1. Malignant Tumor Treatment: including chemotherapy for malignant tumors (including endocrine-specific anti-tumor therapy), radiotherapy for malignant tumors, isotope anti-tumor therapy, interventional anti-tumor therapy, and traditional Chinese medicine anti-tumor therapy.
2. Outpatient hemodialysis and peritoneal dialysis for severe uremia.
3. Anti-rejection treatment after kidney transplantation.
4. Treatment of major psychiatric diseases: schizophrenia, depression (moderate and severe), mania, obsessive-compulsive disorder, mental retardation with mental disorder, epilepsy with mental disorder, paranoid psychosis.
According to the provisions of the Trial Measures, the residents' major disease insurance includes dialysis treatment for severe uremia, anti-rejection treatment for renal transplantation, treatment for malignant tumors (chemotherapy, endocrine-specific treatment, radiation therapy, isotope therapy, interventional therapy, and traditional Chinese medicine), treatment for some psychiatric illnesses (schizophrenia, moderately or severely depressive disorders, manic-depressive disorders, obsessive-compulsive disorders, mental disorders accompanied by mental developmental delay, epilepsy), and treatment of paranoid mental disorders. mental disorder, epilepsy with mental disorder, paranoid psychosis).
It should be noted that the following cases are not covered by the medical insurance for major illnesses:
1. Unauthorized treatment in non-scheduled hospitals (except for emergency rescue);
2. Occupational diseases, injuries sustained on the job, or recurrence of work-related injuries; injuries caused by traffic accidents (we recommend purchasing a commercial accidental injury insurance);
3. Injuries caused by the violation of law;
4. Food poisoning caused by liability accidents;
5. Suicide resulting in treatment (except for psychotic episodes);
6. Injuries caused by medical malpractice;
7. According to the state and municipal regulations, medical expenses should be paid for by the city (recommended to purchase a commercial supplemental medical insurance).
The process of reimbursement for major medical insurance
1. Required documents for reimbursement of major medical insurance
1) Participant's ID card;
2) Participant's medical certificate or card;
3) Original and copy of the settlement list of medical expenses.
2. The process of reimbursement for major medical insurance
1)The insured person should bring the above materials to the medical insurance section of the local fixed-point hospital to fill in the relevant forms for the preliminary examination;
2)The fixed-point hospital will report the information of the insured residents who are qualified for the preliminary examination to the municipal medical insurance agencies for examination;
3)The final examination of the insured residents will be organized by the municipal medical insurance agencies to issue the reimbursement for the major medical insurance. Organize the issuance of reimbursement for major medical insurance.
Legal basis:
Guiding Opinions on Carrying Out Work on Major Disease Insurance for Urban and Rural Residents
Fifth, urban and rural residents of the major disease insurance contracting methods
(a) the way to take the purchase of major disease insurance from the commercial insurance institutions. Local government departments of health, human resources and social security, finance, and development and reform formulate basic policy requirements for financing, reimbursement scope, minimum compensation ratio, and management of medical treatment and settlement for major disease insurance, and select commercial insurance organizations to undertake major disease insurance through government tendering. The tender mainly includes specific compensation ratios, profit and loss ratios, and equipped contracting and management forces. Commercial insurance organizations that meet the basic entry requirements participate in the bidding on a voluntary basis, and after winning the bidding, they undertake major disease insurance in the form of an insurance contract, bear the operational risks, and are responsible for their own profits and losses. The premium income of commercial insurance organizations undertaking major disease insurance is exempted from business tax according to the current regulations. Has been carried out in urban and rural residents of the major disease protection, supplemental insurance and other areas, to gradually improve the mechanism, do a good job of convergence.
(ii) standardize the bidding and contract management of major disease insurance. Each region should adhere to the principles of openness, fairness, impartiality and honesty, establish and improve the bidding mechanism, standardize the bidding process. Commercial insurance organizations should bid in accordance with the law. The bidder shall sign an insurance contract with the successful commercial insurance organization, clearly defining the responsibilities, rights and obligations of both parties, and the cooperation period shall be no less than three years in principle. The principle of balancing income and expenditure, preserving capital and making a small profit shall be followed, the profit rate of commercial insurance organizations shall be reasonably controlled, and assessment methods centering on the level of protection and the satisfaction of the insured (co-insured) shall be established. In order to facilitate the long-term and stable operation of major disease insurance and effectively guarantee the actual benefit level of the insured (co-insured), a corresponding dynamic adjustment mechanism can be established in the contract for the excess balance and policy losses. Each region should continue to improve the content of the contract and explore the development of a unified model contract for the whole province (region and city). Due to the violation of the contract, or other serious damage to the rights and interests of the participants (co-operation), the two parties to the contract can be terminated in advance or terminate the cooperation, and to be held accountable in accordance with the law.
(C) strict commercial insurance organizations basic access conditions. Commercial insurance institutions undertaking major disease insurance must have the following basic conditions: meet the necessary conditions for operating health insurance as stipulated by the CIRC; operate special health insurance business in China for more than five years and have good market reputation; have a sound service network and strong professional capability in medical insurance; have full-time staff with medical and other professional backgrounds; and the headquarters of the commercial insurance institution agrees to the participation of the branch in local The headquarters of the commercial insurance institution agrees to the participation of the branch in the local major disease insurance business and provides support in business, finance and information technology; and is able to realize separate accounting for the major disease insurance business.
(4) Continuously improve the capacity and level of major disease insurance management services. The management of funds is standardized, and premiums obtained by commercial insurance institutions undertaking major disease insurance are accounted for separately to ensure the safety of funds and guarantee solvency. It has strengthened the connection with the urban residents' medical insurance and the New Rural Cooperative Medical Insurance, and provided "one-stop" instant settlement services to ensure that the public can enjoy the benefits of major disease insurance in a convenient and timely manner. With the authorization of the urban residents' medical insurance and New Rural Cooperative Medical Insurance agencies, they can rely on the information systems of the urban residents' medical insurance and New Rural Cooperative Medical Insurance to carry out the necessary information exchanges and data***sharing, so as to improve the service process and simplify the reimbursement procedures. Commercial insurance organizations will give full play to their national network and other advantages, and provide participants with services such as off-site settlement. In concert with basic medical insurance, it promotes the reform of payment methods, regulates medical behavior and controls medical costs in accordance with diagnostic and treatment norms and clinical paths.
Commercial insurance organizations should effectively strengthen management, control risks, reduce management costs, improve service efficiency, speed up settlement, and make timely and reasonable payments to medical institutions in accordance with regulations. Encourage commercial insurance institutions to provide diversified health insurance products on the basis of undertaking good major disease insurance business.