Reimbursement materials:
1. Valid ID document of the insured person
2. Medical insurance card or social security card of the insured person
3. Shanghai Bank medical insurance identification card or bank debit card with UnionPay logo
4. The details are as follows:
(1) When applying for reimbursement of outpatient and emergency medical fees, you should also bring the special receipt/receipt for outpatient medical fees. Emergency medical fee receipts, relevant medical history information and copies, "outpatient and emergency medical record book" emergency page and copies (medical expenses incurred in the city's designated medical institutions for those whose medical relationship is the city's medical insurance). In case of damage to the medical insurance card, it is also necessary to provide the "Notice of Damage to Medical Insurance Card"
(2) To apply for reimbursement of hospitalization and emergency observation room observation expenses, the insured person should also provide a special receipt for medical expenses, a list of medical expenses during the period of hospitalization (a list of medical expenses for observation in the emergency room) and a copy of the same, and a summary of the discharge from the hospital and a copy of the same.
(3) When applying for piecemeal reimbursement of outpatient medical expenses for major illnesses, the insured person should also provide a special receipt for outpatient medical expenses, a certificate of diagnosis of the disease and a copy of the certificate, and a report of the relevant examination and a copy of the report.
5. Other relevant information required by the medical insurance agency
6. If the application is entrusted to another person, it is also necessary to provide a valid identity document of the entrusted person
In order to cooperate with the implementation of the municipal government's "Shanghai Employees' Basic Medical Insurance Measures", to carry forward the glorious tradition of the working class' solidarity, love, mutual assistance and mutual aid, and to effectively help hospitalized retired workers to reduce the financial burden of their personal expenses. In order to effectively help hospitalized retired workers reduce the financial burden of part of their own medical expenses and enable them to recover early from their illnesses, we will continue to provide them with the best possible medical care. As a complementary approach to the reform of the city's employee health insurance system, the Shanghai Retired Workers Hospitalization Supplementary Medical Mutual Aid Protection Plan (hereinafter referred to as the Plan) is hereby formulated.
Subjects
Article 1
1, unit group participation
All retired workers who are covered by the Shanghai Employees' Basic Medical Insurance can participate in this plan on a voluntary basis through the Retirement Management Committee of their original units, and apply for participation in this plan through the Shanghai Employees' Mutual Benefit Association. The number of participants should not be less than 75% of the total number of retired workers in the unit (based on the information on the number of retired workers in the unit provided by the Social Security Center). Active employees who are bereaved of their labor and enjoy retirement health insurance benefits comparably should participate in this plan.
2. Community Participation
Retired workers who meet the conditions for community participation, such as social retirees who are covered by the Shanghai Employee Basic Medical Insurance, can go to the service points of the labor unions of the various communities (streets and towns) of the city to apply for participation in June every year.
Participation Procedures
The following materials should be provided when participating in the insurance:
1. Materials to be provided by the unit group for participation in the insurance
(1) the "insurance policy" which is filled in completely and stamped with the official seal;
(2) a list of participants (including serial number, name, ID number and dry insurance) made in EXCEL or FOXPRO format, and a list of the participants (including serial number, name, ID number and dry insurance). (including serial number, name, ID number and dry insurance four fields, enjoy the "dry insurance" treatment of the participants should be in the "dry insurance" field write "yes") of the computer CD-ROM (do not need to be accompanied by a printed list) or USB flash drive (must be provided with its matching). (2 copies of the printed roster must be provided). In order to reduce the workload of the insured units and improve the accuracy of the information of the insured persons, the insured units can download the list of the last period's insured persons from the website of the Association (URL:) when the insurance is renewed for the full term, and make additions or deletions to the list of the current period's insured persons and then make a computer disc or USB flash drive on the list;
(3) The "In-service Employees' Hospitalization Supplementary Medical Mutual Aid Insurance Plan Enrollment Form" or "Comprehensive Comprehensive Medical Mutual Aid Protection Scheme for In-service Employees Enrollment Form "or" Comprehensive Supplementary Medical and Accidental Mutual Aid Insurance Plan Application Form ";
(4) one of the following payment vouchers: ① a copy of the credit voucher or cash release order stamped with the bank's business seal; ② printout of the unit's online banking payment voucher.
2, the community should be provided by the materials
(1) my ID card;
(2) my "pension approval form" and other social security center printout of the relevant certificate or "retirement certificate, Retirement Certificate" or "Retirement Certificate".
Article 3: Enrollment Time
1. Enrollment of Unit Groups
Participating units can no longer apply for enrollment for uninsured retired employees 10 days after the starting date of enrollment (except for newly-retired employees, who should be provided with the "Pension Approval Forms" of the newly-retired employees and must enroll in the insurance within 2 months of the completion of the retirement formalities). (except for newly retired employees, who should be provided with a "Pension Authorization Form" and must enroll within 2 months after completing retirement procedures).
2. Community Participants
Community participants must go to the service points of the labor unions in each community (street or town) in June every year to go through the procedures for enrollment (newly retired members of the community without a unit can enroll in the insurance within 2 months after completing the retirement procedures, but they should provide the "pension approval form").
Coverage fee
Article 4 Coverage Fee Payment Standard:
1. Contribution Standard for Unit Group Participation
The contribution standard for unit group participation in the insurance is RMB 207 per person (without participating in the "In-service Employees' Hospitalization Supplementary Medical Care Mutual Aid Insurance Plan" or "Comprehensive Supplementary Medical Care and Accident Insurance Plan", the contribution standard for unit group participation is RMB 207 per person). (For units that do not participate in the "Comprehensive Supplementary Medical and Accident Mutual Aid Insurance Plan for In-service Employees" or the "Comprehensive Supplementary Medical and Accident Mutual Aid Insurance Plan", the contribution rate is RMB 222 per person.)
2. Contribution standards for community-based insurance participants
All community-based insurance participants should enroll in the community-based insurance in June 2013 or within one year after their retirement, and from 2014 onwards, they will be charged at different contribution standards for the first-time enrollment or re-enrollment after the interruption of renewal of the insurance (except for newly retired persons), and the contribution standards are as follows:
(1) Retired persons who have retired before June 2013 should enroll in the community-based insurance in June 2013 or within one year after their retirement. (1) Retirees who have retired before and enrolled in June 2013, and new retirees who enrolled for the first time within one year of their retirement after June 2013, will be charged at the contribution rates announced in the year of payment, and from the following year onwards, they will be charged at the contribution rates announced in the year of renewal.
(2) From 2014 onwards, the following three categories of persons who participate in the insurance for the first time or renew the insurance after the interruption, will be charged according to the corresponding multiples of the contribution standard published in the year of payment:
① persons who have retired before June 2013, and who participate in the insurance for the first time after June 2013;
② new retirees in each year after June 2013, and who have not participated in the insurance within one year of retirement, will be charged according to the contribution standard published in the year of payment. (ii) New retirees in any year after June 2013, who are not enrolled in June within one year, and who enroll for the first time after that.
The contribution amount for the above two categories of personnel is charged according to the following formula:
First-time contribution rate = contribution rate published in the year of payment × (1+n1)
Note: n1 refers to the years of non-enrollment after retirement counted from 2013, counting from 1 year, and any more than 3 years are counted as 3 years; from the next year onwards, the contribution rate is charged according to the contribution rate published in the year of renewal.
3) Retirees who were once insured but did not renew their insurance on time and then insured after the interruption, the contribution amount of such persons shall be charged according to the following formula:
Contribution standard of the first year = contribution standard published in the year of contribution × (1+n2)
Note: n2 refers to the years elapsed from the interruption of the last renewal of the insurance calculated from 2013 onwards to the current one, starting at 1 year, all of which exceeding 3 years shall be calculated at 3 years. All years in excess of 3 years are counted as 3 years; from the following year onwards, contributions are charged in accordance with the contribution rates published in the year of renewal.
The contribution rate for community participants is 222 yuan per person.
Article 5: The insured can only enroll in 1 copy of the insurance within the coverage period. The number of copies exceeded is regarded as invalid.
Term of Coverage
Article 6
1, unit group coverage
The term of coverage is one year, the first time to pay premiums and submit all the required materials for coverage from 00:00 on the day after the expiration of the period of coverage up to 24:00 on the date of expiration of the period of coverage. Renewal procedures will be conducted separately after the expiration date (see Article 14 of the Plan).
2. Community Participants
The period of coverage is one year or less:
(1) For those who enroll in June: the period of coverage is one year, from 00:00 hours on June 2 of the current year to 24:00 hours on June 1 of the following year.
(2) For new social retirees who first enroll within 2 months of retirement: the coverage period is from 00:00 hours on June 2 of the current month to 24:00 hours on June 1 of the year within one year.
Renewal procedures will be carried out in June every year (see Article 14 of the Plan).
Coverage Liability
Article 7: The coverage of this plan shall be for the following four types of treatments in the hospitals recognized by the city's medical insurance department:
1. Inpatient treatment;
2. Emergency observation room observation treatment (hereinafter referred to as the Emergency Observation Room Observation Treatment) for which the medical fees are settled according to the inpatient standard;
3, Outpatient major illness (see the bylaws for specific definitions, hereinafter referred to as the same) treatment;
4. Home hospital bed treatment.
Article 8 The 30-day exemption period is implemented for the first enrollment or re-enrollment after interruption. After the exemption period, the Association will pay a certain percentage of the individual's out-of-pocket medical expenses (including the categorized out-of-pocket medical expenses of outpatient major illnesses; excluding medical expenses within the starting standard of hospitalization and the categorized out-of-pocket medical expenses of inpatient and family hospital beds; excluding out-of-pocket expenses. The same hereinafter) shall be paid as a percentage of the supplemental medical insurance benefits.
Article 9: Criteria for payment of Supplementary Medical Benefits for Hospitalization, Emergency Observation Room Observation, and Family Hospital Bed Treatment:
1. For medical expenses within the scope of payment of the Coordinated Fund (above the starting payment standard and below the maximum payment limit) which are part of the individual's own medical expenses, the Association will pay Supplementary Medical Benefits at the rate of 60% of the said expenses.
2. For medical expenses within the scope of the Additional Fund above the maximum payment limit of the Coordinated Fund that are the responsibility of the individual, the Association will pay 70% of the supplemental medical insurance benefit.
Article 10: Criteria for payment of Supplementary Medical Insurance Benefits for Outpatient Treatment of Major Diseases:
For categorized outpatient treatment of major diseases, and outpatient treatment of major diseases within the scope of payment of the Coordination Fund and the Supplementary Fund that is partially covered by the individual, the Association will pay 50% of the Supplementary Medical Insurance Benefits of the expenses.
Article 11: Accumulated Maximum Benefit for Supplementary Medical Benefit:
The accumulated maximum benefit for the Supplementary Medical Benefit for the insured person during the period of coverage is 40,000 RMB.
When the accumulated maximum benefit amount is reached, the coverage responsibility will be terminated.
Article 12: If the insured person's treatment has not been completed (i.e. the hospital has not yet settled the medical expenses) during the Exclusion Period or at the end of the Coverage Period, after the hospital has settled the medical expenses at the end of the treatment, the Company will pay the medical expenses for the days after the Exclusion Period of the treatment period and during the Coverage Period in the ratio of the number of days in the treatment period to the total days in the treatment period multiplied by the medical expenses for the individual's own share in accordance with the provisions of Article 9, Article 10, and Article 11 The corresponding Supplementary Medical Benefit. If the Insured Person has not completed the treatment at the end of the Coverage Period but renews the Coverage within 10 days of the expiration of the Coverage Period, the Supplemental Medical Benefit will be paid according to the respective Coverage Period.
Article 13: The liability of the coverage shall be terminated at the end of the coverage period.
Article 14
1. If the insured person enrolled in a unit group renews the policy within 10 days from the date of expiration of the coverage period, the starting date will be the same as that of the previous period and the 30-day exemption period will be canceled (except for new enrollees at the time of renewal). Renewal within 10 days of the expiration date of the coverage period will be treated as the first enrollment and will still be subject to the 30-day exclusion period.
2. The expiration date of the coverage period of the insured person in the community is June 1, and he must go to the service point of the labor union in June for the renewal procedures (for those who have already applied for the withholding procedures, the insurance will come into effect after the withholding of the money to the account, and he does not need to apply for the renewal procedures again. For those who have not deducted the money, they should pay cash for renewal in June of that year, and continue to deduct the money on behalf of the following year without going through the renewal procedure again). .
Exceptions
Article 15 of the following cases, the Association will not be responsible for the payment of supplemental medical benefits:
1. Medical expenses incurred during the exemption period when the insured person started treatment before enrollment or during the 30-day exemption period after enrollment;
2. Medical expenses incurred at the expiration of the period of coverage when the medical expenses of that treatment have not yet been settled and the coverage has not been renewed, and the number of days of treatment exceeds the period of coverage;
3. Medical expenses incurred at the end of the coverage period when the medical expenses of that treatment have not yet been settled and the coverage has not been renewed. Medical expenses incurred during the coverage period;
3. Medical expenses for work-related injuries and occupational diseases;
4. Medical expenses within the starting standard for hospitalization and categorized out-of-pocket expenses for inpatient hospitalization and family hospital beds;
5. Individual out-of-pocket medical expenses not covered by the medical insurance;
6. All kinds of deception or cheating on the part of the participating units or the insured.
Article 16 The Association shall terminate its responsibility for the protection of the insured unit or the covered person if the insured unit or the covered person commits any of the acts referred to in Article 15, paragraph 6.
Application and Payment of Supplementary Medical Benefits
Article 17: Application for Supplementary Medical Benefits shall be accompanied by the following documents:
1. "Application Form for Payment of Inpatient Medical Mutual Benefits";
2. The original of the original of the special receipts for inpatient medical expenses for medical treatment based on the vouchers of the health insurance ( The original of the special receipt is not required for "outpatient major diseases", and the original of the settlement statement and detailed list of the relevant medical expenses and the copy of the special receipt for medical expenses issued by the city districts (counties) or overseas medical insurance service centers recognized by the city medical insurance department must be provided for sporadic reimbursement;
3. Uremic patients who have been hospitalized for various reasons need to provide a hospital discharge summary (other than those who have been hospitalized for other reasons). Discharge summary is required for patients with uremia who are hospitalized for various reasons (other patients are not required to provide); outpatient major illnesses must provide outpatient major illnesses receipts; home hospital beds must provide proof of the establishment and withdrawal of beds;
4. Application for payment requires a copy of the insured person's pension account with the Bank of Shanghai, the Agricultural Bank of China, the Postal Savings Bank of China, the Bank of China, the Agricultural Bank of Shanghai, the Shanghai Agricultural Bank of China, or the Construction Bank of China in the city. In addition to the above pension accounts, the insured person can also provide a copy of the current savings passbook account of the Shanghai branch of China Postal Savings Bank, a copy of the debit card and current savings passbook account of the Shanghai branch of the Bank of Shanghai or the Agricultural Bank of China.
Article 18: The insured person shall make an application at the trade union service point of each community (street or town) after five working days from the date of issuance of special receipts for medical expenses by the hospitals or certificates of medical expenses by the medical insurance service centers of each district (county) of the city (including foreign medical insurance service centers recognized by the medical insurance department of the city).
Article 19: Upon receipt of the application with complete formalities from the insured person concerned, the Union shall verify and transfer the supplementary medical insurance fund into the relevant bank account provided by the insured person within 30 days.
Article 20: The right of a covered person to apply for the payment of supplementary medical insurance benefits from the Association shall be forfeited if it is not exercised within two years from the date of issuance of the special receipt for medical expenses.
Change of information
Article 21
1. Change of information of the unit enrolled in the insurance
If the unit changes its basic information (name, address, zip code, contact person and contact phone number, etc.) after enrollment in the insurance, the unit shall notify the Customer Service Department of the Association in writing within 15 days of the change. In case of failure to notify in writing, the Association will send the relevant notice to the original contact person or contact address and it will be deemed to have been delivered to the insured unit.
2. Changes in the information of community participants
If the personal information (contact address, telephone number, etc.) of a community participant changes after enrollment, the participant should go to the service point of the labor union in the community (street or town) where the enrollment procedure is carried out to apply for the change of information in a timely manner; if the participant does not apply for the change of information, the Union will not be able to contact the participant according to the original contact information, and the participant will bear the responsibility of all the consequences caused. The person who fails to do so will be held responsible for all the consequences.
Others
Article 22: The Association shall implement special accounting for the guarantee fee, and the operation, settlement and management of the guarantee fee shall be under the leadership of the Board of Directors and the supervision of the Supervisory Board. Based on the actual payment situation in the previous year and the changes in the implementation methods of the Basic Medical Insurance Coordination Fund and the Local Additional Medical Insurance Fund, as well as the changes in subsidies from the government and relevant departments, the Association shall decide on the charging rate of the guarantee fee and the percentage of the supplementary medical guarantee payment for the following year accordingly. The premiums will be adjusted every two years starting from 2014.
Attachments
Article 23: The outpatient treatment of major diseases covered by this plan refers to the following:
1. anti-rejection treatment after dialysis and kidney transplantation for uremia;
2. psychiatric treatment for outpatient treatment of major diseases covered by the medical insurance;
3. chemotherapy of malignant tumors (including chemotherapy of malignant tumors) within the period of the medical treatment of major diseases covered by the medical insurance;
4. chemotherapy of malignant tumors (including chemotherapy of malignant tumors) within the period of the treatment of major diseases covered by the medical insurance. The malignant tumor chemotherapy (including endocrine-specific anti-tumor therapy), radiation therapy, isotope anti-tumor therapy, interventional anti-tumor therapy, traditional Chinese medicine anti-tumor therapy, and the necessary related examinations.
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