1. Conditions for enjoying benefits

(1) Pay the principal of Guangzhou “Suisuikang” commercial supplementary health insurance (hereinafter referred to as “Suisuikang”) in full in accordance with regulations Participants in the municipal social medical insurance can enjoy "Suisui Kang" on the basis of corresponding employee social medical insurance, employee major disease medical subsidies, employee supplementary medical insurance or urban and rural residents' social medical insurance, and urban and rural residents' serious illness medical insurance benefits. treatment.

(2) In addition to item (1), other "Suisuikang" insured persons (hereinafter referred to as other insured persons) who are settled by the city's social medical insurance information system shall enjoy the corresponding benefits. On the basis of medical security benefits, enjoy "Suisuikang" treatment; those who are not settled by this city's social medical insurance information system can enjoy "Suisuikang" treatment according to the following standards:

1. Other insured persons If the medical security benefits are higher than the social medical insurance benefits for employees in this city (including medical subsidies for major illness of employees, the same below), they will enjoy the "Suisuikang" treatment in addition to the corresponding medical security benefits;

2 . Those who meet one of the following circumstances will enjoy "Suisuikang" benefits after calculation based on the social medical insurance benefits for employees in this city:

(1) The insured's medical security benefits are lower than the social medical insurance benefits for employees in this city

(2) If the insured does not enjoy social medical insurance or other medical security benefits, the medical expenses shall be compliant with the city’s employee social medical insurance policy.

II. Types of benefits

(1) Compensation for hospitalization and special basic medical expenses

During the guarantee period, the insured shall receive treatment at designated medical institutions in accordance with regulations Among the basic medical expenses incurred for hospitalization and outpatient treatment of specific diseases, Suisuikang will pay 80% of the annual accumulated personal expenses exceeding 16,000 yuan, with the maximum annual cumulative payment limit of 1 million yuan.

Personally paid expenses refer to: the minimum payment standard and the following expenses in the basic medical expenses of social medical insurance, and the expenses paid by individuals in the first payment period according to the proportion.

The medical expenses incurred by the insured for the designated surgery and treatment of a single disease shall be synchronized with the Guangzhou social medical insurance benefits, and claims shall be settled according to the hospitalization benefits (the same below).

(2) Compensation for hospitalization compliant drug expenses and inspection and examination expenses

During the guarantee period, the insured is hospitalized in a designated medical institution in accordance with regulations and needs to use legitimate medicines due to his or her illness. Among the regulated drug fees and inspection and examination fees, "Suisuikang" will pay 70% of the annual cumulative personal expenses exceeding 16,000 yuan, with the maximum annual cumulative payment limit of 1 million yuan.

Personally borne expenses refer to: drugs and inspection fees paid by individuals in advance according to the prescribed proportion, drugs and inspection fees exceeding the social medical insurance limit standard, and payment limits beyond the social medical insurance drug catalog. Drug expenses, drugs that are not included in the social medical insurance catalog and are not included in the negative list, and inspection and examination expenses.

Expenses for drugs and examinations that exceed the social medical insurance limit standards refer to: expenses that exceed the annual maximum payment limit of social medical insurance, expenses that exceed the single hospitalization examination and examination payment limit of social medical insurance for urban and rural residents, Expenses exceeding the payment standards for some drugs in the social medical insurance catalog.

The drug expenses and inspection fees incurred by the insured when hospitalized in various special (need) wards, overseas Chinese, Hong Kong and Macao wards are not included in the scope of payment of this item.

(3) Compensation for outpatient compliance drug costs

During the guarantee period, the insured shall undergo general outpatient (emergency) treatment at selected designated medical institutions or designated specialist medical institutions in accordance with regulations. ) For medical and outpatient treatment of specific diseases, among the compliant drug expenses incurred due to medical conditions, the personal expenses will be paid by "Suisuikang" in accordance with the following standards, and the annual cumulative maximum payment limit is 300,000 yuan.

Personally paid expenses refer to: drug expenses paid by individuals in advance according to the prescribed proportion, drug expenses exceeding the social medical insurance limit standards, drug expenses that are not within the payment scope of the social medical insurance drug catalog, social medical care Drug expenses that are not included in the insurance catalog and are not included in the negative list.

Drug expenses that exceed social medical insurance limits refer to: expenses that exceed the annual maximum payment limit of social medical insurance, expenses that exceed the monthly/annual outpatient limit, and expenses that exceed the maximum payment limit of the outpatient specific disease overall fund The cost exceeds the payment standards for some drugs in the social medical insurance catalog.

Drug expenses incurred by the insured at special medical outpatient clinics that exceed the payment scope and standards of social medical insurance are not included in the scope of this payment.

1. Compliance drug expenses incurred during the use of negotiated drugs and innovative drugs that meet the designated indications during the agreement period (including purchases at designated pharmacies with prescriptions from relevant specialists at designated medical institutions and outpatient visits at designated medical institutions Among the expenses of innovative drugs used for treatment), "Suisuikang" will pay 60% of the annual accumulated personal expenses exceeding 16,000 yuan.

For the designated innovative drug catalog, scope of indications, and list of designated pharmacies for purchasing innovative drugs, please follow the "Suisuikang" public account for consultation; innovative drugs will enter the social medical insurance drug catalog or negotiate the drug catalog during the agreement period. Automatically withdraw from the innovative drug catalog.

2. Among the compliance expenses incurred by using other drugs, "Suisuikang" will pay 50% of the annual accumulated personal expenses exceeding 45,000 yuan.

(4) Compensation for medical expenses of specific insured persons

1. Compensation for special medical consumables

During the coverage period, insured persons aged 18 and below For persons who have been diagnosed with type 1 diabetes by a physician or above from the deputy director of the endocrinology department of a tertiary designated medical institution, among the expenses incurred in purchasing the insulin pump main unit and related consumables at designated medical institutions and designated pharmacies, the personal expenses shall be borne by " Suisuikang" pays 70%. Among them, the maximum payment limit for the insulin pump host is 42,000 yuan, and the insured is limited to reporting once within 3 years (2021~2023); the maximum payment limit for insulin pump-related consumables is 3,250 yuan/quarter.

Relevant consumables include: medicine storage, tubing, and blood glucose test strips.

Please see Appendix 1 for a list of designated pharmacies for purchasing insulin pumps and related consumables.

2. Compensation for the cost of long-acting injections for designated schizophrenia patients

During the guarantee period, the insured is a schizophrenia patient who has long-acting injections recognized by the city’s health department Patients on the treatment list who take irregular medications or have schizophrenia of grade 3 or above do need to use paliperidone palmitate injection (Sansida) or paliperidone palmitate ester injection (Santuda) due to their condition. The personal burden of long-acting injection drug costs incurred will be 100% paid by "Suisuikang".

There is no maximum annual payment limit for expenses that comply with this treatment obligation, and they are not included in the cumulative calculation of other benefits.

3. Compensation for medical expenses for personal injury due to courageous acts of righteousness

During the coverage period, the insured person who has been recognized by the relevant departments of this city as a righteous act of righteousness within the administrative region of this city suffers personal injury due to righteous acts of righteousness. , during the treatment period, 100% of the personal burden of medical expenses, nursing fees and other compliant medical expenses will be paid by "Suisuikang", and the annual cumulative maximum payment limit is 100,000 yuan.

4. Compensation for screening costs for designated diseases

During the coverage period, screening for designated diseases such as nasopharyngeal cancer, liver cancer, breast cancer, prostate cancer, and colorectal cancer is covered For insured persons who undergo screening for designated disease types at designated screening hospitals, the "Suisuikang" fund will pay up to 100 yuan per person per year for screening expenses that meet the regulations. 80% of the actual cost is paid.

Relevant screening items are limited to general outpatient screening. If general outpatient examination expenses have been reimbursed by social medical insurance, they will not be included in the reimbursement scope of this project.

Please see Appendix 2 for the screening scope and screening items for designated diseases, and see Appendix 3 for designated screening hospitals.

3. Special Agreement

(1) Benefit Accounting

The benefits of "Suisuikang" are calculated after enjoying corresponding social medical insurance or other corresponding medical security benefits. proceed later.

The insured persons who enjoy the medical assistance benefits in this city will enjoy the medical assistance benefits in accordance with the regulations after enjoying the "Suisuikang" benefits.

Medical expenses incurred during hospitalization will be settled according to the date of discharge of the insured person for "Suisuikang" benefits.

(2) Medical treatment in other places

The insured who meets the relevant social medical insurance policies and regulations for medical treatment in other places shall receive inpatient and outpatient treatment for specific diseases and general outpatient services at designated medical institutions in other places ( Compliance medical expenses incurred by individuals for emergency treatment shall be included in the reimbursement scope of "Suisuikang" according to regulations.

(3) Situations in which overall payment is not allowed

1. "Suisuikang" will not pay the medical expenses incurred by the insured who does not seek medical treatment in accordance with the relevant provisions of the corresponding social medical insurance. .

2. Situations in which social medical insurance will not cover the entire operation, hospitalization or outpatient services, such as various cosmetology, plastic surgery, non-functional orthopedics, weight loss, treatment of freckles, mole removal, skin care, dental implants, etc. "Suisuikang" will not pay for expenses incurred such as teeth cleaning, glasses, prosthetic eyes, prosthetic limbs, hearing aids, smoking cessation, alcohol cessation, etc.

3. "Suisuikang" will not pay for non-disease treatment items, such as various health examinations, pre-marital examinations, travel physical examinations, occupational physical examinations, outbound physical examinations, etc.

4. Diagnosis and treatment items for various infertility (pregnancy) and sexual dysfunction (such as: male infertility, female infertility examination and treatment fees, sexually transmitted disease identification examination and treatment fees, violations of family planning All medical expenses), various teaching, scientific research and clinical verification project expenses, "Suisuikang" will not pay.

5. The insured’s expenses that should be borne by a third party are expenses paid by work-related injury insurance, maternity insurance and personal expenses after payment, which occur when seeking medical treatment abroad (including Hong Kong, Macao and Taiwan) "Suisuikang" will not pay for medical expenses and other non-payable expenses stipulated by laws and regulations.

6. As of December 31, 2022, for people whose promises when applying for insurance are inconsistent with the actual situation, and who do not belong to the applicable population of "Suisuikang", the insurance contract will be invalid, and the insurance company will not assume insurance liability. and refund the full premium paid.

(4) Negative list of non-payable traditional Chinese medicine pieces and medicinal materials

The cost of ointments and the following medicines and medicines that are mainly used for nourishing and health care and contain national precious and endangered wild animals and plants. Traditional Chinese medicine pieces are not included in the coverage of "Suisuikang", specifically including: donkey-hide gelatin, white sugar ginseng, red ginseng, Korean red ginseng, pangolin (vinegar mountain pangolin, artillery mountain pangolin), tortoiseshell, cordyceps, honey, dog treasure, turtle deer Xianjiao, toad oil, sea dragon, seahorse, monkey date, wine-based propolis, antelope horn, antelope horn tip powder (antelope horn slices, antelope horn powder), deer antler (antler powder, deer antler slices), maple, agate, Bezoar (natural bezoar), coral, musk, Tianshan snow lotus, fresh dendrobium (Dendrobium officinale), saffron (crocus), American ginseng, blood root, bird's nest, wild ginseng, mountain ginseng, pearl, purple river car, various Animal organs (except chicken gizzard) and fetus, whip, tail, tendons and bones.

Note: The drugs listed above include crude drugs and processed medicinal materials and decoction pieces.

(5) Negative list of non-payable medical examination service fees

Medical consultation fees (including psychological consultation, health consultation), stroke prediction, health prediction, vaccination and other expenses.

Note: The overall non-payment situation and the negative list of non-payment will be dynamically adjusted according to the city’s social medical insurance policy.

(6) Contents of drugs that will not be paid for Comply with the indications and usage and dosage listed in the instructions. "Suisuikang" will not pay for other medicines and expenses other than the city's "dual-channel" medicines that the insured incurred during the period of medical treatment at designated medical institutions from designated medical institutions to purchase medicines at retail pharmacies outside the hospital.

IV. Benefit Settlement

(1) "One-stop" Settlement

The insured who is settled by the Guangzhou Social Medical Insurance Information System, in this The medical expenses incurred by the city’s designated medical institutions for hospitalization, outpatient treatment of specific diseases, and general outpatient (emergency) outpatient treatment will be settled by the designated medical institutions through the Guangzhou Social Medical Insurance Information System, and the medical expenses that meet the insurance liability will be "spring" at the same time. "Suikang" benefits are "one-stop" settlement, and the insured does not need to pay the fees paid by "Suuikang" and apply for claims separately. The insured can view the relevant settlement information of "Suisuikang" by printing the medical expense settlement form at a designated medical institution.

(2) Sporadic claims

For the medical expenses incurred by the insured under the following circumstances that do not meet the "one-stop" settlement and are in compliance with the "Suisuikang" insurance liability, Implement "Suisuikang" sporadic claims settlement.

"Suisuikang" sporadic claims means: the applicant submits the required certificates and information online through the "Suisuikang" official account or the insurance company's official account to apply for sporadic claims, and the settlement will be settled after review , the fees paid by "Suisuikang" will be directly transferred to the bank account designated by the applicant.

Please see Appendix 4 for details of the required certificates and information.

1. The insured’s medical expenses are settled online for medical insurance in other places.

2. Medical expenses for other insured persons that are not settled by the Guangzhou Social Medical Insurance Information System.

3. The insured persons who belong to the city’s employee social medical insurance and urban and rural residents’ social medical insurance need to receive outpatient treatment at non-selected city designated medical institutions due to serious illness. Or the compliant drug expenses incurred for outpatient treatment at designated specialist medical institutions do not fall into the Guangzhou Social Medical Insurance Information System settlement situation.

4. Students in universities and technical secondary schools who are subject to lump-sum settlement of general outpatient services under social medical insurance for urban and rural residents shall be transferred to other medical institutions for treatment by the general outpatient medical institutions designated by the school in accordance with regulations. Compliant drug expenses incurred at designated medical institutions after diagnosis will be partially reimbursed by the general outpatient medical institutions designated by the school.

5. Designated pharmacies are responsible for purchasing innovative drugs, special medical consumables, and personal injury medical expenses.

(3) Medical expenses for medical treatment in this city or in other places without medical insurance settlement

On the premise of complying with the relevant policies and regulations of Guangzhou’s social medical insurance, if the insured person due to special If you are unable to conduct online medical insurance settlement in time due to medical treatment in this city or in other places, you need to go to the service hall of each medical insurance branch center in Guangzhou to submit sporadic medical insurance reimbursements. The amount that is within the scope of "Suisuikang" compensation will be based on the "one-stop" service According to the process, settlement will be made directly after enjoying the reimbursement of social medical insurance benefits.