1. Malignant tumor treatment: including chemotherapy (including endocrine-specific anti-tumor therapy), radiotherapy, isotope anti-tumor therapy, interventional anti-tumor therapy and traditional Chinese medicine anti-tumor therapy.
2. Outpatient hemodialysis and peritoneal dialysis for severe uremia.
3. Anti-rejection therapy after renal transplantation.
4. Treatment of severe mental illness: schizophrenia, depression (moderate or severe), mania, obsessive-compulsive disorder, mental retardation with mental disorder, epilepsy with mental disorder, paranoid psychosis.
It should be noted that the following situations are not within the scope of reimbursement of serious illness medical insurance:
1. See a doctor in a non-designated hospital without approval (except for emergency rescue);
2. Suffering from occupational diseases, work-related injuries or recurrence of old injuries; Injuries caused by traffic accidents (commercial accident insurance is recommended);
3. Injury caused by my illegal behavior;
4. Food poisoning caused by accidents;
5. Being treated for suicide (except psychotic episode);
6. Injuries caused by medical accidents;
According to the regulations of the state and this Municipality, the medical expenses shall be borne by themselves (it is recommended to purchase commercial supplementary medical insurance).
Second, the proportion of reimbursement for serious illness medical insurance
1. Deductible: 20,000 yuan. More than 20 thousand can be reimbursed through serious illness medical insurance.
2, serious illness medical insurance deductible above the reimbursement ratio is:
1) 20,000-50,000 yuan: 50% reimbursement for critical illness medical insurance;
2) 50,000 yuan-65,438+10,000 yuan: the medical insurance for serious illness is reimbursed by 60%;
3) More than RMB 65,438+10,000: 70% of the medical insurance for critical illness will be reimbursed.
3. Upper limit of annual reimbursement: 300,000.
Third, the reimbursement process of serious illness medical insurance
1. Materials required for reimbursement of serious illness medical insurance
1) ID card of the insured;
2) medical insurance or medical insurance card of the insured;
3) Original and photocopy of medical expense settlement list.
2. Serious illness medical insurance reimbursement process
1) The insured shall bring the above materials to the medical insurance department of the local designated hospital to fill in the relevant forms for preliminary examination;
2) Designated hospitals will report the information of insured residents who have passed the preliminary examination to the urban medical insurance agency for review;
3) The insured residents who pass the final examination shall be reimbursed by the urban medical insurance agency for serious illness medical insurance.
Four, serious illness medical insurance reimbursement period
It has been two years since the first diagnosis or recurrence of malignant tumor, of which Chinese medicine treatment for malignant tumor can be enjoyed for five years.
New changes in medical insurance policy for serious illness
Compared with previous years, what changes have been made in the new policy of serious illness medical insurance? Its changes are mainly reflected in the following aspects:
1. Lower the minimum threshold: the minimum threshold is reduced from 20,000 yuan to 6,543,800 yuan+0.8 million yuan.
2. Increase the proportion of reimbursement: among them, the proportion of adult residents, children and college students who participate in Class I payment will be increased from 60% to 65%; The proportion of adult residents participating in the second payment has increased from 50% to 55%.
3. Increase of the over-limit subsidy: 90% of the employees' medical insurance insured will be reimbursed; Residents' medical insurance participants, adult residents, children and college students will be reimbursed 80% in the first file and 70% in the second file.
4. Increase in large subsidies: 75% of employees' medical insurance participants will be reimbursed; 60% reimbursement for adult residents, children and college students who pay the first grade; Adult residents who pay the second grade will be reimbursed 50%.
5. Free vaccination for children: Children over 4 years old receive the second dose of varicella vaccine free of charge.
Legal basis:
People's Republic of China (PRC) social insurance law
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.