The latest policy on Shanghai's major medical insurance in 2017
I. Scope of Shanghai's major medical insurance
This notice is applicable to the insured who participate in the basic medical insurance for urban residents in Shanghai and enjoy the benefits of the residents' major medical insurance (hereinafter referred to as "insured residents").
Two, the residents of the major medical insurance agency
(a) Municipal Medical Insurance Business Management Center (hereinafter referred to as the Municipal Medical Insurance Center) by the Municipal Bureau of Human Resources and Social Security (Municipal Medical Insurance Office) (hereinafter referred to as the Municipal Bureau of Human Resources and Social Security (Municipal Medical Insurance Office)) commissioned by the Municipal Government Procurement Center for the public tender, to determine the contractors of the residents of the major medical insurance of the commercial insurance agency; and the Municipal Medical Insurance Center signed a contract with the commercial insurance agency to determine the contractors of the major medical insurance of the residents of the Municipal Municipal Municipal Municipal Municipal Municipal Municipal Medical Insurance Center. Medical Insurance Center and commercial insurance institutions to sign residents of major medical insurance entrusted contract, using the purchase of services to implement residents of major medical insurance.
(2) The commercial insurance organization selected by the insured residents when they first apply for reimbursement of residents' major medical insurance shall be the designated agency for reimbursement of medical expenses for residents' major medical insurance in that year; once selected, no change shall be made in principle during the year.
Three, the residents of the major medical insurance coverage treatment
(a) According to the provisions of the Trial Measures, the residents of the major medical insurance, including dialysis treatment of severe uremia, renal transplantation anti-rejection treatment, treatment of malignant tumors (chemotherapy, endocrine-specific treatment, radiation therapy, isotope therapy, interventional therapy, traditional Chinese medicine treatment), part of the psychiatric treatment (schizophrenia, moderate to severe depression, mania, obsessive-compulsive disorder, mental retardation with mental disorder, epilepsy with mental disorder, paranoid psychosis).
From September 1, 2015, medical expenses incurred by students enrolled in Shanghai's institutions of higher education who suffer from hemophilia and aplastic anemia are included in the scope of residents' major disease insurance.
(2) The individual portion of the medical expenses incurred by insured residents suffering from the above major diseases at designated medical institutions of Shanghai basic medical insurance and in compliance with the provisions of Shanghai basic medical insurance shall be included in the scope of payment of the residents' major disease insurance, and 50% shall be reimbursed by the funds of the major disease insurance. Among them, the insured residents who have participated in the Shanghai Municipal Hospitalization Medical Mutual Aid Fund for Primary and Secondary School Students, Infants and Children shall first deduct the part paid by the mutual aid fund.
(3) The scope of payment, audit and management of residents' major disease insurance shall refer to the relevant provisions of Shanghai workers' basic medical insurance for outpatient major diseases.
Four, the residents of the reimbursement of major medical insurance materials
(a) the insured residents (excluding students of institutions of higher learning) applying for reimbursement of residents of the major medical insurance, should provide the following materials:
1. ID card (if you do not receive an ID card to provide other valid identity documents), "social security card" (or "social security card (health insurance)");
2.
2. Receipts for medical expenses in accordance with the provisions of Shanghai Municipal Health Insurance or the reimbursement statement of Shanghai Urban Residents' Basic Health Insurance;
3. Outpatient and emergency medical records, hospital discharge summaries, detailed lists of expenses and other relevant information;
4. Agreement on the establishment of a contractual service relationship with the community health service center or the community-based family doctor for the first time of the year;
5.5. If the reimbursement is entrusted to another person, the entrusted person should also provide the entrusted person's ID card along with the above information.
(2) When applying for reimbursement of residents' major medical insurance, students enrolled in institutions of higher education should provide the following materials:
1. ID card (or other valid ID cards if they have not received an ID card), student ID card;
2. Hospitalization settlement vouchers for medical care;
3. Receipts of medical expenses in accordance with the provisions of the Shanghai Municipal Medical Insurance or the Shanghai Municipal Medical Insurance Reimbursement Settlement Statement Urban residents' basic medical insurance reimbursement statement;
4. Outpatient and emergency medical records, discharge summaries, detailed lists of expenses and other relevant information;
5. If you delegate someone else to handle the reimbursement, the delegatee must provide the delegatee's ID card along with the above information.
V. The reimbursement process of residents' major medical insurance
(1) After incurring major medical expenses, the insured residents should apply for reimbursement of major medical expenses at the commercial insurance organization of their choice within six months from the date of the medical expense receipt and provide the corresponding materials.
(2) After accepting the application, the commercial insurance organization will review the medical expenses in accordance with the relevant regulations of Shanghai residents' major illness insurance.
(3) The commercial insurance organization will complete the audit, settlement and reimbursement payment of the declared medical expenses within 5 working days. Payment of reimbursement is in principle made in the form of bank cards.
VI. Settlement and Disbursement of Residents' Major Disease Insurance Expenses
(1) Settlement of Medical Expenses
1. Commercial insurance organizations shall summarize the reimbursement expenses of residents' major disease insurance on a monthly basis, fill in the expense settlement form and the settlement declaration form, and generate the computerized database data.
2. From the 1st to the 10th of each month, the commercial insurance organization shall apply to the municipal health insurance center for settlement of medical expenses with the medical expense settlement form, the settlement declaration form and the computer database data of the previous month.
3. The Municipal Health Insurance Center audits the settlement expenses declared by the commercial insurer according to the relevant regulations of Shanghai Urban Residents' Basic Health Insurance, and does not pay for the expenses that do not comply with the regulations; the expenses that do comply with the regulations will be disbursed by the end of each month.
(2) Settlement of service fees
Commercial insurance institutions, based on the actual reimbursement situation after the full-year assessment, will fill in the first quarter of the following year the application form for payment of service fees for the Shanghai Urban Residents' Major Disease Insurance, and will be allocated the service fees within 10 working days after the review by the Municipal Medical Insurance Center.
(3) The above funds for purchasing residents' major disease insurance shall be charged to the basic medical insurance fund for urban and rural residents in accordance with the provisions of the Circular on the Measures for Financial Layoff of Urban and Rural Residents' Major Disease Insurance Purchased from Commercial Insurance Institutions by Using the Basic Medical Insurance Fund from the Ministry of Finance, the Ministry of Human Resources and Social Security, the Commission for Health and Family Planning, and the CIRC (Caixa [2013] No. 36).
(d) the municipal health insurance center is responsible for the development of residents of major medical insurance assessment methods, the commercial insurance institutions to undertake residents of major medical insurance for daily and annual assessment; assessment results are linked to the settlement of service costs.
Seven, other
(a) the insured residents applying for residents' major medical insurance treatment, should also be eligible to enjoy the basic medical insurance for urban residents in Shanghai.
(2) The start time for commercial insurance institutions to accept applications for reimbursement of residents' major disease insurance is January 30, 2015.
(c) This notice shall be implemented as of January 30, 2015, and shall be valid until December 31, 2016.
Expenses incurred during the period from July 1, 2014 to the date of implementation of this document, which are eligible for coverage under the Shanghai Resident's Major Disease Insurance, may be reimbursed in accordance with the provisions of this document.
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