I. Annual deductible
Continuous insurance: 6,543,800 yuan;
Initial or intermittent insurance: 6.5438+0.5 million yuan.
Second, the proportion of compensation is 75%, and continuous insured personnel have preferential treatment. The annual deductible of the first insurance liability (medical expenses paid by individuals within the scope of medical insurance) was reduced from 6,543,800 yuan to 6,543,800 yuan; The annual deductible of the first-time or intermittent insured is reduced from 6,543,800+0.8 million yuan to 6,543,800+0.5 million yuan.
During the insurance period, the medical expenses incurred by the insured in the designated medical institutions of basic medical insurance due to illness or accident, after being reimbursed and settled by medical insurance, belong to the self-funded part outside medical insurance coverage (subject to the medical insurance statement, including all self-funded and over-priced self-funded expenses), and will be reimbursed by this insurance.
Three, in medical insurance coverage, the individual pays (security responsibility) medical expenses, one of the following circumstances, shall be exempted:
(1) Expenses that are not paid according to the regulations of the medical insurance at the same level in Sichuan Province or the medical insurance management institution in Chengdu.
(2) Medical expenses incurred due to work-related injuries (occupational diseases) and childbirth, including but not limited to medical expenses incurred due to treatment of infertility, artificial insemination, pregnancy, delivery (including dystocia), abortion, birth control (including sterilization) and prenatal and postpartum examination.
(3) Medical expenses incurred by designated medical institutions other than medical insurance in medical insurance coverage.
(4) Medical expenses that should be borne by the third party.
(5) Other expenses that shall not be paid according to laws and regulations.
Four, the specific high drug costs (guarantee responsibility 2) liability exemption in any of the following circumstances:
(1) The insured was first or intermittently diagnosed with malignant tumor (including leukemia and lymphoma) before 0: 00 on July 1 day, 2022;
(2) The drug prescription is inconsistent with the compensation scope in the Catalogue of Specific High-priced Drugs of Huirongbao.
(3) Drugs that are not purchased by hospitals or pharmacies agreed by this product.
(4) If the drug prescription exceeds one month at a time, it will exceed part of the drug expenses.
(5) The prescription of the drug is inconsistent with the indications, usage and dosage listed in the drug instructions approved by the State Pharmaceutical Products Supervision and Administration, or the relevant medical data cannot prove that the disease of the insured meets the indications for using a specific drug.
(6) The expenses incurred if the disease status of the insured is determined to be drug-resistant through inspection (drug resistance: refers to one of the following two situations):
① Drug resistance is defined as the progress of solid tumor lesions according to RECIST (therapeutic evaluation standard of solid tumor).
② Non-solid tumors (including leukemia, multiple myeloma, myelofibrosis, lymphoma and other hematological malignancies) often have no definite mass or are small in size and difficult to find. After standardized treatment, according to the guidelines of relevant professional institutions, the results of bone marrow morphology, flow cytometry and specific gene detection were comprehensively evaluated, and the conclusion of disease progress was drawn, which was defined as drug resistance. )
(7) The medical expenses incurred by the insured who meets the requirements for applying for charitable relief drugs but fails to apply for relief projects due to the insured's failure to submit relevant applications or incomplete application materials; The insured passes the aid audit, but fails to receive the aid drugs due to the insured's reasons, which is regarded as the insured's voluntary waiver of the applicable insurance rights under the product insurance contract.
Five, outside medical insurance coverage, personal medical expenses (security responsibility three) in any of the following circumstances, shall be exempted:
(1) Medical expenses incurred by the insured due to personal reasons (including but not limited to unconfirmed long-term off-site medical treatment, off-site referral, temporary off-site hospitalization, general outpatient (emergency) consultation, etc. ).
(2) The insured belongs to the expenses paid by industrial injury insurance and maternity insurance and the personal expenses after payment.
(3) Medical expenses incurred in overseas (including Hong Kong, Macao and Taiwan) medical treatment.
(4) Medical expenses that should be borne by the third party.
(5) The expenses for the insured to purchase the drugs in the second guarantee responsibility.
(6) When the medical insurance for surgery, hospitalization or outpatient service is not reimbursed, such as various expenses for beauty, plastic surgery, non-functional orthopedics, weight loss, freckle removal, mole removal, skin care, dental implants, tooth cleaning, glasses, artificial eyes, hearing AIDS, smoking cessation and alcohol withdrawal.
(7) Non-disease treatment items, such as various health check-ups, premarital check-ups, travel check-ups, occupational check-ups, exit check-ups and other expenses.
(8) Various diagnosis and treatment items of infertility (pregnancy) and sexual dysfunction (such as the examination and treatment fees for male infertility and female infertility, the examination and treatment fees for sexually transmitted diseases, and all medical expenses that violate family planning), as well as various teaching, scientific research and clinical verification diagnosis and treatment items.
(9) List of Chinese herbal pieces and medicinal materials that will not be paid:
The expenses of ointment mainly used for nourishing and health care and containing precious and endangered wild animals and plants of the country, the following medicines and Chinese herbal pieces are not covered by this product. Specifically, it includes Colla Corii Asini, White Sugar Ginseng, Korean Red Ginseng, Squama Manis (vinegar pangolin, pangolin scales), Tortoise Shellfish, Cordyceps sinensis, honey, Goubao, Colla Plastri Testudinis, Oviductus Ranae, Syngnathus, Hippocampus, Monkey Date, Propolis, Cornu Saigae Tataricae powder (antelope horn powder) and Cornu Cervi Pantotrichum.
(10) Unpaid consulting service fee:
Medical consultation fees (including psychological consultation and health consultation), stroke prediction, health prediction, vaccination and other expenses.
(1 1) Other expenses not paid according to laws and regulations.
legal ground
People's Republic of China (PRC) social insurance law
Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:
(a) shall be paid by the industrial injury insurance fund;
(2) It shall be borne by a third party;
(three) shall be borne by public health;
(4) Go abroad for medical treatment.
Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.
Thirty-first social insurance agencies may, according to the needs of management services, sign service agreements with medical institutions and pharmaceutical business units to standardize medical service behavior. Medical institutions shall provide reasonable and necessary medical services for the insured.
Thirty-second individuals across the overall regional employment, the basic medical insurance relationship with my transfer, the cumulative payment period.