Policies and systems related to the Critical Illness Medical Card

Social insurance reimbursement method for serious illness: If the medical expenses of serious illness are within the reimbursement scope of the basic medical insurance drug list, diagnosis and treatment items, etc., the insured person can bring his ID card, social security card and medical expenses, drug expenses and other documents directly to the social insurance agency and medical institutions for reimbursement.

Legal basis] Article 26 of the Social Insurance Law of the People's Republic of China.

The treatment standards of basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with national regulations.

Article 28.

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.

If you still have questions about this issue, it is recommended that you organize the relevant information and communicate with a professional in detail.

First, the serious illness medical insurance is a special medical insurance established to protect the medical needs of urban employees for critical illnesses**, which is used to pay for the medical expenses (excluding out-of-pocket expenses) that exceed the maximum payment limit of basic medical insurance for insured persons participating in the basic medical insurance for urban employees.

Second, according to the regulations:

Medical expenses incurred in one of the following circumstances are not covered by critical illness medical insurance:

1.Seeking medical treatment in non-designated hospitals without approval (except for emergency rescue);

2.Suffering from occupational diseases, work-related injuries or work-related injuries**;

3.Injuries caused by traffic accidents;

4.Causing harm due to one's own violation of the law;

5.Food poisoning caused by a liability accident;

6.Caused by suicide;

7.Injuries caused by medical malpractice;

8.According to the provisions of the state and the city, the medical expenses shall be borne by themselves.

Third, diseases that can be included in the reimbursement scope of critical illness medical insurance:

Not all diseases are "serious diseases", nor can they be reimbursed all-round, China's insurance industry has unified and standardized the expression of the 25 most common diseases in critical illness insurance products, and the names of these 25 diseases are as follows:

1. Malignant tumors—excluding some early-stage malignant tumors.

2. Acute myocardial infarction.

3. Sequelae of stroke - permanent dysfunction.

4. Major organ transplantation or hematopoietic stem cell transplantation - allogeneic transplantation.

5. Coronary artery bypass grafting (or coronary artery bypass grafting) - thoracotomy is required.

6. End-stage renal disease (or chronic renal failure, uremia stage) - dialysis** or kidney transplantation.

7. Loss of multiple limbs—complete disconnection.

8. Acute or subacute severe hepatitis.

9. Benign brain tumors - craniotomy or radiation**.

10. Decompensated chronic liver failure - excluding alcohol or drug abuse.

11. Sequelae of encephalitis or sequelae of meningitis - permanent dysfunction.

12. Deep coma - excluding alcohol or drug abuse.

13. Deafness in both ears - permanent and irreversible.

14. Blindness in both eyes - permanent and irreversible.

15. Paralysis - permanent completeness.

16. Heart valve surgery - thoracotomy is required.

17. Severe Alzheimer's disease - complete loss of the ability to live independently.

18. Severe brain injury - permanent functional impairment.

19. Severe Parkinson's disease - complete loss of the ability to live independently.

20. Severe burns - up to at least 20% of the body surface area 21. Severe primary pulmonary hypertension - with manifestations of heart failure.

22. Severe motor neuron disease - complete loss of the ability to live independently.

23. Loss of language ability - complete loss and positive loss for at least 12 months.

24. Severe aplastic anemia.

25. Aortic surgery - thoracotomy or laparotomy is required.

Extended reading: [Insurance] How to buy, which one is better, teach you to avoid these insurance"pits"

Serious illness insurance is to reimburse urban and rural residents for the high medical expenses incurred due to serious illness, with the purpose of solving the problem of "poverty due to illness and return to poverty due to illness", so that the vast majority of people will no longer fall into economic difficulties due to illness.

On August 24, 2012, the National Development and Reform Commission, the Ministry of Health, the Ministry of Finance, the Ministry of Human Resources and Social Security, the Ministry of Civil Affairs, and the Insurance Regulatory Commission issued the Guiding Opinions on Carrying out Serious Illness Insurance for Urban and Rural Residents.

In view of the heavy burden of major illnesses on urban residents' medical insurance and the New Rural Cooperative Medical System, market mechanisms should be introduced to establish a serious illness insurance system to reduce the burden of serious illnesses on urban and rural residents, and the reimbursement ratio of serious illness medical insurance should not be less than 50%.

What is medical insurance serious illness co-ordination?

Legal analysis: Serious illness medical insurance is a special medical insurance established to protect the medical needs of urban employees for major diseases**, which is used to pay for the medical expenses (excluding out-of-pocket expenses) that exceed the maximum payment limit of basic medical insurance for insured persons participating in the basic medical insurance for urban employees during the year.

Legal basis: Provisions on the Medical Treatment Period for Sick or Non-work-related Injuries of Enterprise Employees

Article 3 When an employee of an enterprise needs to stop working for medical treatment due to illness or non-work-related injury, he or she shall be given a medical treatment period of three months to 24 months according to his actual working years and the number of years of working in the unit: (1) if the actual working experience is less than 10 years, three months if the actual working experience is less than five years; Six months for more than five years. (2) Where the actual working years are more than 10 years, the working years are less than 5 years in the unit, and 6 months are those who have worked in the unit for less than 5 years; 9 months for those between five and ten years; 12 months for between 10 and 15 years; 18 months for between 15 and 20 years; 24 months for more than 20 years.

Article 4 Where the medical treatment period is three months, the accumulated sick leave time within six months shall be calculated; 6 months is calculated based on the accumulated sick leave time within 12 months; Nine months shall be calculated as the accumulated sick leave time within 15 months; 12 months shall be calculated as the accumulated sick leave time within 18 months; 18 months shall be calculated based on the accumulated sick leave time within 24 months; 24 months shall be calculated based on the accumulated sick leave time within 30 months.

Legal analysis: Serious illness medical insurance is a special medical insurance established to protect the medical needs of urban employees for major diseases**, which is used to pay for the medical expenses (excluding out-of-pocket expenses) that exceed the maximum payment limit of basic medical insurance for urban employees who participate in the basic medical insurance for urban employees.

Legal basis: Provisions on the Medical Treatment Period for Sick or Non-work-related Injuries of Enterprise Employees

Article 3 When an employee of an enterprise needs to stop working for medical treatment due to illness or non-work-related injury, he or she shall be given a medical treatment period of three months to 24 months according to his actual working years and the number of years he has worked in the unit: (1) if the actual working years are less than 10 years, if the actual working years are less than five years, the medical treatment period shall be three and 24 months; Six months for more than five years. (2) Where the actual working years are more than 10 years, the working years are less than 5 years in the unit, and 6 months are those who have worked in the unit for less than 5 years; 9 months for those between five and ten years; 12 months for between 10 and 15 years; 18 months for between 15 and 20 years; 24 months for more than 20 years.

Article 4 The medical treatment period of three months shall be calculated according to the cumulative sick leave time within six months; 6 months is calculated based on the accumulated sick leave time within 12 months; Nine months shall be calculated as the accumulated sick leave time within 15 months; 12 months shall be calculated as the accumulated sick leave time within 18 months; 18 months shall be calculated based on the accumulated sick leave time within 24 months; 24 months shall be calculated based on the accumulated sick leave time within 30 months.

1. Adjustment of the new policy of serious illness medical insurance.

1. Increase the proportion of serious illness insurance payment for urban and rural residents1 Increase the proportion of payment for the part exceeding 180,000 yuan in the whole year to 60; 2 The proportion of payment that exceeds the maximum payment limit of the urban and rural residents' medical insurance pool** will be increased to 90.

2. Raise the annual maximum payment limit of critical illness insurance for urban and rural residents1 The annual maximum payment limit of serious illness insurance for urban and rural residents will be increased to 400,000 yuan; 2. For those who have participated in the city's urban and rural residents' medical insurance for 2 years or more, the maximum annual payment limit of urban and rural residents' serious illness insurance will be increased to 450,000 yuan. 3 For the insured persons who are eligible for social medical assistance under the treatment of medical fee reduction, there is no annual maximum payment limit for serious illness insurance for urban and rural residents.

3. The policy content of the comparison and adjustment of the serious illness medical insurance policy for urban and rural residentsThe current policy intends to adjust the part of the policy that exceeds 180,000 yuan or more throughout the year, and the part that is under the maximum payment limit is 50 60 from the serious illness insurance funds, and the part above the maximum payment limit is 70 90 The maximum payment limit of the serious illness insurance is 120,000 yuan, and if it has been insured for more than 2 years but less than 5 years, it will be increased by 30,000 yuan; If the insurance has been insured for 5 consecutive years, it will be increased by 60,000 yuan. 400,000 yuan; for those who have participated continuously for 2 years or more, it will be increased to 450,000 yuan; There is no upper limit for those who are recipients of social medical assistance who enjoy the treatment of medical fee reduction and exemption.

2. Although the reimbursement scope of the critical 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. In some cities, the serious illness covered by the medical insurance is not defined according to the type of disease, but according to the personal expenses of residents.

For example, in Beijing, only the high expenses of "expenses that meet the reimbursement scope of basic medical insurance for urban and rural residents in Beijing, after reimbursement by basic medical insurance", are included in the payment scope of serious illness insurance for urban and rural residents in Beijing for "secondary reimbursement". Whether it is by disease type or by cost, it points to one point, that is, "in line with the reimbursement scope of basic medical insurance for residents".

3. The newly adjusted payment ratio of the critical illness medical insurance for urban and rural residents will be partially covered by the serious illness insurance**, and individuals do not need to pay separately.

The so-called serious illness medical insurance does not refer to a serious illness, after enjoying the social security reimbursement, if the sum of the part of the individual self-payment + self-payment exceeds the average salary of last year, it will enter the reimbursement scope of serious illness medical insurance.

I can only give you an example of the reimbursement scope of the critical illness medical insurance, because there is no exact amount:

Hypothesis: The local average social salary in Hainan (Haikou) City in 2011 is 40,000 yuan, and your father's ** process is reimbursed through medical insurance:

1. The total amount of self-paid part + self-paid diagnosis and treatment items and drugs is 30,000 yuan, then it will not be included in the reimbursement scope of serious illness medical treatment.

2. The total amount of self-paid part + self-paid diagnosis and treatment items and drugs is 50,000, then according to the requirements of the country's new policy, the reimbursement ratio is not less than 50%, and another 50% can be reimbursed through the serious illness medical insurance, that is, 10,000.

However, according to what you said, it belongs to remote medical treatment, so to enjoy the medical insurance policy, you need to go to the local social security bureau (Hainan) to apply for remote medical treatment before seeking medical treatment in other places, and after obtaining permission, you can enjoy the reimbursement of medical insurance, otherwise you will not be able to enjoy it.

So, all things considered, let's say that your father enjoys medical insurance reimbursement + serious illness medical reimbursement The reimbursement ratio should be "= more than 75%" - provided that everything meets the reimbursement requirements.

Rectal cancer and spread to liver cancer, of course, is a serious illness medical insurance, because your father is insured in Hainan, to Changsha **, belongs to a different place for medical treatment, in the social security directly affects the reimbursement ratio, generally speaking, the social security reimbursement ratio of serious illness in the range of 35%-50%, how much money you use, according to the proportion of a calculation.