Shanghai Huifu Insurance is customized for Shanghai based on the city's medical and living standards, closely linked to the social medical insurance, and provides millions of dollars of insurance coverage and convenient health services to the city's basic medical insurance enrollees at an affordable price, thus enhancing the level of health protection for the citizens of Shanghai.
I. Product Summary
1. Scope of Insurance: All insured persons participating in Shanghai Basic Medical Insurance (Interpretation 1)
2. Age of Insurance: Unlimited
3. Health Condition: Exempted from medical checkups, and covered and payable for pre-existing conditions
4. Waiting Period: No waiting period
5. Period of Insurance: 1 year
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6、Payment method: Single payment
7、Premium: RMB 129/person/year
8、Summary of Shanghai Huifeng Insurance Coverage in 2022
9、Claims: Whether participants are hospitalized in the general department of the second-level and above designated hospitals in Shanghai or abroad, if they use the Shanghai medical insurance card to settle the medical bill in real time, they can apply for specific hospitalization out-of-pocket medical expenses insurance benefits. If the claim is not settled in real time with the Shanghai Medical Insurance Card, the claim can only be made after the settlement of the Shanghai Basic Medical Insurance. The four responsibilities of domestic specific high-cost drug expense benefit/proton and heavy ion medical insurance benefit/overseas special drug expense benefit/CAR-T therapy drug expense benefit do not require the use of medical insurance card, but the claim can be applied for only if the medical institutions specified in the product specification of the above four responsibilities are used for medical treatment.
10. Surrender: The policy can be withdrawn in full before July 1 when the policy takes effect, and no surrender will be accepted after July 1 (inclusive) when the policy takes effect.
II. Insurance Liability
(1) Specific Hospitalization Out-of-Pocket Medical Expenses Benefit
During the insurance period, the insured person is hospitalized in the general inpatient department of the local second-class or above designated hospital for medical insurance (definition 2) due to illness or accidental injury, and the reasonable and necessary specific hospitalization out-of-pocket medical expenses (definition 3), which are settled by the Shanghai Basic Medical Insurance and deducted by 20,000 RMB annual deductible, will be refunded to the insured person. For medical expenses (definition 3), the insurance benefit will be 70% for non-pre-existing conditions and 50% for pre-existing conditions (definition 4). The annual benefit is limited to $300,000 for a single drug (definition 5), $200,000 for a single hospitalization for surgical materials, and one annual benefit for a PET-CT examination.
The total amount of benefit for the insured person is limited to 1,000,000 RMB for specific hospitalization out-of-pocket medical expenses, and the insurer's liability for the insured person will be terminated when the total amount of benefit for specific hospitalization out-of-pocket medical expenses reaches 1,000,000 RMB in a single payment or in the aggregate.
If the insured person is admitted to the hospital during the insurance period and has not been discharged from the hospital when the insurance period expires, the insurance company will still pay the insurance benefit according to the above mentioned scope of payment and percentage of payment of the insured person's out-of-pocket medical expenses incurred after the expiration of the insurance period until the end of the current hospitalization, but the maximum length of time shall not exceed 30 days.
(2) Domestic Specified High Cost Drugs Benefit
During the insurance period, the insured person, after registering at the second level or above hospital in Shanghai, and being diagnosed with a specific disease (Interpretation 7) by a designated specialist doctor (Interpretation 6), who will write an outpatient medical record and issue a prescription, will be able to purchase and use the "Domestic Specified High Cost Drugs Catalog" (Interpretation 8) at the outpatient clinic of the second level or above hospital in Shanghai, or at a pharmacy in Shanghai that has a qualification for selling drugs. (Specified High Cost Drug List) (Interpretation 8), the insurance company will pay 70% of the drug costs incurred by people with non-pre-existing conditions and 30% of the drug costs incurred by people with pre-existing conditions.
The total amount of benefits paid by the insurer to the insured person for specific domestic high cost drugs is limited to one million dollars, and the insurer's liability for the insured person shall be terminated when the total amount of benefits paid for specific domestic high cost drugs reaches one million dollars in one or more installments.
If the medicines in the Domestic Specified High Cost Drug List involve charitable assistance, they shall be implemented in accordance with the assistance program of the charitable organization, and the cost of the medicines assisted by the charitable organization shall not be included in the scope of payment of this product.
Drugs purchased at the Specialty Pharmacy (Interpretation 9) for Domestic Specified High-Value Drugs are eligible for direct drug payment and home delivery.
(3) Proton and Heavy Ion Medical Insurance Benefit
If the insured person receives proton or heavy ion treatment for malignant tumor in a medical institution (definition 10) qualified for proton or heavy ion treatment in Shanghai during the insurance period, the insurance company will pay for the reasonable and necessary expenses incurred for localization and formulation of radiotherapy plan, as well as the expenses for the implementation of proton or heavy ion radiotherapy (excluding bed charges, chemotherapy fees). The insurer will pay 70% of the cost of locating and planning the radiotherapy program and 30% of the cost of administering proton and heavy ion radiation therapy (excluding other costs such as bed charges and chemotherapy fees) for people with non-pre-existing conditions and 30% for people with pre-existing conditions.
The total amount of medical insurance benefit for proton and heavy ion for the insured person shall be limited to 300,000 RMB, and the liability of the insurance company shall be terminated when the total amount of medical insurance benefit for proton and heavy ion reaches 300,000 RMB in one or more payments.
(4) Overseas Special Drug Expense Insurance Benefit
During the insurance period, the insured person, after registering at Boao Super Hospital, Boao International Hospital, Boao Evergrande International Hospital, and Ruijin Hospital of Shanghai Jiaotong University School of Medicine Hainan Hospital (Boao Research Hospital of Hainan), and being diagnosed with a specific disease by the designated specialist, and having the outpatient medical record written and prescription issued, shall pay the outpatient or inpatient benefit to the insured person in the outpatient or inpatient department of the four hospitals mentioned above, and the insurance company shall not pay any benefit for the insured person. The insurance company will pay the insurance benefit for the drug expenses incurred by the outpatient or inpatient department of the four hospitals at 70% for the non-pre-existing condition group and 30% for the pre-existing condition group, if the purchase and use of the drugs in the Overseas Specific Drugs Catalogue (Interpretation 11) are in line with the limitations of the applicable diseases and indications.
The total amount of benefit for overseas special drug expenses paid by the insurer to the insured person is limited to RMB 300,000, and the insurer's liability to the insured person will be terminated when the total amount of benefit for overseas special drug expenses paid by the insurer reaches RMB 300,000 at one time or in several instances.
(E) CAR-T Therapy Drug Expense Benefit
During the insurance period, the insured person is diagnosed and recognized by the designated specialist as eligible for CAR-T therapy and undergoes CAR-T therapy at the designated hospital for CAR-T therapy ("Interpretation 12"), and purchases and uses drugs in the "List of Specific Drugs for CAR-T Therapy" ("Interpretation 13") in the designated hospital for CAR-T therapy that meets the criteria for CAR-T therapy. Interpretation 13), the insurer will pay 100% of the benefit for the drug costs incurred for both the non-pre-existing and pre-existing condition groups.
The total amount of benefits payable by the insurer to an insured person for CAR-T therapy drug costs is limited to 500,000 RMB, and the insurer's liability to the insured person for such benefits shall cease when the total amount of benefits payable for CAR-T therapy drug costs reaches 500,000 RMB in one or more installments.
III. Compensation Principle
The insurance company will pay the liability insurance benefits within the scope of the insurance liability of this contract. If the insured person has already received compensation for the corresponding expenses from any other sources, the insurance company will pay the insurance benefits according to the lesser of the amount of benefits calculated according to the above insurance liability standard, and the balance of the insured person's medical or pharmaceutical expenses after the insured person has been compensated.
4. Exemption of Liability
This product shall not be liable to pay benefits for the insured person's medical expenses caused by the following circumstances:
1. Infertility treatments, artificial insemination, pregnancy, childbirth (including obstructed labor), miscarriage, abortion, sterilization (including sterilization), prenatal and postpartum checkups as well as complications caused by the above reasons.
2. Medical expenses incurred for work-related injuries (occupational diseases).
3. Medical expenses that should be borne by a third party.
4. Medical expenses incurred for medical treatment abroad (including Hong Kong, Macao and Taiwan).
5. The insurer shall not be responsible for the payment of insurance benefits for matters that are not covered by laws, regulations, policies and documents.
6. If the insured person is hospitalized in bed or should be discharged but refuses to be discharged, the insurer shall not be responsible for the payment of the insurance benefit for all the medical expenses incurred from the date of the hospital's determination of his/her discharge from the hospital ("hospitalization in bed" refers to the insured person who has been formally hospitalized, and who is not in bed or in the hospital for 24 hours a day during the period of hospitalization, including The insured person is not in bed or hospital for 24 hours a day during the hospitalization period, including cases in which the insured person does not receive any treatment for a number of consecutive days during the hospitalization period, but only incurs nursing care fees, consultation fees and bed charges.
7. Expenses incurred for experimental or research treatments and their consequences that are not scientifically or medically approved; treatments not approved by the authority of the place where the treatment is given, drugs or medicines not licensed or approved by the government of the place where the treatment is given; all types of medical appraisals, including but not limited to, medical malpractice appraisal, psychiatric appraisal, fetal gender appraisal for pregnant women, injury examination appraisal, paternity appraisal, Genetic identification costs;
8. Plastic surgery, cosmetic or plastic surgery, sex reassignment surgery and complications of the foregoing surgery or medical malpractice resulting from the foregoing surgery; medical expenses incurred by the insured person for preventive, sports and fitness, recuperative or convalescent care, medical counseling, health care, or non-disease treatment programs; eyeglasses or contact lenses, vision correctors, aids, orthopedic appliances, hearing aids, prosthetic limbs, prosthetic eyes, wheelchairs, crutches and other functional auxiliary materials or rehabilitation-type devices.
9. Exemption of Domestic Specified High Cost Drugs and Overseas Special Drugs
(1) The prescription of drugs does not conform to the scope of Domestic Specified High Cost Drugs or Overseas Special Drugs of this product.
(2) Drugs not purchased at the hospital or pharmacy agreed upon for this product.
(3) The cost of medicines exceeding the portion of one month or more per medicine prescription.
(4) Domestic prescriptions for specific high-value medicines do not conform to the indications and dosages listed in the instructions for the medicine approved by the State Food and Drug Administration; the relevant medical materials do not prove that the insured person is suffering from a disease that is consistent with the indications for the use of the specific medicine.
(5) The prescription of overseas special medicines does not conform to the indications and dosage stated in the instruction manual of the medicine approved by the management department of the region where the medicine is exported; and the relevant medical materials do not prove that the disease suffered by the insured person is in line with the indications for the use of the specific medicine.
(6) The prescription of the medicine is not issued by the designated specialist of the designated hospital outpatient registration.
(7) The insured person's disease condition, after review, is determined to have been resistant to the drug, and the expenses incurred (drug resistance is defined as a. solid tumor lesions in accordance with RECIST (Solid Tumor Treatment Efficacy Evaluation Criteria) disease progression, which is defined as drug resistance. b. non-solid tumors (including leukemia, multiple myeloma, myelofibrosis, lymphoma, and other malignant tumors) in the clinic is often without a clear mass or the mass is small and difficult to detect. After standardized treatment, the results of bone marrow morphology, flow cytometry, and specific genetic tests of the patients will be evaluated according to the guideline specifications of the relevant professional organizations (including: Chinese Society of Clinical Oncology (CSCO), Chinese Society of Hematology, China Association of Anti-Cancer Societies (CACS) Hematology and Tumor Specialized Committee, the National Health Commission (NHRC), and the National Comprehensive Cancer Network (NCCN) of the U.S.) to arrive at a comprehensive evaluation of disease progression. A comprehensive evaluation was performed to conclude disease progression, which was defined as drug resistance.
(8) Pharmaceutical expenses incurred by the insured person who is eligible to apply for charitable assistance for medication, but the application for the assistance program is not approved due to the insured person's failure to submit the relevant application or submission of incomplete application materials; and the insured person who passes the examination for assistance, but fails to receive the assistance medication for the reasons of the insured person is deemed to voluntarily waive the insurance rights and benefits applicable under the present contract.
V. Interpretation
1. Shanghai Basic Medical Insurance: refers to Shanghai Employees' Basic Medical Insurance and Shanghai Urban and Rural Residents' Basic Medical Insurance.
2. Hospitalization: means the insured person is admitted to an official ward of a hospital for treatment and formal admission and discharge procedures, but does not include the following:
(1) the insured person is admitted to the Emergency Observation Room, family hospital beds, or joint wards;
(2) the insured person is admitted to the Rehabilitation Ward (Rehabilitation Department) or receives rehabilitation treatment;
(3) the insured person Hospitalization in the course of which the insured person does not receive examination and treatment related to the diagnosis of admission within 1 day, or is hospitalized for less than 24 hours within 1 day, except for temporary treatment at an outside hospital in accordance with medical advice;
(4) Other unreasonable hospitalization, including cases where no treatment is given for a number of consecutive days during hospitalization, and only nursing care fees and bed charges are incurred.
3. Specific hospitalization out-of-pocket medical expenses: refers to the specific drugs, surgical materials and inspection and test fees in the out-of-pocket medical expenses in the bills settled by Shanghai Basic Medical Insurance during the hospitalization period, excluding the medical expenses in the individual and categorized out-of-pocket parts of the basic medical insurance.
Specified Drugs Fees: during hospitalization, the fees for drugs outside the scope of the basic medical insurance fund's payment catalog prescribed by a licensed medical practitioner and having a drug approval number issued by the State Drug Administration or a certificate of registration of imported drugs or a certificate of registration of medicinal products, including the fees for Western medicines, proprietary Chinese medicines and Chinese herbal medicines, but excluding the following: (1) Chinese herbal medicines which mainly play a role of nutritional supplementation; (2) Chinese herbal medicines which mainly play a role of nutritional supplementation; and (3) Chinese herbal medicines which mainly play a role of nutritional supplementation. Chinese herbal medicine; (2) animals and animal organs that can be used as medicine; (3) medicines with beauty and weight loss as their health care functions.
4. Pre-existing condition group: refers to the group of people who are registered or enjoying the treatment of outpatient major diseases of Shanghai workers or urban and rural residents within two years before the date of insurance, the scope is as follows:
(1) dialysis of severe uremia (hemodialysis, peritoneal dialysis);
(2) anti-rejection after renal transplantation;
(3) treatment of malignant tumors (chemotherapy, endocrine specific therapy, radiation therapy, isotope therapy, chemotherapy, endocrine treatment, radiotherapy, radiotherapy, radiotherapy, radiotherapy, radiotherapy, radiotherapy, isotope therapy, isotope therapy). therapy, radiotherapy, isotope therapy, interventional therapy, traditional Chinese medicine therapy);
(4) treatment of some psychiatric diseases (schizophrenia, moderate to severe depression, mania, obsessive-compulsive disorder, mental retardation accompanied by psychiatric disorders, epilepsy accompanied by psychiatric disorders, paranoid psychosis);
(5) hemophilia, aplastic anemia for students enrolled in the Shanghai higher education institutions of the city.
5. Single Drug Fee: the total cost of drugs with the same chemical name
6. Designated Specialist: The designated specialist should meet the following four qualifications at the same time: (1) a valid Chinese People's Republic of China (People's Republic of China) Certificate of Qualification for Medical Practitioners; (2) a valid Chinese People's Republic of China (People's Republic of China) Certificate of Practice for Medical Practitioners, and register with the relevant authorities on schedule; (3) having a valid Chinese People's **** and the State's "Physician's Title Certificate" of the title of attending physician or attending physician or above; (4) the hospital served by the relevant physician in confirming the diagnosis or prescribing to the patient is a hospital of the second level or above and serves the clinical departments related to the treatment of the prescribed indications.
7. Specific diseases: lung cancer, head and neck cancer, gastric cancer, melanoma, esophageal cancer, liver cancer, breast cancer, prostate cancer, ovarian cancer, lymphoma, brain tumor, leukemia, multiple myeloma, neuroblastoma, colorectal cancer, fallopian tube cancer, peritoneal cancer, gastrointestinal mesenchymal stromal tumors, cholangiocarcinoma, uroepithelial carcinoma, Fabre's disease, mucopolysaccharide storing disease (type II, IVA), transcytosis, and other diseases. thyroxine protein amyloidosis polyneuropathy (ATTR-PN), idiopathic pulmonary arterial hypertension
8, Domestic Specific High-Value Drugs Catalog
*The insurance company will adjust the Domestic Specific High-Value Drugs List in due course according to the updating of the National Essential Drugs Catalog
9, Specialty Pharmacy:
10, Shanghai City, China, with the qualification of proton, Heavy Ion Therapy Qualified Medical Institutions: Hospitals engaged in the medical practice of proton and heavy ion therapy with the approval and consent of the Shanghai Municipal Health Administrative Department.
11, Overseas Special Drugs Catalog
12, CAR-T Therapy Designated Hospitals
Shanghai medical institutions that have received training and certification in the use of Fosun Kite Biotechnology Co. Specific Drug Catalog