Beijing Supplementary Medical Insurance Reimbursement Scope

Compared with basic medical insurance, supplementary medical insurance includes enterprise supplementary medical insurance, commercial medical insurance, social mutual assistance and community medical insurance, which is a powerful supplement to basic medical insurance and an important part of multi-level medical security system.

Different from basic medical insurance, supplementary medical insurance is not enforced by national legislation, but is voluntarily participated by employers and individuals. It is a kind of supplementary insurance that the unit or individual appropriately increases the medical insurance items according to the needs and possible principles after the units and employees participate in the unified basic medical insurance, so as to improve the insurance protection level.

Basic medical insurance and supplementary medical insurance are not contradictory, but complementary and irreplaceable, and their purpose is to provide medical security for employees.

What are the detailed terms of supplementary medical insurance? Here, the payment, reimbursement scope and reimbursement method of supplementary medical insurance premium are explained.

I. General principles

Article 1 In accordance with the Regulations of Beijing Municipality on Basic Medical Insurance and the Interim Measures of Beijing Municipality on Supplementary Medical Insurance for Enterprises, the Provisions on Supplementary Medical Insurance of China International Technical and Intellectual Cooperation Company (hereinafter referred to as the Provisions) are formulated. China International Technical Intelligence Cooperation Company's Supplementary Medical Insurance (hereinafter referred to as "Supplementary Medical Insurance") reimburses the outpatient (emergency) and inpatient medical expenses within the basic medical scope beyond the scope of Beijing's basic medical insurance and large medical mutual fund.

Article 2 These Provisions are applicable to China employees (hereinafter referred to as the insured) who have signed a contract with China International Technical and Intellectual Cooperation Corporation (hereinafter referred to as CIIC) and choose this supplementary medical insurance (see the annex of the contract for the specific insurance scheme and reimbursement standard), foreign-funded enterprises and other enterprises, organizations or groups (hereinafter referred to as the employing unit), and their age range is 65,438+. It does not include the personnel entrusted by CIIC individuals for filing, retirees and foreigners working in the above-mentioned institutions.

On the basis of basic medical insurance, retirees enjoy the unified supplementary medical insurance for retirees established in Beijing. Foreigners can participate in comprehensive accident medical insurance insured by CIIC in commercial insurance companies.

Employers need to insure all employees who meet the insurance requirements. All employees of the same employer enjoy the same supplementary medical insurance plan.

Article 3 The insured can only participate in this supplementary medical insurance on the basis of participating in the basic medical insurance and the large medical mutual fund. The responsibility of this supplementary medical insurance will not apply to the insured who has suffered from the following major diseases or hospitalization before participating in this supplementary medical insurance, and is in a full-time or half-time period. The insured shall truthfully inform the past history of major diseases and bear the responsibility of not telling the truth.

Major diseases include: malignant tumor, heart disease (dysfunction above Grade II), myocardial infarction, cancer, leukemia, hypertension (above Grade II), liver cirrhosis, chronic obstructive bronchial disease, cerebrovascular disease, chronic kidney disease, major organ metastasis, diabetes, aplastic anemia, congenital disease, psychosis or schizophrenia, epilepsy, specific infectious diseases, AIDS, sexually transmitted diseases, etc.

Medical expenses incurred in medical institutions designated or recognized by CIIC for the first time within 90 days after this supplementary medical insurance comes into effect shall be reimbursed, and the reimbursement of such expenses shall be implemented in accordance with the provisions of Beijing Basic Medical Insurance.

The second is the payment of supplementary medical insurance premiums.

Article 4 An employer who has signed a contract with CIIC and participated in supplementary medical insurance shall submit the insurance materials in time and pay the management fee (including supplementary medical insurance premium), Beijing basic medical insurance premium and Beijing maternity insurance premium in full and on time.

Fifth medical expenses and maternity expenses cannot be reimbursed in the medical insurance center because they are not paid in full and on time, and supplementary medical insurance will not be paid.

Three, supplementary medical insurance reimbursement scope and content

Article 6 The scope and contents of reimbursement for supplementary medical insurance are completely the same as those of Beijing basic medical insurance. The medical expenses of the insured shall conform to the basic medical insurance drug list, diagnosis and treatment list and service list stipulated by this Municipality. Self-funded items stipulated in the basic medical care or self-funded supplementary medical insurance shall not be reimbursed.

Article 7 After the medical expenses for outpatient (emergency) consultation and hospitalization of the insured are reimbursed by the basic medical insurance and/or the large medical mutual fund, the supplementary medical insurance shall be reimbursed according to the reimbursement ratio, deductible and limit stipulated in the supplementary medical insurance scheme agreed with the employer.

Article 8 according to the contract signed with the employer, the maternity expenses (including general hospitalization expenses, examination expenses, operation expenses, delivery expenses, medicine expenses, etc.). Except for self-funded drugs and self-funded items, female employees who meet the relevant family planning regulations of the state and the government shall be reimbursed according to Beijing maternity insurance and other relevant regulations. The total reimbursement limit of maternity insurance and supplementary medical insurance is 8,000 yuan (if there are other reimbursement limits in the contract, it shall be handled according to the agreement).

Article 9 According to the contract with the employer, the insured has an only child (including twins or multiple births) under the age of 18 who meets the national family planning regulations and has China nationality, and the medical expenses are reimbursed at the rate of 50%. Reimbursement items and the upper limit shall be implemented according to the contract. Children need to go to hospitals at or above the county level (level 2) or public children's hospitals for medical treatment. Children who participate in Beijing medical insurance for serious illness of students and children will be reimbursed by supplementary medical care after the settlement of Beijing medical insurance for serious illness of students and children.

Children's reimbursement shall be implemented in accordance with the basic medical insurance regulations, the regulations of Beijing Municipality on the administration of public medical care, the provisions of Beijing Municipality on medical insurance for serious illness of students and children, and the catalogue of children's drugs used by Cizhi Company. Children's medical treatment should conform to the principle of one place per year (based on the place where children are reimbursed for the first time in a natural year).

Article 10 According to the contract with the employer, after the insured pays the supplementary medical insurance premium for one year, each person can enjoy a medical examination at the medical examination center designated by CIIC every year, and CIIC will provide the insured with corresponding medical examination services. After the medical examination, the insured shall bear the expenses if there are any problems that need to be reexamined. Ciic establishes health records for the insured, and the physical examination results will be used as a reference for reviewing the reimbursement documents of the insured.

Cic can provide special physical examination services in high-end physical examination centers. The employer can choose from several physical examination centers designated by Cic, and the physical examination items can be selected by itself. Fees are charged according to the quotation of the medical examination center.

Article 11 If the insured and their children have no medical expenses (including birth and family planning expenses) in a supplementary medical year, they can apply to the CIIC Workers' Health Service Center within three months after the end of the supplementary medical year, and those who meet the requirements after examination can receive health incentive fees.

Twelfth the following medical expenses, this supplementary medical insurance will not be paid:

(1) Self-funded drugs other than those stipulated in the basic medical insurance;

(2) Drug expenses inconsistent with the diagnosis;

(three) all medical expenses for outpatient and hospitalization in medical institutions other than the designated medical institutions;

(four) medical expenses that do not meet or exceed the scope and standard of reimbursement of basic medical insurance;

(five) all medical expenses caused by traffic accidents, medical accidents and other accidents;

(six) all medical expenses caused by drug abuse, fighting and other illegal acts;

(seven) all medical expenses caused by suicide, self-mutilation, alcoholism, etc. ;

(eight) all medical expenses incurred abroad (including Taiwan Province, Hongkong and Macao);

(nine) all medical expenses for medical treatment in special needs clinics and hospitalization in special needs wards;

(ten) all medical expenses for diagnosis and treatment of infertility, all medical expenses for pre-pregnancy examination and all medical expenses for preventive medication;

(eleven) medical expenses that should be paid by individuals in accordance with the provisions of the state and this Municipality.

Four, supplementary medical insurance reimbursement methods

Thirteenth this supplementary medical insurance is based on the principle of basic medical payment in advance. In a natural year, the medical expenses incurred by the insured for outpatient (emergency) consultation or hospitalization due to illness exceeding the Qifubiaozhun of basic medical insurance shall be reimbursed by the basic medical insurance in advance. Supplementary medical insurance reimburses the medical expenses paid by employees in proportion in the basic medical insurance coverage on the basis of the segmented list issued by the medical insurance center and the original copy of the original documents or segmented medical expense bills, detailed lists and original diagnosis certificates issued by the hospital. The settlement year is synchronized with the basic medical insurance (according to the natural year).

Article 14 If the medical expenses for outpatient (emergency) consultation of insured persons do not exceed the basic medical insurance Qifubiaozhun at the end of the year, they will be reimbursed by supplementary medical insurance from the end of the year to the first quarter of the following year based on the original documents of medical expenses, special prescriptions for medical insurance, outpatient medical records, detailed list of expenses and other original materials; The medical expenses incurred in the current year after the reimbursement of supplementary medical insurance shall not be reimbursed.

Fifteenth insured hospitalization medical expenses should go through the reimbursement procedures at CIIC within one month after discharge. Maternity expenses of female employees who meet the national family planning regulations shall be reimbursed to CIIC within three months after childbirth. Medical expenses of employees' children can be reimbursed at any time in the current year.

Sixteenth insured persons shall provide relevant reimbursement materials in accordance with the provisions of the basic medical insurance. If the reimbursement materials do not meet the basic medical requirements, supplementary medical insurance will not be paid.

Article 17 The reimbursement of drug expenses shall be based on the amount stipulated in the basic medical insurance: acute diseases shall not exceed three days, chronic diseases shall not exceed seven days, and three boxes or boxes of external drugs shall be prescribed. When the dose exceeds the prescribed dose, the excess shall be paid by the insured. The medicine prescribed should be consistent with the disease treated. If there is any discrepancy, all medical expenses will not be reimbursed.

Article 18 When the insured who works in other places and participates in the local basic medical insurance is reimbursed for outpatient (emergency) consultation and hospitalization expenses, the local basic medical insurance will reimburse them first, and then the materials will be submitted to CIIC for supplementary medical reimbursement procedures. If the local basic medical insurance does not reimburse outpatient and emergency expenses, it can be handed over to CIIC for supplementary medical reimbursement at any time.

Verb (abbreviation of verb) medical management

Nineteenth this supplementary medical insurance is managed by designated medical institutions. When the insured person is sick, he should go to four designated medical institutions or designated Chinese medicine hospitals, designated specialized hospitals and 3A hospitals in this city with the medical insurance manual in accordance with the basic medical regulations. When visiting the hospital, the hospital scans the bar code and uploads the documents. All expenses incurred by the insured for medical treatment in non-designated medical institutions shall be borne by the individual.

Twentieth insured personnel can be reimbursed only after completing the entry formalities and the employer pays the supplementary medical insurance premium in full and on time. When the dispatch/service contract of the insured is terminated, this supplementary medical insurance liability shall be terminated at the same time. If the medical expenses incurred before the termination of the contract do not exceed the basic medical insurance Qifubiaozhun, they will be reimbursed by this supplementary medical service within one month after the termination of the contract; The part exceeding the basic medical insurance Qifubiaozhun shall be reimbursed by supplementary medical insurance within one month after the reimbursement of basic medical insurance.

Article 21 The insured shall abide by the provisions of the basic medical insurance, the national free medical policy and the supplementary medical insurance of China and Chile, and shall be obliged to provide reimbursement materials as required. In case of medical fraud, CIIC has the right to refuse to pay medical expenses and continue to provide supplementary medical insurance services, and the insured who has paid shall be returned in time. At the same time, CIIC reserves the right to solve the above problems through legal means depending on the seriousness of the case.

Supplementary clause of intransitive verbs

Article 22 CIIC shall be responsible for the interpretation of these provisions, and the compensation scheme adopted by the insured shall be subject to the contract agreement between CIIC and the employer.

Article 23 For matters not covered in this regulation, please refer to Employee Service Manual, Medical Insurance Manual, Application Form for Reimbursement, Materials Required for Reimbursement, etc. More detailed tips and regulations on medical reimbursement, maternity insurance regulations and medical expenses reimbursement period.

This item is very helpful to me (2)

According to the Regulations of Dongguan Supplementary Medical Insurance promulgated and implemented by Dongguan Social Security Bureau, employers, villages/communities and individuals who have participated in the basic social medical insurance in Dongguan can participate in the supplementary medical insurance in Dongguan. However, many citizens are not very clear about the supplementary medical insurance policy in Dongguan, and they don't know how to participate in the insurance, how to reimburse, and what is the reimbursement ratio. Today, I will explain in detail the reimbursement ratio of supplementary medical insurance in Dongguan.

First, enjoy basic medical insurance benefits, in line with the proportion of reimbursement within the scope of the three directories:

10.5 million yuan and less than or equal to 65438+ 10 million yuan: 20%;

2. More than 654.38+million yuan, less than or equal to 1.5 million yuan: 30%;

3. 1.5 million yuan, not exceeding the maximum payment limit of basic medical insurance: 40%.

Two, more than the maximum payment limit of basic medical insurance reimbursement ratio:

1, less than or equal to 65438+ ten thousand yuan: 85%;

2.65438+ over 10,000 yuan: 70%;

Three, supplementary medical insurance specific outpatient reimbursement ratio:

1, employees: 75%;

2. Retirees: 80%.

Four, enjoy the basic medical insurance maternity medical expenses reimbursement ratio:

1, one-time maternity allowance: 1500 yuan;

2. One-child allowance: 800 yuan;

3. Maternity allowance for male employees: 280 yuan.

Supplementary note: The personal account of Dongguan Supplementary Medical Insurance is used to pay the medical expenses incurred by me and my family members in the designated medical institutions of social security in this city, as well as related expenses such as vaccination and health examination; When the balance exceeds 1000 yuan, the excess can be used to pay for self-paid medical expenses for hospitalization.

Extended reading:

What cannot be reimbursed for supplementary medical insurance?

Supplementary medical insurance is an important supplement to social medical insurance. Many people don't understand supplementary medical insurance. What cannot be reimbursed for supplementary medical insurance? What is the reimbursement process that can be reimbursed? What is its insurance target?

Non-reporting type

1. Medical expenses incurred in non-designated medical institutions without approval;

2. Suicide and self-mutilation (except mental illness);

3. Fighting, fighting, alcoholism, drug abuse and other injuries cause crimes or violate the Public Security Administration Punishment Law;

4. Traffic accidents, accidental injuries, medical accidents, etc.

5. Being treated for beauty, plastic surgery, physical defects, etc.

6. Belonging to the scope of industrial injury insurance (including occupational diseases) or maternity insurance payment;

7. Other non-payment circumstances stipulated by the national and provincial medical insurance policies.

elementary knowledge

The minimum qifubiaozhun is 250 yuan.

Qifubiaozhun is: 250 yuan, a community health service institution; 350 yuan, a first-class hospital; 500 yuan, a secondary hospital; 700 yuan, a tertiary hospital.

In accordance with the provisions of Qifubiaozhun above and below the maximum payment limit of hospitalization medical expenses, in different levels of designated medical institutions to pay different proportions:

1. Urban non-employed residents

Community health service institutions: 70% paid by the overall fund and 30% borne by individuals; First-class hospitals: 60% of overall funds and 40% of individuals; Secondary hospitals: 50% paid by the overall fund and 50% borne by individuals; Third-level hospitals: 40% is paid by the overall fund, and 60% is borne by individuals.

2 children's overall fund payment ratio increased by 5% according to the corresponding standards of urban non-employed residents.

Second-class outpatient serious illness expenses can be reimbursed.

According to reports, serious outpatient diseases include: special outpatient diseases (radiotherapy and chemotherapy for malignant tumors, outpatient renal dialysis, taking anti-rejection drugs after organ transplantation) and chronic diseases (hypertension, coronary heart disease, diabetes).

Outpatient treatment of special diseases: 50% from the overall fund and 50% from individuals; Outpatient treatment of chronic diseases: In one year, if the medical expenses for outpatient treatment of chronic diseases in designated medical institutions exceed 350 yuan, the excess will be paid by the overall fund according to the standard of 50%, and the maximum payment limit of the overall fund is 2,000 yuan.

Reimbursement process

After the insured residents are hospitalized, they shall pay a certain fee in advance (including Qifubiaozhun and personal out-of-pocket deposit), and the designated medical institutions shall determine the overall payment part and the personal payment part at the time of discharge.

Emergency hospitalization expenses incurred by insured residents in different places due to family visits, vacations and other reasons are included in the scope of medical insurance fund payment. When reimbursing, you need to provide the discharge summary, the first page of medical records, copies of long-term and temporary doctor's orders, hospitalization expenses list, hospitalization documents, disease diagnosis certificate and hospital grade certificate.

Insurance object

Residents' medical insurance is applicable to the following persons who are not included in the basic medical insurance for urban workers:

1, primary and secondary school students (including students from vocational high schools, technical secondary schools and technical schools) and other children under the age of 18 (including children of migrant workers who have been studying and living in cities with their parents for a long time);

2. Non-employed urban residents with urban household registration in this city and 18 years of age or older.

Bian Xiao will arrange it for you. I hope you can learn more about supplementary medical insurance. Identify which supplementary medical insurance cannot be reimbursed and who can participate in supplementary medical insurance.

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