I. Reimbursement of Basic Medical Expenses for Hospitalization and Outpatient Specific Diseases
During the period of coverage, 80% of the basic medical expenses incurred by the insured for hospitalization and outpatient specific disease treatment in designated medical institutions as stipulated by the regulations shall be paid for by the "Spike Wellness" for the portion of the expenses that exceeds 18,000 RMB in the annual aggregate, with an annual aggregate maximum payment limit of 1,000,000 RMB. The annual cumulative maximum payment limit is 1 million yuan.
The expenses borne by the individual include the starting standard and the following expenses of the basic medical expenses of social medical insurance, and the expenses that the individual pays proportionally in the ***payment section.
Medical expenses incurred by the insured person undergoing designated surgical single-disease treatment will be reimbursed and settled in accordance with the hospitalization treatment in synchronization with the social medical insurance treatment in Guangzhou. (The same below)
II. Reimbursement of Hospitalization Compliance Drug Costs and Test and Inspection Costs
During the period of coverage, if the insured person is hospitalized in a designated medical institution in accordance with the regulations and incurs costs of compliance drugs and test and inspection costs which are indeed required by his/her medical condition, the portion of personal burden of the costs which exceeds an annual total of 18,000 yuan will be paid by the Spike Health Insurance Plan, with 70% of the annual total paid by Spike Health Insurance Plan. "
The annual accumulative maximum payment limit is 1 million yuan.
The costs borne by individuals are defined as the costs of medicines and tests paid by individuals in accordance with the prescribed percentage, the costs of medicines and tests exceeding the limit of the social health insurance, the costs of medicines that do not fall within the scope of payment restrictions of the drug list of the social health insurance, and the costs of medicines and tests outside the catalog of the social health insurance and not belonging to the negative list.
Exceeding the limit standard cost of social medical insurance refers to the cost exceeding the annual maximum payment limit of social medical insurance, the cost exceeding the payment limit of urban and rural residents' social medical insurance for a single hospitalization test and examination, and the cost exceeding the payment standard of some medicines in the catalog of social medical insurance.
The costs of medicines and test and inspection costs incurred by the insured person hospitalized in various special wards, foreign guests and overseas Chinese, Hong Kong and Macao wards are not included in the scope of this payment.
3. Outpatient Compliance Drug Expense Reimbursement
During the coverage period, if the insured person undergoes outpatient treatment for specific diseases and general outpatient (emergency) treatment at the selected designated medical institutions in accordance with the regulations, and if the insured person incurs the cost of compliance drugs due to the need of the medical condition, the cost borne by individuals will be paid by "Sui SuiYuKang" according to the following standards. The annual cumulative maximum payment limit is 300,000 yuan.
Personally borne costs are defined as: drug costs paid by the individual in accordance with the prescribed percentage, drug costs exceeding the limit of the social health insurance, drug costs that do not fall within the restricted scope of payment of the drug list of the social health insurance, and drug costs that are not included in the negative list of the drug list and are not covered by the social health insurance.
Wherein, the costs exceeding the social medical insurance limit standard refer to the costs exceeding the annual maximum payment limit of the social medical insurance, the costs exceeding the monthly/annual limit of the outpatient clinic, the costs exceeding the maximum payment limit of the coordinating fund of the outpatient clinic for specific diseases, and the costs exceeding the payment standard of some of the medicines in the social medical insurance catalog.
Expenses incurred by the insured person for medicines in excess of the scope and standard of payment of social medical insurance at the outpatient special medical care clinic shall not be included in the scope of payment under this item.
1. The part of the annual total cost of over RMB 18,000 for the use of nationally negotiated drugs and innovative drugs in line with the designated scope (including the cost of innovative drugs purchased from designated pharmacies with the prescription of the relevant specialist physician of the designated medical institution and used for outpatient treatment of specific diseases or general outpatient treatment of the designated medical institution) shall be paid 60% by the Spike Medical Care Plan. Spike Health will pay 60% of the annual accumulated personal expenses of 18,000 RMB or more.
2. 50% of the annual accumulated personal expenses of 50,000 yuan or more incurred for the use of other medicines will be paid by SuiYuHang.
4. Compensation for special medical consumables
If an insured person aged 18 years or below is diagnosed with type 1 diabetes mellitus by a physician who is the deputy director of the endocrine specialty of a tertiary designated medical institution or a physician of at least three years of age, the costs incurred for the purchase of the main body of insulin pumps and related consumables (including medication reservoirs, tubing and blood glucose test strips) from designated medical institutions and pharmacies in the year of participation shall be paid by "Spike Wellness". 70% of the costs incurred for the purchase of insulin pump and related consumables (including storage device, tubing and blood glucose test strips) at designated medical institutions and designated pharmacies during the insured year will be paid by "Suiyukang". The maximum payment limit for insulin pump host is 42,000 RMB, and the insured person is limited to one claim in 3 years (2021-2023); the maximum payment limit for the cost of consumables related to the use of insulin pump is 3,250 RMB/quarter.
V. Compensation for Screening Expenses for Specified Diseases
The insured persons who belong to the scope of screening for specified diseases such as nasopharyngeal cancer, liver cancer, breast cancer, prostate cancer, colorectal cancer, etc., and who have been screened by the specified screening hospitals for the specified diseases in the insured year will be paid by the Spike Health for a maximum of The maximum amount payable by Spike Health is 100 RMB per person per year, and 80% of the actual cost if the screening cost is less than 100 RMB.
The relevant screening program is limited to general outpatient screening, if the general outpatient social health insurance reimbursement of the examination costs are not included in the reimbursement scope of the program.
Special Notes:I. Accounting for Treatment
The accounting for treatment of "SuiYuKang" will be carried out after enjoying the social medical insurance of Guangzhou or other medical insurance treatment of the city.
An insured person who is entitled to the city's medical assistance benefits will be entitled to medical assistance benefits in accordance with the regulations after enjoying the benefits of "Sui Sui Age Health".
Medical expenses incurred for hospitalization will be settled according to the date of the insured person's discharge from the hospital.
The medical expenses incurred for hospitalization and outpatient treatment of specific diseases in designated medical institutions in other places are included in the reimbursement scope of "Suiyukang" according to the regulations for the insured who meet the relevant policy regulations of Guangzhou social medical insurance for medical treatment in other places.
Circumstances of non-reimbursement
1. If the insured person ceases to participate in the social medical insurance of Guangzhou or other medical insurance of the city during the period of insurance, medical expenses incurred during the period of cessation of enjoyment of the benefits of the social medical insurance or other medical insurance of the city shall not be included in the reimbursement of Suiyukang.
2. Spike Health will not pay for medical expenses incurred by the insured person for medical treatment not in accordance with the relevant provisions of the city's social medical insurance (including unrecognized medical expenses incurred for inpatient and outpatient treatment of specific diseases for long term medical treatment in a different place, referral from a different place, or temporary medical treatment in a different place, etc.).
3. Spike Health will not pay for expenses incurred for surgery or hospitalization that are not reimbursed by the social health insurance system as a whole, such as cosmetic surgery, plastic surgery, non-functional orthopedic surgery, weight loss, treatment of freckles and moles, skincare, inlays and cleaning of teeth, fitting of glasses and prosthetic eyes, artificial limbs, and hearing aids, and so on.
4. The Spike Health will not pay for expenses incurred for non-disease treatment programs, such as health checkups, pre-marital checkups, travel checkups, occupational checkups, and outbound checkups.
5. All kinds of infertility and sexual dysfunction treatment programs (e.g. male infertility, female infertility examination and treatment fees, identification of venereal disease examination and treatment fees, and all medical fees for violation of family planning), and all kinds of teaching, scientific research, and clinically verified diagnostic and treatment programs are not covered by Spike Health.
6. "Spike Health" will not pay for expenses that should be borne by a third party, expenses paid by Workers' Compensation Insurance and Maternity Insurance and expenses borne by the individual after payment, medical expenses incurred for medical treatment outside of Hong Kong (including Hong Kong, Macao, and Taiwan), and other non-payable expenses stipulated by laws and regulations.
4. Negative list of non-reimbursable traditional Chinese medicine tablets and herbs
Acacia Gum, White Sugar Ginseng, Red Ginseng, Korean Red Ginseng, Andrographis Paniculata (vinegared ginseng, shelled ginseng), Tortoiseshell Shell, Cordyceps Sinensis, Honey, Dog Treasure, Gum of Turtle and Deer (Gum of Turtle and Deer), Toadstool Oil, Hai Long (Sea Dragon), Sea Horse (Sea Horse), Date of Monkey (Date of Monkey), Bee Propolis made of wine, Antelope Angle (Galea Antler), Antelope Angle Tip Powder (Antelope Angle Sterling Tablet, Antelope Angle Powder), Antler Velvet Antlers (Antler Velvet Antler Powder, Antelvet Antler Tablet ), Ma Bao, agate, oxalis (natural oxalis), coral, musk, Tianshan snow lotus, fresh dendrobium (dendrobium), saffron (saffron), American ginseng, blood exhaust, bird's nest, wild ginseng, mountain ginseng, pearl, Zihechuan, leopard fetus, deer fetus, tiger penis, deer whip, goat whip, cattle whip, dog whip, fur seal, deer tail, deer ankles, pig's ankles, cow's ankles, tiger bone, deer bone.
V. Negative list of non-reimbursable consultation service fees
Medical consultation fees (including psychological counseling and health counseling), stroke prediction, health prediction, and vaccination.