuals with more than 10,000 yuan will be compensated, and 17% will be compensated for the part less than 10,000 yuan. Hospitalization individuals suffering from diseases other than 20 types of major diseases will be compensated 50% for the part of medical expenses of more than 10,000 yuan and less than 100,000 yuan, and 60% of the compensation will be given for more than 100,000 yuan. Each insured resident will be compensated up to 200,000 yuan by annual critical illness insurance.

According to the regulations, there are the following 19 special diseases in the medical insurance: laughing tuberculosis, childhood autism, complete growth hormone deficiency, malignant tumors, chronic heart failure, chronic respiratory failure, chronic renal failure, chronic liver failure, severe Alzheimer's disease, Parkinson's disease, chronic aplastic anemia, chronic viral hepatitis, hemophilia, systemic lupus erythematosus, cerebrovascular accident, hypertension, diabetes, severe mental disorders, anti-rejection after tissue and organ transplantation, etc.

1. How to deal with chronic diseases under medical insurance.

1. Processing conditions: Insured persons participating in supplementary medical insurance, including:

1. Suffering from 12 chronic diseases: diabetes, hypertension (stage tremor), chronic hepatitis (except hepatitis A), malignant tumors, coronary heart disease, Parkinlin's disease, sequelae of stroke (including cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage), chronic bronchitis (including bronchial asthma), chronic nephritis (including renal insufficiency), rheumatoid arthritis, systemic erythema, chronic aplastic anemia.

2. Co-ordinate the medical expenses with a maximum payment limit of more than 40,000 yuan.

II. Handling Procedures:

1) The outpatient expenses of 12 chronic diseases exceed 800 yuan, and the supplementary medical insurance** payment ratio is 70%, and the maximum payment limit is 2,500 yuan; If the self-payment exceeds 600 yuan for those over 70 years old, the supplementary medical insurance ** payment ratio is 80%, and the maximum payment limit is 3,000 yuan.

2) Co-ordinate the part with a maximum payment limit of more than 40,000 yuan, and 90% of the supplementary medical insurance**, with a maximum payment limit of 160,000 yuan.

3. Bring the required materials to the local social security department for processing, and consult the local social security department for details.

Application materials: original and photocopy of resident ID card, social security card, a recent one-inch bareheaded color **, a copy of the inpatient medical record related to the declared disease (stamped with the special seal for the photocopying of the hospital's inpatient medical record) and related imaging data (such as X-ray, CT film and examination report, etc.).

4. Wait for the reimbursement to be issued.

2. What diseases are included in the scope of medical insurance reimbursement?

What are the types of diseases covered by the critical illness medical insurance: Although the serious illness medical insurance does not clearly stipulate the types of diseases, more than 20 major diseases of NCMS have reference significance, including childhood leukemia, congenital heart disease, end-stage renal disease, breast cancer, cervical cancer, severe mental illness, drug-resistant tuberculosis, AIDS infection, hemophilia, chronic myeloid leukemia, cleft lip and palate, lung cancer, esophageal cancer, gastric cancer, type I diabetes, hyperthyroidism, acute myocardial infarction, cerebral infarction, colon cancer, and rectal cancer. Shandong Province has clearly included the first batch of 20 diseases in the scope of serious illness medical insurance.

Reimbursement scope: For some particularly expensive serious diseases, China will establish a supplementary medical insurance reimbursement system, and on the basis of basic medical insurance reimbursement, reimbursement will be given again, and the actual reimbursement ratio is not less than 50.

Article 35 of the Regulations on the Administration of Medical Institutions: Medical establishments shall handle the special diagnosis and treatment and treatment of patients with infectious diseases, mental illness, occupational diseases, etc., in accordance with the provisions of relevant state laws and regulations.

Sycamore Tree Insurance Network helps you answer your questions

Hello, there are certain differences in the scope of medical insurance for serious illnesses in different regions. Among them, the serious illness medical insurance includes 20 major diseases such as rural childhood leukemia, colon cancer, severe mental illness, AIDS opportunistic infection, childhood congenital heart disease, cervical cancer, end-stage renal disease, multidrug-resistant tuberculosis, breast cancer, hemophilia, lung cancer, esophageal cancer, hyperthyroidism, gastric cancer, rectal cancer, cerebral infarction, chronic myeloid leukemia, type diabetes, acute myocardial infarction, cleft lip and palate, etc.

For some areas, the serious illness covered by the critical illness medical insurance is not defined according to the type of disease, but according to the medical expenses incurred by the residents. For the expenses that fall within the scope of reimbursement of the basic medical insurance for local residents, after the reimbursement of the basic medical insurance, the remaining medical expenses will be included in the payment scope of the serious illness medical insurance for local residents for the second reimbursement.

This year, the reimbursement ratio of serious illness medical insurance is for medical expenses that exceed the maximum reimbursement limit of basic medical insurance, which will be reimbursed by social security institutions in accordance with: 85% of the expenses below 0 to 40,000 yuan, 90% of the expenses below 40,000 yuan to 80,000 yuan, and 95% of the expenses above 80,000 yuan. The maximum reimbursement limit is $150,000 per medical year.

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China's critical illness insurance includes: deafness in both ears, blindness in both eyes, paralysis and blindness, heart valve surgery, malignant tumors, acute myocardial infarction, sequelae of stroke, major organ transplantation or hematopoietic stem cell transplantation, coronary artery bypass grafting, end-stage renal disease, multiple limb loss, acute or subacute abrasive hepatitis, benign brain tumor, deep coma, severe Alzheimer's disease, etc.

Article 28 of the Social Insurance Law.

Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facility standards, and emergency and rescue medical expenses shall be paid from the basic medical insurance in accordance with national regulations.

Article 29.

The part of the medical expenses of the insured persons that should be paid by the basic medical insurance** shall be directly settled by the social insurance agency and the medical institution and the drug business unit.

The administrative department of social insurance and the administrative department of health shall establish a system for the settlement of medical expenses for medical treatment in other places to facilitate the insured persons to enjoy basic medical insurance benefits. Cover key.