1, valid identity document of the insured.

2, the insured medical insurance card or social security card

3. Shanghai Bank medical insurance ID card or bank debit card with UnionPay logo.

4. Details are as follows:

(1) When applying for reimbursement of outpatient and emergency medical expenses, you should also bring special receipts for outpatient medical expenses/emergency medical expenses, relevant medical history materials and copies, emergency attached pages, and copies of outpatient and emergency medical record books (medical expenses incurred by local personnel in designated medical institutions in this city). If the medical insurance card reports the loss, it is also necessary to provide the Notice of Reporting the Loss of the Medical Insurance Card.

(2) When applying for reimbursement of hospitalization observation expenses in emergency observation room, the insured shall also provide special receipt for medical expenses, list of medical expenses during hospitalization (list of medical expenses observed in emergency observation room) and its copy, discharge summary and copy.

(3) When applying for sporadic reimbursement of outpatient medical expenses for serious illness, the insured shall also provide special receipts for outpatient medical expenses, disease diagnosis certificates and photocopies, relevant inspection reports and photocopies.

5, medical insurance agencies required to provide other relevant information.

6. If you entrust others to handle it, you must also provide the valid identity certificate of the client.

In order to cooperate with the implementation of the "Measures of Shanghai Municipality on Basic Medical Insurance for Employees" by the municipal government, carry forward the glorious tradition of solidarity, friendship and mutual assistance of the working class, and effectively help retired employees hospitalized due to illness to reduce their financial burden of medical expenses, so that they can rest at ease and recover as soon as possible. As a supporting measure for the reform of the medical insurance system for employees in this Municipality, the Supplementary Medical Mutual Assistance Plan for Retired Employees in Shanghai (hereinafter referred to as the Plan) is formulated.

Security object

first

1, insured units and organizations

All retired workers who belong to the basic medical insurance coverage of Shanghai workers can join the scheme through the organization and group of the retirement management meeting of the original unit on a voluntary basis, and go through the procedures of joining the scheme in Shanghai Workers' Security Mutual Aid Association. The number of insured persons shall not be less than 75% of the total number of retired employees of the unit (subject to the information on the number of retired employees provided by the social security center). All employees who enjoy retirement medical insurance benefits should participate in this plan.

2. Community insurance

Social retirees who are included in the basic medical insurance coverage of Shanghai employees, as well as other retired employees who meet the conditions of community insurance, can go through the insurance procedures at the trade union service points of various communities (streets, towns) in this city every June.

Insurance procedure

Article 2 The following materials shall be provided when applying for insurance:

1, the materials that units and groups need to provide for insurance.

(1) Complete the Application Form and affix the official seal;

(2) Computer CD (no need to attach a printed list) or USB flash drive (including four fields of serial number, name, ID number and insured amount, and the insured who enjoys the insured amount should write "Yes" in the insured amount field). In order to reduce the workload of the insured units and improve the accuracy of the insured information, the insured units can download the last insured list (website:) from the association website when the insurance expires, add and subtract the current insured list on the list and make it into a computer CD or USB flash drive;

(3) Insurance Policy for Supplementary Medical Assistance Scheme for On-the-job Employees or Insurance Policy for Comprehensive Supplementary Medical Assistance and Accident Assistance Scheme;

(4) One of the following payment vouchers: ① A copy of the credit voucher or cash remittance slip stamped with the bank seal; (2) Printed payment voucher of online bank of the company.

2, the community insured materials should be provided.

(1) my ID card;

(2) My Pension Verification Form and other relevant certificates printed by the Social Security Center or one of the Retirement Certificate and Resignation Certificate.

Article 3 Time of participation in insurance

1, insured units and organizations

Since the date of enrollment 10 days later, the insured unit can no longer go through the enrollment procedures for uninsured retired employees (except for newly retired employees, but the Pension Approval Form for Newly Retired Employees should be provided, and must be insured within 2 months after completing the retirement procedures).

2, the community insured object

Community insured persons shall go through the insurance formalities at the trade union service points of various communities (streets and towns) in this city every June (new social retirees without units can be insured within 2 months after going through the retirement formalities, but the Pension Verification Form is required).

Guarantee fee

Article 4 Standards for payment of safety fees:

1, unit group insurance payment standard

The payment standard for units and groups participating in the insurance is 207 yuan/person (the payment standard for units not participating in the "on-the-job employees' hospitalization supplementary medical mutual assistance security plan" or "comprehensive supplementary medical care and accidental mutual assistance security plan" is 222 yuan/person).

2, the community insured object payment standard

All community insured persons should join the community within June 20 13 or within one year after retirement. Those who are insured for the first time since June 20 14 or who are insured after the renewal is interrupted will be charged according to different payment standards (except for new retirees). The payment standard is as follows:

(1) Retirees who retired before June 20 13 will be insured in June 20 13, and new retirees who retire for the first time within one year after June 2013 will be charged according to the payment standard published in the year of payment, and will be charged according to the payment standard published in the year of renewal from next year.

(2) Since 20 14, the following three types of personnel will be charged according to the corresponding multiple of the payment standard published in the year of payment after their first insurance or intermittent insurance:

(1) If you retire before June 2013, you will be insured for the first time after June 2065 438+03;

(2) 2065438+new retirees in each year after June 2003, who have not been insured in June within one year of retirement, will be insured for the first time in the future.

The payment amount of the above two types of personnel is charged according to the following formula:

First payment standard = payment standard published in the current year ×( 1+n 1)

Note: n 1 refers to the year after uninsured retirement from 20 13, and from 1, and all those over 3 years are counted as 3 years; From the following year, it will be charged according to the payment standard announced in the year of renewal.

③ For retirees who have been insured but have not renewed their insurance on time, the payment amount shall be charged according to the following formula:

Payment standard in the first year = payment standard published in the year of payment ×( 1+n2)

Note: n2 refers to the year from 20 13, when the last renewal of insurance was interrupted, to the year of this enrollment, starting from 1, and all those exceeding 3 years are counted as 3 years; From the following year, it will be charged according to the payment standard announced in the year of renewal.

The payment standard for community insured objects is 222 yuan/person.

Article 5 The insured can only participate in 1 copy during the guarantee period. Extra copies are deemed invalid.

warranty period

Article 6

1, insured units and organizations

The guarantee period is 65,438+0 years, from 0: 00 the next day to 24: 00 when the insurance premium is paid for the first time and the qualified insurance materials are submitted. After the expiration, the renewal procedures shall be handled separately (see Article 14 of this scheme).

2, the community insured object

The warranty period is 1 year or 1 year:

(1) Insurance in June: the guarantee period is 1 year, from 0: 00 on June 2nd of that year to 24: 00 on June1day of the following year.

(2) If a newly retired social worker is insured for the first time within 2 months after retirement, the guarantee period is from 0: 00 on the 2nd of that month to 24: 00 on June 1 year.

Go through the renewal formalities in June every year (see Article 14 of this scheme).

Safeguard responsibility

Article 7 The scope of protection responsibility of this plan covers the following four cases of seeing a doctor in a hospital recognized by the medical insurance department of this Municipality:

1, hospitalized;

2, according to the hospitalization standard settlement in the emergency observation room (hereinafter referred to as the emergency observation room) for observation and treatment of medical expenses;

3, outpatient serious illness (see annex, the same below) treatment;

4. Family sickbed treatment.

Article 8 A 30-day inspection-free period shall be implemented for the first time or after the interruption. After the exemption period, the association will pay the medical expenses of the individual (including the classification of outpatient serious diseases; Does not include medical expenses within the hospitalization Qifubiaozhun and medical expenses for hospitalization and family bed classification; Excluding self-funded expenses. The same below) pay supplementary medical insurance premiums according to a certain proportion.

Ninth hospitalization, emergency observation room stay in hospital for observation, family bed treatment of supplementary medical insurance payment standard:

1. For medical expenses (above the deductible and below the maximum payment limit) paid by the overall fund, the Association will pay 60% of the medical expenses as supplementary medical insurance fund.

2. The Association pays 70% of the supplementary medical insurance premium for the medical expenses paid by individuals within the scope of the supplementary fund above the maximum payment limit of the overall fund.

Tenth outpatient treatment of serious illness supplementary medical insurance payment standard:

Serious illness outpatient medical expenses, belonging to the overall fund and additional funds to pay within the scope of the individual's own part, according to the cost of 50% paid by the supplementary medical insurance fund.

Eleventh supplementary medical insurance fund cumulative maximum payment limit:

During the guarantee period, the accumulative maximum payment limit of the supplementary medical insurance fund of the insured is 40,000 yuan.

When the cumulative maximum amount of compensation reaches, the guarantee liability is terminated.

Article 12 If the insured fails to complete the treatment within the exemption period or the guarantee period expires (that is, the hospital has not settled the medical expenses), after the treatment, the society will multiply the proportion of the days after the exemption period and the guarantee period to the total number of treatment days by the personal medical expenses, and pay the corresponding supplementary medical insurance according to the provisions of Articles 9, 10 and 11. If the insured has not finished the treatment at the expiration of the guarantee period, but continues to participate in the insurance within 10 days after the expiration of the guarantee period, the supplementary medical insurance fund will pay according to their respective guarantee periods.

Article 13 The liability for suretyship shall terminate at the expiration of the suretyship period.

Article 14

1. Insured persons insured by units or groups shall renew their insurance coverage within 10 days after the expiration of the insurance period. The insurance commencement date is the same as the previous period, and the 30-day exemption period is cancelled (except for new policyholders). Follow-up insurance 10 days after the expiration of the guarantee period is regarded as the first insurance, and a 30-day exemption period is still needed.

2. The deadline for community insurance is 1 year in June, and the insured must go through the renewal formalities at the trade union service point in June (if the withholding formalities have been handled, the insurance will take effect after it is received, and I don't need to go through the renewal formalities. If it is not received, it shall pay the cash renewal in June of that year, and continue to withhold it in the following year, without going through the renewal procedures. )。

Excluded liability

Fifteenth the following circumstances, the association will not be responsible for the payment of supplementary medical insurance premiums:

1, the medical expenses during the exemption period when the insured starts treatment before enrollment or within 30 days after enrollment;

2. The medical expenses incurred by the treatment that has not been settled and not renewed after the expiration of the guarantee period exceed the number of days of treatment within the guarantee period;

3. Medical expenses for work-related injuries and occupational diseases;

4, hospitalization Qifubiaozhun within the medical expenses and hospitalization, family bed expenses;

5, do not belong to the scope of medical insurance reimbursement of personal medical expenses;

6. All kinds of deception and fraud by the insured or the insured.

Article 16 If the insured unit or the insured commits one of the acts listed in Item 6 of Article 15, the FSC will terminate its guarantee liability.

Application and payment of supplementary medical insurance fund

Article 17 When applying for supplementary medical insurance, the following materials shall be provided:

1, Application Form for Payment of Inpatient Medical Mutual Aid;

2. Original special receipt for hospitalization medical expenses for medical treatment with medical insurance certificate ("outpatient serious illness" does not need to provide the original special receipt), and sporadic reimbursement shall provide the original statement and detailed list of relevant medical expenses and a copy of the special receipt for medical expenses issued by the foreign medical insurance affairs center recognized by the medical insurance department of this Municipality;

3. Uremic patients hospitalized for various reasons need to provide a discharge summary (other patients do not need to provide it); Outpatient critical illness must provide outpatient critical illness receipt; Family beds must provide proof of bed building and bed withdrawal;

4. To apply for payment, you need to provide a copy of the insured's pension account in Shanghai Bank, China Agricultural Bank, China Postal Savings Bank, China Bank, Shanghai Rural Commercial Bank or China Construction Bank. In addition to the above pension account, the insured can also provide a copy of the current savings passbook account of China Postal Savings Bank Shanghai Branch, and a copy of the debit card and current savings passbook account of Shanghai Bank or China Agricultural Bank Shanghai Branch.

Article 18 The insured shall, within five working days from the date when the hospital or the medical insurance service center of each district (county) of this Municipality (including the foreign medical insurance service center recognized by the medical insurance department of this Municipality) issues a special receipt for medical expenses, apply to the trade union service points of each community (street, town).

Article 19 After receiving the application from the insured with complete procedures, the Association will transfer the supplementary medical insurance fund into the relevant bank account provided by the insured within 30 days after verification.

Article 20 If the insured fails to exercise the right to apply to this Council for payment of supplementary medical insurance fund within two years from the date of issuing the special receipt for medical expenses, it will be lost.

Information change

Article 21

1, change of company insurance information

If the basic information (name, address, zip code, contact person and telephone number, etc. If the company changes after registration, it shall notify our customer service department in writing within 15 days after the change. If there is no written notice, the relevant notice shall be sent according to the original contact person or contact address, and it shall be deemed to have been delivered to the insured unit.

2. Changes in community insurance information

If personal information (contact address, telephone number, etc. ) of the community insured changes after the insured, it should be timely to the community (street, town) trade union service points for information change procedures. Those who have not gone through the information change procedures will not be able to contact according to the original contact information, and all the consequences arising therefrom will be borne by themselves.

other

Article 22 The Association shall conduct special accounting for the guarantee fee, and the operation, settlement and management of the guarantee fee shall be supervised by the leadership of the Council and the board of supervisors. According to the actual payment situation in the previous year, the changes in the implementation methods of the basic medical insurance pooling fund and the local supplementary medical insurance fund, and the changes in subsidies from the government and relevant departments, the Association will decide the charging standard of the security fee for the next year and the payment ratio of the supplementary medical insurance fund accordingly. Since 20 14, the premium is adjusted every two years.

supplementary terms

Twenty-third outpatient serious illness treatment within the scope of this plan refers to the scope of outpatient serious illness treatment included in medical insurance:

1, uremia dialysis and anti-rejection therapy after renal transplantation;

2. Mental patients who enjoy outpatient treatment of serious illness medical insurance;

3. Enjoy chemotherapy (including endocrine-specific anti-tumor therapy), radiotherapy, isotope anti-tumor therapy, interventional anti-tumor therapy, traditional Chinese medicine anti-tumor therapy and necessary related examinations of malignant tumors during medical treatment of serious illness in medical insurance outpatient department.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.