What diseases are covered by critical illness medical insurance, and what serious illnesses are cove

1. What diseases are covered by medical insurance for serious illnesses?

1. Serious illness medical insurance mainly includes 20 diseases, namely: 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, 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.

2. Legal basis: Article 28 of the Social Insurance Law of the People's Republic of China.

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.

2. How to reimburse the medical insurance for hospitalization and serious illness.

Hospitalization Critical Illness Medical Insurance Reimbursement Steps:

1. After the seriously ill patient is hospitalized, he or she should first send the diagnosis certificate, the diagnosis and treatment manual of his basic medical insurance and other materials to the medical insurance department of the hospital where he lives for registration and verification, so as not to affect the reimbursement of inpatient medical expenses.

2. Outpatient medical expenses need to be reimbursed according to the specified time, and there are two opportunities to apply for outpatient reimbursement for 23 diseases such as liver cirrhosis a year, and 7 diseases such as leukemia have one application opportunity at the end of each quarter.

Critical illness insurance includes severe and critical illness insurance, including severe and life-threatening, unguaranteed quality of life, inability to take care of oneself, poor disease prognosis, and serious shortening of life.

At present, there are about 20 kinds of diseases included in the critical illness insurance in China, including malignant tumors such as leukemia, pheochromocytoma, small cell liver cancer, and acute myocardial infarction, which refers to irreversible infarction of the heart caused by myocardial ischemia.

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.

The Detailed Rules for the Implementation of the Social Insurance Law of the People's Republic of China jointly formulated the definition of critical illness insurance in accordance with the previous medical definition of critical illness insurance jointly formulated by the Insurance Association of China and the Chinese Medical Doctor Association, including: 1) malignant tumors - excluding some early-stage malignant tumors 2) acute myocardial infarction 3) sequelae of stroke - permanent functional impairment 4) major organ transplantation or hematopoietic stem cell transplantation - allogeneic transplantation 5) coronary artery bypass grafting (or coronary artery bypass grafting) - thoracotomy required.

There are different criteria for defining a serious illness. From an ethical point of view, it is a disease that is prone to life-threatening and death-threatening; From an economic point of view, it is a disease that is too expensive; From a medical point of view, it means that the grassroots cannot see the diseases that must be seen in large hospitals. We implement critical illness insurance, which is defined by cost.

The former Ministry of Health's NCMS major medical insurance started from the types of diseases, including 22 diseases such as childhood leukemia and congenital heart disease. However, this time it is explicitly required that the definition be based on the occurrence of high medical expenses. When the out-of-pocket portion of an individual's out-of-pocket payment exceeds a certain amount, it can lead to catastrophic medical expenses for the family, and this disease is a serious illness.

In the future, China will promote the smooth transition from NCMS critical illness insurance to critical illness insurance.

According to the World Health Organization's definition of "catastrophic medical expenditure" for a household, a household is considered to have incurred catastrophic medical expenditures if it is more than or more than 40% of the family's general consumption. Due to the different incomes in different places, the standards are also different. "The most important thing is to establish a stop-loss mechanism for residents to cope with catastrophic medical expenses, so as to improve the guarantee function of the medical security system.

This will be a better reflection of fairness. ”

Legal basisDetailed Rules for the Implementation of the Social Insurance Law of the People's Republic of China

Serious illnesses in medical insurance are not only the types of diseases, but only special projects that are activated after the medical expenses exceed the reimbursement ceiling of the basic medical insurance**.

Under normal circumstances, the upper limit of medical insurance basic medical reimbursement is 80,000 yuan, and the part of reimbursement exceeding 80,000 yuan will be reimbursed by serious illness medical insurance. The reimbursement ceiling of general critical illness medical insurance is 180,000. Basic medical insurance + serious illness medical insurance can reimburse a total of 260,000 yuan.

It seems like a lot, but if you really need to be reimbursed to 260,000, the actual cost will be more than 400,000. Because serious illnesses are now dependent on imported drugs, most of these drugs and ** expenses are self-paid.

Critical illness insurance is defined by the occurrence of high medical expenses, rather than by specific diseases, so there is no specific type of disease.

The 20 diseases included in the critical illness benefit are: 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, rectal cancer.

The coverage of critical illness insurance should be connected with the medical insurance for urban Huishan residents and the New Rural Cooperative Medical System. Urban residents' medical insurance and NCMS shall provide basic medical security in accordance with policy provisions. On this basis, the critical illness insurance mainly protects the eligible medical expenses that need to be borne by the urban residents after the medical insurance and the NCMS compensation in the case of high medical expenses incurred by the insured (combined) person suffering from a serious illness.

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 as the judgment standard, and the specific amount of the disturbance shall be determined by the local government.