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, 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.

◆ Annual payment limit: Not exceeding 1.5% of the average annual salary of employees across the city in the year before last.

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.

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):

1. 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):

1. If the insured person seeks treatment at a selected designated treatment institution, the pooling fund will cover 60% of the expenses.

2. Among the Class II specific diseases, if the prescriptions for the six specific diseases of chronic obstructive pulmonary disease, coronary heart disease, sequelae of cerebrovascular disease, rheumatoid arthritis, bronchial asthma, and chronic hepatitis B are issued by contracted family doctors at designated community health institutions within the city, the payment ratio will be 80%.

General outpatient visit

◆ Within the range of designated medical institutions within the city, one community health institution or other primary medical institution can be selected 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 takes effect immediately upon confirmation. If the selection is changed, it will take effect from the following month.

Referral for general outpatient visit

◆ In case of the need of referral for general outpatient treatment due to the condition, the referral procedures should be handled by the selected designated medical institution with access to the pooling account for general outpatient expenses, and the patient should be transferred to other designated medical institutions within the city with diagnostic and treatment capabilities.

◆ The referral for the same disease is valid within 30 days from the date of issuance and can be used for multiple visits. For some special diseases, the referral validity period can be extended to one year.

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.