Measures for the Implementation of the New Rural Cooperative Medical Serious Illness Insurance

1. Reimbursement process of rural serious illness medical insurance.

1. The recipient of assistance shall submit a written application to the village (resident) committee where the household registration is located;

2. After receiving the application, the village (resident) committee shall investigate and verify the authenticity of the application materials submitted by the applicant and the applicant's family income, and submit the investigation and verification opinions to the village (resident) representative meeting for democratic evaluation;

3. After the democratic appraisal of the village (resident) representative meeting, the village (resident) representative meeting shall put forward democratic evaluation opinions, and the qualified applicants shall be publicized in the open column of village (resident) affairs, and the publicity period shall not be less than 3 days;

4. If there is no objection to the publicity, the village (resident) committee shall put forward the preliminary review opinions, and submit other materials to the township (town) people's ** and sub-district offices for review;

5. The township (town) people's ** and sub-district offices shall review the materials submitted by the village (resident) committee, and submit the audit opinions and other materials to the county (city, district) civil affairs department for examination and approval;

6. The county (city, district) civil affairs department shall review the materials submitted by the township (town) people and sub-district offices. For those who meet the requirements, fill in the approval opinions and the amount of assistance, and issue the "Serious Illness Medical Assistance Certificate for Urban and Rural Residents in Difficulty" uniformly printed by the Civil Affairs Bureau and the Health Bureau, and send it to the financial department at the same level for review; For those who do not meet the conditions for assistance, the applicant shall be promptly notified and the reasons shall be explained.

2. The following materials shall be provided for individual applications:

1. Application for medical assistance;

2. Household registration booklet, ID card of the person applying for assistance;

3. Copy of rural (urban) low guarantee;

4. Discharge certificate and transfer certificate of the applicant for hospitalization;

5. Original invoice for hospitalization medical expenses;

6. Copies of medical diagnosis and medical records.

3. Reimbursement ratio of rural outpatient medical insurance for serious illnesses.

For the reimbursement ratio of rural outpatient serious illness medical insurance, the starting line standard is 20,000 yuan, and if it exceeds 20,000 yuan, it can be reimbursed through serious illness medical insurance. Above the starting payment line, the reimbursement ratio of critical illness medical insurance is:

10,000-50,000 yuan, serious illness medical insurance can be reimbursed according to 50%.

10,000-100,000 yuan, serious illness medical insurance can be reimbursed according to 60%.

If the amount is more than 10,000 yuan, the serious illness medical insurance can be reimbursed according to 70%.

【Abstract】NCMS Critical Illness Insurance is a policy implemented on the basis of NCMS basic medical insurance, which gives the right to reimburse large medical expenses for the second time. It is understood that the reimbursement ratio of NCMS serious illness medical insurance is at least 50%, and the compensation ratio is 60% for the part above 50,000 yuan to 100,000 yuan. 1. NCMS Critical Illness Insurance compensates according to the level of medical expenses.

【Abstract】NCMS Critical Illness Insurance is a policy implemented on the basis of NCMS basic medical insurance, which gives the right to reimburse large medical expenses for the second time. It is understood that the reimbursement ratio of NCMS serious illness medical insurance is at least 50%, and the compensation ratio is 60% for the part above 50,000 yuan to 100,000 yuan.

1. NCMS Critical Illness Insurance compensates according to the level of medical expenses. After the participating patients are compensated according to the current NCMS basic medical security policy, the annual cumulative compliant medical expenses borne by the individual are deducted from the NCMS serious illness insurance threshold, and the compensation ratio is 50% within 50,000 yuan; For the part between 50,000 yuan and 100,000 yuan, the compensation ratio is 60%; For the part above 100,000 yuan, the compensation ratio is 70%.

2. According to the calculation of the participating year, the annual cap line is 250,000 yuan.

In the event that the participant suffers from a serious illness and incurs high medical expenses, after being compensated according to the current NCMS policy, the part of the eligible medical expenses that need to be borne by the individual exceeds the threshold will be covered by the serious illness insurance.

The starting line shall be set by each city divided into districts, and shall not be higher than 15,000 yuan in principle. It will be adjusted according to the statistics and the actual situation in the future. In principle, it is determined once a year. For those who meet the conditions for medical assistance (rural poor households), the minimum payment line will be reduced by 50%.

Within the maximum payment limit, the higher the medical expenses, the higher the payment ratio, and the minimum reimbursement ratio is not less than 50%, so that residents can get rid of the dilemma of "poverty due to illness and return to poverty due to illness".

Legal analysis: The reimbursement scope of rural serious illness medical insurance includes 20 types of major diseases, including leukemia, end-stage renal disease, breast cancer, cervical cancer, severe mental illness, drug-resistant tuberculosis, etc.

Legal basis: "Detailed Rules for the Implementation of the Social Insurance Law of the People's Republic of China" Article 8 The medical expenses incurred by the insured persons in the agreed medical institutions shall be paid from the basic medical insurance in accordance with the provisions of the State if they meet the standards of the basic medical insurance drug list, diagnosis and treatment items and medical service facilities.

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.

Legal Analysis: Scope of Rural Cooperative Serious Illness Medical Insurance: First or main diagnosis of childhood leukemia, childhood congenital heart disease, end-stage renal disease, breast cancer, cervical cancer, severe mental illness, multidrug-resistant tuberculosis, AIDS opportunistic infection, lung cancer, esophageal cancer, gastric cancer, colon cancer, rectal cancer, chronic myeloid leukemia, acute myocardial infarction, cerebral infarction, hemophilia, etc.

Legal basis: Social Insurance Law of the People's Republic of China

Article 2: The State shall establish social insurance systems such as basic endowment insurance, basic medical insurance, work-related injury insurance, unemployment insurance, and maternity insurance, to protect citizens' right to receive material assistance from the State and society in accordance with law in the event of old age, illness, work-related injury, unemployment, childbirth, and so forth.

Article 72: Social insurance agencies are to be established in the coordinating regions. According to the needs of work, social insurance agencies may set up branches and service outlets in their respective areas with the approval of the local social insurance administrative departments and institutional establishment management organs. The personnel expenses of the social insurance agencies and the basic operating and management expenses incurred in handling social insurance shall be guaranteed by the finance department at the same level in accordance with the provisions of the State.

Article 73: Social insurance agencies shall establish and improve operational, financial, security, and risk management systems. Social insurance agencies shall pay social insurance benefits in full and on time.

If you participate in NCMS and have one of the 22 major diseases, you can generally apply for reimbursement, but the specific scope of reimbursement is as follows:

1. Within the scope of 22 types of major diseases in NCMS;

2. The hospital for medical treatment is a county-level or municipal-level designated medical institution;

3. Recipients of the minimum subsistence guarantee for urban and rural residents, rural families impoverished due to illness, rural households with five guarantees, key preferential recipients who enjoy regular bereavement allowances from the civil affairs department, retired workers in the 60s who enjoy regular and quantitative living subsidies from the civil affairs department, and extremely poor workers approved by the Federation of Trade Unions.

Whether the specific reimbursement depends on the local NCMS serious illness insurance policy, if you meet the criteria for the serious illness subsidy, you can receive the subsidy as long as you submit the relevant materials.

NCMS Serious Illness Medical Insurance covers 20 types of major diseases, including rural childhood leukemia, childhood congenital heart disease, severe mental illness, breast cancer, cervical cancer, end-stage renal disease, multidrug-resistant tuberculosis, AIDS opportunistic infection, lung cancer, esophageal cancer, gastric cancer, colon cancer, rectal cancer, chronic myeloid leukemia, acute myocardial infarction, cerebral infarction, hemophilia, type I diabetes, hyperthyroidism, cleft lip and palate, etc. The actual reimbursement rate of hospitalization expenses for patients shall not be less than 70%, and the maximum reimbursement rate can reach 90%.

For high medical expenses, the annual cumulative compliant medical expenses borne by the individual may exceed the annual per capita disposable income of urban residents and the annual per capita net income of rural residents announced by the local statistics department in the previous year, and the specific amount shall be determined by the local government.