Designated medical institutions for one old and one young insured

About "one old and one small insurance" —— Four questions about the reimbursement scope of special diseases of medical insurance for students and children in Beijing.

Notice on issues related to the scope of reimbursement for special diseases

Jing Lao She Yi Fa [2007]No. 127

The county labor and social security bureau, the designated medical institutions:

In order to implement the requirements of the Notice of the Beijing Municipal People's Government on Printing and Distributing the Implementation Opinions on Establishing the Medical Insurance System for Urban Elderly and Students' and Children's Serious Illness in Beijing (J.L.S. [2007]1No.) and the Specific Measures for Implementing the Medical Insurance System for Students' and Children's Serious Illness in this Municipality (J.L.S. [2007] No.95), the medical insurance for students' and children's serious illness is now available for outpatient service.

1. Medical expenses incurred by medical insurance personnel for serious illness of students and children (hereinafter referred to as the insured) due to taking anti-rejection drugs and outpatient treatment of hemophilia and aplastic anemia after outpatient radiotherapy and chemotherapy for malignant tumor, renal dialysis and renal transplantation shall be reimbursed according to the special disease policy of outpatient medical insurance for serious illness of students and children.

Second, outpatient malignant tumor radiotherapy and chemotherapy, renal dialysis, kidney transplantation after taking anti-rejection drugs for medical expenses reimbursement scope, the implementation of basic medical insurance outpatient special disease reimbursement scope provisions.

Three, hemophilia, aplastic anemia outpatient treatment, the scope of medical expenses reimbursement, limited to the need to check, treatment and use of related drugs. Among them, the scope of reimbursement for western medicine is shown in the annex, and Chinese medicine is limited to Chinese herbal pieces. Others refer to expenses that meet the scope of reimbursement of basic medical insurance and supplementary reimbursement of medical insurance for serious illness of students and children.

Four, designated medical institutions should strictly implement the provisions of medical insurance for serious illness of students and children and clinical diagnosis and treatment norms, reasonable inspection, reasonable treatment, rational use of drugs, not according to the outpatient special disease settlement and outpatient special disease treatment has nothing to do with medical expenses. Any medical expenses incurred in violation of the above provisions will not be paid by the medical insurance fund for serious illness of students and children.

Five, the insured outpatient special disease declaration and approval and designated medical institutions, the implementation of basic medical insurance management regulations.

Six, this notice shall be implemented as of September 1 2007.

Attachment 1: reimbursement scope of western medicine for hemophilia outpatient treatment

Annex 2: reimbursement scope of western medicine in aplastic anemia outpatient department

Beijing Municipal Bureau of Labor and Social Security

On July 30, 2007, the document on the detailed rules for the implementation of the "one old and one small" serious illness medical insurance system-7. The detailed rules for the implementation of the "one old and one small" serious illness medical insurance system.

Specific measures for the implementation of medical insurance system for serious illness of students and children in this Municipality

The document number is Jing Lao She Yi Fa [2007] No.95.

Promulgated by Beijing Municipal Bureau of Labor and Social Security

Promulgated in June 2007-12

Effective date: 2007-09-0 1

Normative documents at the legal level

first

In order to ensure the smooth implementation of the medical insurance system for serious illness of students and children in this Municipality, these measures are formulated according to the Implementation Opinions on Establishing the Medical Insurance System for Serious Illness of Urban Elderly and Students and Children in Beijing (J.F. [2007]11No.) and with reference to the relevant provisions of this Municipality's basic medical insurance.

Article 2 The scope of personnel participating in medical insurance for serious illness of students and children in this Municipality includes:

(1) Students with non-agricultural household registration in this Municipality who are enrolled in primary schools, junior high schools, senior high schools, secondary specialized schools, technical schools, secondary vocational and technical schools, special schools, reform schools and various ordinary institutions of higher learning (full-time academic education) within the administrative area of this Municipality;

(2) Non-school children, children in nurseries and scattered babies (excluding newborns born within 28 days) who have non-agricultural household registration in this city before August of the year of insurance payment and are under the age of/kloc-0.

The above persons are collectively referred to as the "Insured".

essay

In schools and kindergartens, the insured person holds the household registration book from July/KLOC-0 to September 30 every year, handles the payment procedures of medical insurance for serious illness of students and children in schools and kindergartens, and pays the medical insurance premium for serious illness in one lump sum according to the payment standard; /kloc-non-school children and scattered infants under the age of 0/6 shall go through the payment procedures of medical insurance for serious illness of students and children from June 1 day to August 3 1 day every year, and their parents shall pay the medical insurance premium for serious illness in one lump sum at the street (township) social security office where their household registration is located (hereinafter referred to as "social security office") according to the payment standard.

Article 4

Under any of the following circumstances, the insured specified in Items (1) and (2) of Article 2 of these Measures shall be exempted from the medical insurance premium for serious illness that should be paid by individuals. When handling the insurance payment procedures, in addition to holding my household registration book, I should also submit the following relevant documents respectively:

(a) to enjoy the minimum living guarantee for urban residents in this Municipality, and submit the "Beijing Minimum Living Guarantee Certificate for Urban Residents";

(2) Persons who enjoy the living allowance for urban residents in this Municipality shall submit the Certificate of Living Allowance for Urban Residents in Beijing.

Article 5

Medical insurance for serious illness of students and children is from September/kloc-0 to August 3 1 every year. Enjoy critical illness medical insurance from September 1 of the payment year.

Article 6

The insured can pay the medical insurance premium for serious illness of students and children in the form of cash or bank withholding. After the insured person has gone through the insurance payment procedures, he/she will choose a designated medical institution and receive the Handbook of Medical Insurance for Serious Illness of Students and Children in Beijing. If the insured person exceeds the time limit for insurance payment, he will no longer go through the insurance payment procedures for this school year.

Article 7

If the insured person has paid the medical insurance premium for the next school year and died before September 1 of that school year, his parents shall go through the refund formalities at the social security office where the insured person's household registration is located with the death certificate issued by the medical institution or the public security department.

Article 8

The following medical expenses incurred by the insured in accordance with the city's basic medical insurance and medical insurance for serious illness of students and children and the scope of medical service facilities shall be paid by the medical insurance fund for serious illness of students and children according to the regulations:

(a) hospitalization expenses;

(2) Outpatient medical expenses caused by taking anti-rejection drugs, hemophilia and aplastic anemia (hereinafter referred to as "special diseases") after radiotherapy and chemotherapy, renal dialysis and kidney transplantation (including combined liver and kidney transplantation) for malignant tumors;

(three) emergency observation and hospitalization, medical expenses incurred within 7 days before hospitalization;

(four) medical expenses within 7 days before death in case of death under observation of emergency rescue.

Ninth students and children's serious illness medical insurance fund does not pay the following medical expenses:

(1) Being hospitalized in a non-designated medical institution, except for emergency;

(2) Injuries caused by traffic accidents, medical accidents or other liability accidents;

(three) drug abuse, fighting or other illegal acts causing injuries;

(four) due to suicide, self-mutilation, alcoholism and other reasons to receive treatment;

(5) being treated abroad or in Hongkong, Macao Special Administrative Region or Taiwan Province Province;

(six) according to the provisions of the state and this Municipality shall be borne by individuals.

Tenth students and children's serious illness medical insurance fund in a medical insurance year, the first and subsequent hospitalization Qifubiaozhun are 650 yuan.

Article 11

The medical expenses incurred by the insured, Qifubiaozhun above part by individuals and students and children's serious illness medical insurance fund in proportion to share. Among them: 70% is paid by the medical insurance fund for students and children with serious illness, and 30% is borne by individuals. In a medical insurance year, the maximum cumulative payment of the medical insurance fund for serious illness of students and children is 6.5438+0.7 million yuan.

Article 12

The hospitalization period of the insured is 90 days. No more than 90 days shall be settled according to the actual hospitalization days; If it is more than 90 days, it will be settled once every 90 days, and it will be regarded as the second hospitalization after settlement.

Article 13

The outpatient treatment of special diseases by the insured shall be a settlement cycle according to each medical insurance year. When going through the formalities for examination and approval of special diseases, the settlement period is from the date of examination and approval to the annual deadline of this medical insurance.

Fourteenth insured persons suffering from mental illness need long-term hospitalization, from the date of hospitalization for mental illness to the annual deadline of this medical insurance is a settlement period.

Article 15

If the insured person who continuously pays the medical insurance premium for serious illness of students and children in the next school year is hospitalized across the medical insurance year, the medical expenses in this settlement period shall be calculated separately according to the medical insurance year. The medical expenses incurred before August of 3 1 year and the medical expenses paid in this school year are calculated cumulatively; /kloc-The medical expenses incurred since September of 0/year shall be calculated cumulatively with the medical expenses paid in the next school year. The maximum payment amount of medical insurance fund for students and children with serious illness is calculated according to this school year and the next school year respectively.

The medical expenses incurred by the insured within a settlement period shall be paid by Qifubiaozhun. If the insured is hospitalized again in the next school year or enters the next settlement period, the Qifubiaozhun shall be paid according to the first hospitalization.

Article 16

For the insured who have not paid the medical insurance premium for the serious illness of students and children in the next school year, the medical insurance fund for the serious illness of students and children will pay the medical expenses before August 3 1 of the school year, and will not pay the medical expenses incurred after September 1 of the next school year.

Article 17

The insured person can seek medical treatment directly in tertiary designated medical institutions and designated medical institutions' specialties and traditional Chinese medicine hospitals, and can also seek medical treatment directly in the first-class hospitals of designated medical institutions in this city.

If the insured needs to change the designated medical institutions, students and kindergarten children can go through the change procedures from July 1 day to September 30, and non-school children and scattered infants can go through the change procedures from June 1 day to August 3 1 day.

Article 18

When the insured falls ill, he must go to the designated medical institution for medical treatment with the Handbook of Medical Insurance for Serious Illness of Students and Children in Beijing. Designated medical institutions shall examine the medical manuals held by the insured.

Article 19

When the insured can't go to the designated medical institution I selected for medical treatment due to emergency, he can be hospitalized in the nearest designated medical institution, and should be transferred back to my designated medical institution for hospitalization in time after his condition is stable.

Article 20

If the insured person needs to be transferred to the local hospital for treatment due to illness during hospitalization, it shall be proposed by the deputy chief physician of the designated medical institution, and the transfer formalities can be handled only after the approval of the medical insurance office. Cumulative calculation of medical expenses incurred after transfer and medical expenses incurred before transfer.

Article 21

The insured person is hospitalized or outpatient for special diseases, and the medical expenses are paid by the individual in advance, and the medical expenses incurred are borne by the designated medical institutions. At the time of settlement, the payment part of the medical insurance fund for serious illness of students and children shall be settled by designated medical institutions and social insurance agencies, and the rest of the medical expenses shall be settled by individuals and designated medical institutions.

Article 22

If the insured person is admitted to the hospital for emergency rescue and dies after emergency rescue observation, the medical expenses for hospitalization or observation within 7 days before death shall be paid by himself or his parents in cash, and the relevant certificates and medical expenses documents shall be submitted to the social security office where his household registration is located for reimbursement at the time of settlement.

Article 23

The insured for outpatient treatment of special diseases shall go through the examination and approval procedures for special diseases at the social insurance agency where their household registration is located with the diagnosis certificate. The outpatient medical expenses for special diseases in designated medical institutions for special diseases shall be paid by the medical insurance fund for serious illness of students and children according to regulations.

Article 24

If the insured suffers from special outpatient diseases and needs continuous treatment, they can go through the payment procedures at the social insurance agency in the county where the school is located from June 1 day to July 3 1 day every year.

Article 25

If the insured has been hospitalized or treated for special diseases before the insurance payment, the medical expenses before the insurance will be settled, and the medical expenses after the insurance will be paid by the medical insurance fund for serious illness of students and children according to the regulations.

Article 26

The emergency hospitalization expenses incurred by the insured in the designated medical institutions at or above the county level in the field that meet the payment scope of medical insurance for serious illness of students and children in this Municipality shall be reimbursed by the social security office where my household registration is located.

Article 27

Students and children under the age of 16 who live or study in other provinces and cities should register for medical treatment in different places at the social security office where their household registration is located. You can choose two designated medical institutions at or above the county level or children's specialized hospitals and 1 designated medical institutions for medical treatment in this city, and the medical treatment shall be carried out in accordance with the provisions of the payment scope of medical insurance for serious illness of students and children in this city. The medical expenses incurred shall be reimbursed by the social security department where I live.

Article 28

Students and children who enjoy the minimum living guarantee for urban residents and the subsidy for urban residents' living difficulties can continue to apply to the civil affairs department for medical assistance for the urban poor after enjoying the medical insurance for serious illness of students and children.

Article 29

According to the regulations of the education administrative department of this Municipality, students who are not registered in cities and towns in this Municipality and enjoy free tuition fees may voluntarily choose to participate in medical insurance for serious illness of students and children. When handling the insurance payment procedures, the following relevant documents shall be submitted:

(a) the original Beijing educated youth children, submit the original Beijing rural educated youth children's identity certificate issued by the district and county labor and social security bureau;

(two) school-age children and adolescents in the dependents of the army, submitted to the political organs of units above the division (brigade) level;

(3) For the children of postdoctoral staff working in Beijing, a letter of introduction and a letter of arrival issued by the State Postdoctoral Management Committee;

(4) Children of Taiwanese businessmen and their employees (Taiwan compatriots) who invest in Beijing shall submit the approval letter issued by the education administrative department for the children of Taiwan compatriots to study in Beijing;

(5) Children of talents introduced from this city and children of returned overseas students shall submit their parents' Beijing Work Residence Permit;

(6) Students whose parents have formal permanent residence in Beijing shall submit their parents' household registration book in Beijing and the certificate of the relationship between students and their parents issued by the township people's government or street offices in our city.

Thirtieth students and children's serious illness medical insurance does not build personal accounts, regardless of the individual payment period.

Thirty-first matters not specified in these Measures shall be implemented with reference to the Provisions of Beijing Municipality on Basic Medical Insurance and related measures.

Article 32 These Measures shall come into force as of September 6, 2007.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.