Workers and urban and rural residents in Heze who have paid the premium of customized commercial health insurance (hereinafter referred to as "Huihebao") in full enjoy the benefits of "Huihebao" on the basis of enjoying the benefits of basic medical insurance for workers and urban and rural residents in Heze (including but not limited to basic medical insurance, serious illness insurance, medical assistance and re-assistance, the same below).
Second, the insurance liability
(1) Insurance premium for hospitalization expenses in medical insurance coverage:
The reasonable medical expenses incurred in the hospitalization of the designated institutions of basic medical insurance in medical insurance coverage shall be borne by the individual after being reimbursed by the basic medical insurance, serious illness insurance, medical assistance and re-assistance, and shall be liable for compensation in proportion. Deductible 10000 yuan (Phase I: Deductible is accumulated according to the medical insurance year. The payment date in 2022 is 65438+ 10/0, and the payment date in 2023 is 65438+1 0/0, 2023. The second stage: the deductible line is accumulated according to the medical insurance year, the starting date of the deductible line is 65438+ 1) in 2023, the reimbursement ratio is 80%, and the maximum compensation limit is 1 10,000 yuan.
(2) Insurance premium for hospitalization expenses outside medical insurance coverage:
Necessary and reasonable medical expenses (including medicines, consumables and medical treatment items outside the scope of medical insurance reimbursement policy) incurred by hospitalization in designated institutions of basic medical insurance shall be borne by individuals in proportion. Deductible 10000 yuan (Phase I: Deductible is accumulated according to the medical insurance year. The payment date in 2022 is 65438+ 10/0, and the payment date in 2023 is 65438+1 0/0, 2023. The second stage: the deductible line is accumulated according to the medical insurance year, the starting date of the deductible line is 65438+ 1) in 2023, the reimbursement ratio is 60%, and the maximum compensation limit is 1 10,000 yuan.
(3) Special drug insurance premium for critical illness insurance:
The insured person shall be prescribed by the outpatient department of the designated hospital, and be included in the scope of "separate compensation and treatment of special drugs for serious illness insurance in Heze City", and the part that is still borne by the individual after the reimbursement of special drugs for serious illness insurance in Heze City shall be liable for compensation in proportion. Deductible 10000 yuan (Phase I: Deductible is accumulated according to the medical insurance year. The payment date in 2022 is 65438+ 10/0, and the payment date in 2023 is 65438+1 0/0, 2023. The second stage: the deductible line is accumulated according to the medical insurance year, the starting date of the deductible line is 65438+ 1) in 2023, the reimbursement ratio is 80%, and the maximum compensation limit is 1 10,000 yuan.
(4)
) Insurance premium for drugs with special curative effect and rare diseases:
During the insurance period, the insured person shall be prescribed by the outpatient department of the designated hospital, and shall be liable for compensation in proportion to the part of the basic medical insurance drug list or the rare disease drugs and rare disease drugs with special efficacy within the scope of serious illness insurance and medical assistance in our province (including foods with special efficacy for related diseases) that is still borne by the individual after reimbursement of basic medical insurance, serious illness insurance and medical assistance. The deductible is 1 0,000 yuan (Phase I: the deductible is accumulated according to the medical insurance year, and the starting date of the deductible in 2022 is 2022 1 and 2023 1. The second stage: the deductible line is accumulated according to the medical insurance year, and the starting date of the deductible line is 65438+ 1) in 2023, the reimbursement ratio is 80%, and the maximum compensation limit is 500,000 yuan.
(5)
Waiting time:
There is no waiting period for insurance or continuous insurance in 2022.
(6) Time limit for compensation
：
1. Phase I (original phase I renewal fee): from 2022 65438+February 1 to 2023165438+1October 30.
2. Phase II (original phase II renewal and new enrollment): 2023 1 October 1 to February 20231.
The warranty period is one year. The insurance liability period starts at 0: 00 on the effective date of the policy and ends at 24: 00 on the termination date of the policy; Those who leave the hospital after 24: 00 on the termination date of the policy will not be compensated, and those who renew the insurance will be compensated normally.
(7) Past diseases: No past diseases are excluded.
Three. special agreement
(A) treatment accounting
The treatment accounting of "Huihebao" is carried out after enjoying the social medical insurance benefits (including but not limited to basic medical insurance, serious illness insurance, medical assistance, re-assistance, etc.). ).
(2) Going abroad for medical treatment
For medical expenses incurred in hospitalization in medical institutions outside Heze, the responsibility for hospitalization expenses within the scope of medical insurance does not include the first part of medical treatment in different places, and the proportion of reimbursement does not decrease. The proportion of reimbursement outside the medical insurance catalogue decreased 10%.
(3) No compensation.
1. In the following cases, the insured's medical expenses occur, and this product is not responsible for paying insurance money.
(1) shall be borne by a third party;
(2) Payment from industrial injury insurance and maternity insurance;
(3) It should be borne by public health;
(4) The insurer is not liable for the deductible stipulated in the insurance contract;
(5) Medical expenses incurred by the insured who meets the conditions for applying for charitable relief drugs, and fails to submit relevant applications or submit incomplete application materials due to personal reasons of the insured; The insured passes the aid audit, but fails to receive the aid drugs due to the insured's reasons, which shall be deemed as the insured's voluntary waiver of the applicable insurance rights and interests under this contract.
(6) The insurer shall not be responsible for paying insurance benefits for matters that are not paid according to laws, regulations, policies and documents.
2. If the insured stops participating in the basic medical insurance for employees in Heze City and the basic medical insurance for urban and rural residents during the insurance period, the medical expenses incurred during the period of stopping enjoying the basic medical insurance benefits are not included in the reimbursement scope of this product.
3. This product will not pay for the expenses incurred in the case that the next operation or hospitalization social medical insurance is not reimbursed as a whole, such as all kinds of beauty, plastic surgery, non-functional orthopedics, weight loss, freckle removal, mole removal, skin care, tooth implantation, tooth cleaning, glasses, artificial eyes, artificial limbs, hearing AIDS, etc.
4. Non-disease treatment items, such as various health check-ups, premarital check-ups, travel check-ups, occupational check-ups, exit check-ups and other expenses, will not be paid by this product.
5. All kinds of diagnosis and treatment items of infertility (pregnancy) and sexual dysfunction (such as male infertility, female infertility examination and treatment fees, STD identification examination and treatment fees, all medical expenses in violation of family planning), and all kinds of teaching, scientific research and clinical verification diagnosis and treatment items, this product will not be paid.
6. Negative List Drug List:
A. Health care drugs, vitamins and nutrients not covered by medical insurance: adenosine triphosphate and its compound preparation, coenzyme A and its compound preparation, compound coenzyme A, energy mixture, rivanol, hydrolyzed fetal cell syrup, placental globulin, placental gamma protein and placental albumin.
B. preventive vaccines and contraceptives;
C. Drugs mainly used for treating alopecia, losing weight, beautifying, and quitting smoking and drinking.
D. The cost of the plaster prescription and the following medicines and Chinese herbal pieces mainly used for nourishing and health care and containing national precious and endangered wild animals and plants are not included in the protection scope of Huihebao. Specifically, it includes donkey-hide gelatin, white sugar ginseng, Korean ginseng, pangolin (vinegar pangolin, pangolin), tortoise shell, Cordyceps sinensis, honey, dog treasure, tortoise plastron, oviductus Ranae, Syngnathus, hippocampus, monkey dates, wine-processed propolis, antelope horn tip powder (antelope horn pound tablets, antelope horn powder) and so on.
Note: The drugs listed above include raw medicinal materials and processed medicinal materials and decoction pieces.
7, "People's Republic of China (PRC) Social Insurance Law", "People's Republic of China (PRC) Insurance Law" and related laws and regulations shall not be paid;
8. The local basic medical insurance regulations or insurance contracts do not assume the responsibility of paying insurance benefits.
9. If the insured enjoys the local basic medical insurance benefits, but fails to use the basic medical insurance for reimbursement due to personal reasons, this product will not bear the corresponding insurance liability.
10. Designated hospitals and pharmacies for special drugs and drugs with special curative effects for serious illness insurance: The types, designated hospitals and pharmacies for special drugs and drugs with special curative effects for serious illness insurance are uniformly designated by Heze Medical Security Bureau, and any changes will be announced in time in official website or WeChat official account of Heze Medical Security Bureau.
(D) the principle of compensation
Insurance companies pay insurance premiums within the scope of insurance liability. If the patients with non-one-stop and dual-single system have obtained compensation from other channels (including but not limited to basic medical insurance, urban and rural residents' serious illness insurance, free medical care, and commercial medical expenses compensation medical insurance outside this contract), after deducting the compensation obtained from other channels, the insurance company will pay insurance money to the remaining expenses within the insured's insurance liability limit according to the contract.