Category of hospitalization expenses

Benefit payment standard

Deductible

The deductible for hospitalization expenses is determined based on the hospital level:

Notes:

1. Medical expenses below the deductible are paid by the insured person.

2. If the insured person is referred to a different hospital for hospitalization,the deductible will be calculated separately

3. The deductible for out-of-town hospitalization is the same as the local standard.

Payment ratio

for hospitalization expenses

The basic medical expenses above the deductible incurred by the insured person in designated medical institutions within the city for hospitalization treatment are paid by the pooling fund according to the following provisions:

Category of outpatient

expenses

Benefit payment standard

Pooling account for

general outpatient

expenses

◆ Basic medical expenses incurred by the insured person for general outpatient treatment in selected designated medical institutions with access to the pooling account for general outpatient expenses, excluding outpatient consultation fees and level 1 outpatient large equipment examination fees, are paid by the basic medical insurance pooling fund (hereinafter referred to as the pooling fund) according to the following provisions:

◆ Except for emergency rescue, the outpatient basic medical expenses incurred by the insured person in non-selected designated medical institutions with access to the pooling account for general outpatient expenses without referral cannot be paid by the pooling fund. The expenses can be paid by the insured person’s personal account.

◆ Annual payment limit: Not exceeding 6% of the average annual salary of employees across the city in the year before last (7% for retirees). The payment limit in Grade II hospitals or above and specialized hospitals does not exceed 3% of the average annual salary of employees across the city in the year before last (3.5% for retirees).

Outpatient consultation

fees

◆ Outpatient consultation fees incurred at designated medical institutions within the city are 

paid by the pooling fund based on the following ratios: 80% for Grade I hospitals and below,

70% for Grade II hospitals, and 60% for Grade III hospitals. This benefit does not overlap

with that for other outpatient basic medical expenses covered by the pooling fund.

Personal account

◆ The personal account can be used to pay for the following expenses for oneself, spouse,

parents, and children, in accordance with the regulations of China, Guangdong Province, and Shenzhen:

(1) Medical expenses borne by the individual for eligible medical expenses incurred in designated medical institutions by oneself, spouse, parents, and children who have participated in the city’s basic medical insurance.

(2) Expenses incurred by oneself, spouse, parents, and children who have participated in the city’s basic medical insurance for purchasing drugs, medical equipment, and medical consumables at designated retail pharmacies; among them, the expenses for purchasing medical equipment and medical consumables at designated retail pharmacies should not exceed RMB 300 per month.

(3) Health examination and preventive vaccination expenses for oneself, spouse, parents,

and children who have participated in the city’s basic medical insurance.

(4) Payment for oneself for the period after reaching the statutory retirement age but not reaching the minimum payment period for employee medical insurance.

(5) Personal payment for parents and spouse who have reached the statutory retirement age and participate in the basic medical insurance for residents, as well as personal payment for children who participate in the city’s children’s medical insurance or university student medical insurance.

(6) Other expenses in accordance with the regulations of China and Guangdong Province.

◆ Personal account replenishment standards:

Large equipment

examination fee

◆ Payment ratio: 80%

◆ Scope of examination and treatment items for large medical equipment in outpatient

department:

1. Color Doppler Echocardiography;

2. Treadmill ECG;

3. Ambulatory ECG;

4. X-ray computed tomography (CT) scan;

5. Single-photon emission computed tomography;

6. Magnetic resonance imaging (MRI);

7. Intracranial Doppler blood flow imaging;

8. Extracorporeal shock wave lithotripsy;

9. Hyperbaric oxygen therapy;

10. Digital subtraction angiography (DSA) interventional examination and treatment (only applicable to the examination and treatment of cardiovascular and cerebrovascular diseases, interventional therapy of malignant tumors, and emergency rescue of acute massive visceral hemorrhage);

11. Gamma-ray (γ-ray) stereotactic therapy.

Outpatient specific

diseases

If the insured person has been identified with an outpatient specific disease (hereinafter referred to as the “specific disease”) and incurs basic medical expenses for the specific disease at a selected designated medical institution in the benefit enjoyment period, the pooling fund will pay according to the following provisions:

◆ Class I specific diseases:

◆ Class II specific diseases (hypertension, diabetes):

If the insured person receives chronic disease management services at a designated community health institution in the city and is prescribed medication by a contracted family doctor, the pooling fund will cover 90% of the expenses.

2. If the insured person seeks treatment at a selected designated medical institution with access to the pooling account for general outpatient expenses, the pooling fund will cover the expenses according to the provisions for using the pooling account for general outpatient expenses.

◆ Class II specific diseases (other diseases apart from hypertension or diabetes): If the insured person seeks treatment at a selected designated treatment institution, the pooling fund will cover 80% of the expenses.

General outpatient visit

◆ The insured person can select one community health institution or other primary healthcare institution, and one secondary hospital or above or specialized hospital within the designated medical institutions in the city as the designated medical institution with access to the pooling account for general outpatient expenses. The settlement hospital to which the selected community health institution is affiliated and all of its affiliated community health institutions are selected designated medical institutions with access to the pooling account for general outpatient expenses.

◆ The first selection of a community health institution or other primary healthcare institution takes effect immediately. If the selection is changed, it will take effect from the following month. The selection of a secondary hospital or above or specialized hospital is automatically made when the insured person seeks treatment and takes effect immediately. If the selection is changed, it will be automatically updated when the insured person seeks treatment and will take effect immediately.

Category of

outpatient

expenses

Benefit payment standard

Scope of expenses enjoying the

benefits

◆ In basic medical expenses for hospitalization and outpatient specific diseases, the personal out-of-pocket portion (excluding the additional personal out-of-pocket portion due to lower benefit payment ratio in out-of-town settlement of medical expenses) and the portion exceeding the annual payment limit of the basic medical insurance pooling fund and the payment limit for outpatient specific diseases.

◆ Personal out-of-pocket portion of the national negotiated drug expenses incurred during outpatient visits.

◆ Expenses below the deductible for hospitalization.

◆ Other expenses stipulated by China, Guangdong Province, and Shenzhen.

Payment ratio

◆ For accumulated expenses between RMB 10,000 and RMB 30,000 within a medical insurance year, the pooling fund will cover 70%;

◆ For accumulated expenses exceeding RMB 30,000, the pooling fund will cover 80%.

Payment limit

Within a medical insurance year, the payment limit of critical illness insurance is linked to the insured person’s continuous insured period in basic medical insurance.

Out-of-pocket

prepayment

For the use of Class B drugs and diagnostic and treatment items that require out-of-pocket prepayment according to the regulations of China and Guangdong Province, the insured person shall prepay 1% of the expenses.

Starting time of

benefit enjoyment

◆ From the 1st of the following month after the insured person completes the insured procedures and full payment of the basic medical insurance premium, he/she is entitled to enjoy the medical insurance benefits as stipulated by the medical insurance policy.

◆ Retired military personnel who have been transferred to the city and paid the insurance premium

in the receiving month are entitled to enjoy the medical insurance benefits as stipulated by the medical insurance policy from the month of payment.

Continuous

insured period

◆ For insured persons who have accumulated interruptions in the insured period for no more than three months within one medical insurance year, the continuous insured period before and after the interruptions will be combined for calculation upon resuming payment; for accumulative interruptions exceeding three months, the continuous insured period will be recalculated.

◆ For those who make a one-time payment of the basic medical insurance premium, the continuous

insured period will be calculated month by month starting from the 1st of the following month of the

payment.

◆ For those who transition between employee basic medical insurance and resident basic medical insurance, if the interruption of the insured period does not exceed three months, the continuous

insured period will be calculated by combining the periods before and after the interruption.

Medical

insurance year

It refers to the period from January 1 to December 31 of each year.

National

negotiated drug

expenses

The national negotiated drug expenses are not included in the calculation of the annual payment limits for the pooling account for general outpatient expenses and outpatient specific diseases.