Article 1 In order to further improve the medical security system for employees in our city, establish and improve a multi-level medical security system, and effectively reduce the burden of large medical expenses for employees, this plan is formulated according to the order of Luoyang Municipal People's Government.

Article 2 The medical insurance for serious illness of urban workers mentioned in this scheme refers to the institutional arrangement to further protect the high medical expenses incurred by insured patients on the basis of the basic medical insurance for urban workers, which is the expansion and extension of the basic medical security system.

The third basic principle

Adhere to the people-oriented principle and make overall arrangements. Put the protection of people's health rights and interests in the first place, give full play to the synergy and complementarity of employee medical insurance and serious illness insurance, strengthen the connection between systems, form a joint force, and effectively reduce the economic burden of insured employees.

Adhere to the government-led and professional operation. The government is responsible for basic policy formulation, organization and coordination, fund raising and management, and strengthening supervision and guidance. Make use of the professional advantages of commercial insurance institutions to improve the operational efficiency, service level and quality of major illness insurance.

Insist on taking risks and sustainable development. The level of serious illness insurance should be compatible with the economic and social development, medical consumption level and fund affordability of our city. Strengthen the consciousness and function of social mutual assistance, strengthen the principle of fund balance, ensure the safety of funds and realize sustainable development.

Chapter II Fund Raising

Article 4 The income of the serious illness insurance fund includes the insurance premium income, interest income and social donation fund income of the insured. , independent accounting, earmarking, no unit or individual may misappropriate.

Article 5 payment standards. Establish a dynamic adjustment mechanism for payment standards, and the payment standards shall be determined in principle by not exceeding 4% of the average monthly salary of employees in full-caliber urban units in the province. By the medical security department in conjunction with the finance department and the tax department, combined with the comprehensive factors such as the level of economic and social development in our city, medical expenses, employee medical insurance compensation level, the affordability and security level of the serious illness insurance fund, timely adjust the payment standard of serious illness insurance.

The annual payment standard of 202 1 is per capita 190 yuan.

Article 6 overall planning level. Serious illness insurance and employee medical insurance are coordinated at the same level, and municipal co-ordination is implemented.

Article 7 Payment method. The premium of serious illness insurance shall be borne by the unit or individual, and may also be shared by the unit and individual. The specific burden ratio is determined by the unit itself. In principle, the premium of serious illness insurance is paid by the employer, and flexible employees and retirees without units can pay by themselves.

Article 8 Term of payment. The premium of critical illness insurance is paid once a year. In principle, the payment time is from April 1 day to June 30th every year, and you can enjoy the treatment of critical illness insurance from July 1 day. By the social insurance fee collection department and the employee medical insurance fund synchronous collection.

Chapter III Guaranteed Treatment

Article 9 guarantee time. All employees participating in medical insurance in the city should participate in serious illness insurance. The year of serious illness insurance is consistent with the year of employee medical insurance, from July of/kloc-0 to June 30th of the following year.

Article 10 standard of treatment. The insured in the designated medical institutions beyond the maximum payment limit of the medical insurance fund for employees in our city compliance medical expenses, serious illness insurance fund shall be reimbursed in proportion, no deductible, the specific proportion is:

Hospitalization. The payment ratio of tertiary and above medical institutions is 85%, that of secondary medical institutions is 90%, that of primary medical institutions is 95%, and that of retirees is increased by 2%.

Outpatient medical treatment for special diseases. Employees pay 80% and retirees pay 85%.

Medical treatment of major and serious diseases. The proportion of hospitalization medical expenses paid is 85% for county-level medical institutions, 75% for municipal medical institutions and 70% for provincial medical institutions. The proportion of outpatient medical expenses is 85%, the proportion of outpatient peritoneal dialysis for end-stage renal disease is 90%, and the proportion of retirees is increased by 2%.

The policy of payment ratio for referral and transfer of insured persons and medical treatment in different places is consistent with employee medical insurance.

Employee's serious illness insurance is applicable to relevant supporting policies and regulations such as payment by disease.

Article 11 Scope of protection. The payment scope of serious illness insurance is consistent with the payment scope of the medical insurance fund for employees in our city. The medical expenses that meet the requirements are the hospitalization medical expenses within the scope of the policy, excluding the expenses below the deductible line, class B drugs, and the medical treatment items that the individual pays.

Article 12 Payment limit. The maximum annual payment limit for serious illness insurance is 400,000 yuan.

Chapter IV Management of Medical Services

Article 13 Medical management. The insured medical treatment, referral, resettlement and other policies are implemented with reference to the medical insurance policy for employees in our city.

Article 14 Direct settlement. When the insured's compliance medical expenses reach the maximum payment limit of the medical insurance fund for employees in our city, direct settlement will be implemented in the service window of designated medical institutions. When the insured person is discharged from the hospital, he will only bear part of the expenses paid by the individual, and the serious illness insurance fund will pay for it, which will be settled by the agency and medical institutions.

Article 15 Indirect settlement. If direct settlement cannot be achieved, the insured shall advance the hospitalization medical expenses by himself. At the end of medical treatment, the insured shall go through the reimbursement procedures with relevant information at the service window set up by the commercial insurance company in the agency.

Chapter V Management and Supervision

Sixteenth serious illness insurance fund to implement special account management, earmarking. City and county medical insurance agencies set up major illness insurance fund expenditure households and allocated medical treatment funds.

Seventeenth Municipal Medical Insurance Bureau is the competent department of serious illness medical insurance, responsible for formulating the implementation plan of serious illness medical insurance and its supporting measures, and organizing the implementation; Coordinate relevant departments to do a good job in the management and service of medical insurance for serious illness. The county medical insurance bureau should coordinate the territorial serious illness insurance business.

Eighteenth commercial insurance companies should set up service windows or service outlets in medical insurance agencies to provide "one-stop" services for the insured, and at the same time do a good job in cost audit, case investigation and intelligent monitoring.

Article 19 The Municipal Medical Security Center is the agency of employee's serious illness insurance, and is responsible for the formulation of the disbursement plan of the serious illness insurance fund, the supervision of the performance of the entrusted agency, the implementation of the relevant policies and treatment of the serious illness insurance, the early warning and supervision of the risk of the serious illness insurance fund, and the investigation and punishment of the breach of contract.

Chapter VI Supplementary Provisions

Twentieth employee medical insurance policies and related supporting documents, such as designated medical institutions, designated retail pharmacies, drug use scope, diagnosis and treatment items, medical service facilities and payment standards, are applicable to major illness insurance.

Twenty-first Municipal Medical Insurance Bureau in conjunction with the Municipal Finance Bureau and the Taxation Bureau may, according to the medical level of our city and the operation of the serious illness insurance fund, make appropriate adjustments to the payment standard, payment ratio and maximum payment limit in a timely manner.

Article 22 This plan shall be implemented from July 2002 1 year to July 20021year.

Twenty-third this plan is interpreted by the Municipal Medical Security Bureau. If the previous serious illness insurance policy is inconsistent with this plan, this plan shall prevail. In case of grade policy adjustment, the city will adjust and improve the serious illness insurance policy in time as required.