1, minimum payment standard 10000 yuan or more (including 10000 yuan): 80% for employees in tertiary hospitals and 85% for retirees; 85% of employees in secondary hospitals are reimbursed and 90% of retirees are reimbursed; 90% of employees and 95% of retirees in first-class hospitals (including communities) are reimbursed;
2. Qifubiaozhun 1 10,000 yuan or more (including 1 10,000 yuan): 85% of employees in tertiary hospitals and 87% of retirees; 90% for employees in secondary hospitals and 92% for retirees; 95% of employees and 97% of retirees in first-class hospitals (including communities) are reimbursed;
Second, hospitalization
The hospitalization expenses of insured residents within the policy scope of designated medical institutions shall be paid by individuals below the Qifubiaozhun; Qifubiaozhun above is paid by the overall fund in proportion, and the annual maximum payment limit of the basic medical insurance fund for urban and rural residents is 6,543,800 yuan+0.5 million yuan.
Qifubiaozhun and reimbursement ratio of insured residents in hospital
14 years of age (including 14 years of age) insured residents Qifubiaozhun halved, and other insured residents hospitalized in hospitals at or above the county level for the second time and later halved; If you are hospitalized for the same disease for the second time within 30 days, you will only pay the Qifubiaozhun once. The second hospitalization, the hospital level is higher than the first hospital level, only pay the difference between Qifubiaozhun; If the insured residents in Luoyang are hospitalized in Chinese medicine hospitals at or above the county level, the Qifubiaozhun for hospitalization reimbursement will be reduced by 100 yuan on the basis of the standards stipulated by medical institutions at the same level. The proportion of reimbursement of hospitalization medical expenses for insured residents using Chinese medicine services increased by 5%. Chinese medicine service projects refer to Chinese herbal pieces, Chinese patent medicines, Chinese medicine preparations and Chinese medicine diagnosis and treatment projects included in the scope of reimbursement of basic medical insurance.
(2) General outpatient medical treatment
The medical expenses incurred by the insured residents in the outpatient service of designated medical institutions at the grass-roots level within the policy scope shall be reimbursed according to the proportion of 50%, and the annual reimbursement limit shall be 260 yuan/person. The original personal (family) account balance is not clear, but it can be used in primary medical institutions such as township hospitals (community health service centers) or village clinics (community health service stations).
Insured residents who are diagnosed with hypertension and diabetes by designated medical institutions and need medication but do not meet the guarantee standards of Luoyang special disease outpatient service and Henan serious and serious disease outpatient service can be included in the scope of outpatient co-ordination reimbursement, and the drug expenses within the policy scope are reimbursed at 50%, with the highest annual reimbursement limit of 240 yuan/person.
Third, outpatient medical treatment for chronic diseases and special diseases.
Luoyang city will include some diseases (or treatment items) that need long-term or lifelong outpatient treatment and have high medical expenses into the scope of medical treatment for special diseases. There is no Qifubiaozhun for special disease clinics, and the reimbursement rate within the policy scope is 80%, and fixed-point treatment and quota management are implemented. At present, there are 38 kinds of diseases, the specific diseases are:
1, chronic renal failure (non-dialysis treatment);
2. Chemotherapy and radiotherapy for malignant tumors;
3. Anti-rejection therapy after organ transplantation;
4. Schizophrenia;
5. Emotional psychosis (moderate to severe depression);
6. Severe refractory obsessive-compulsive disorder;
7. Complications of diabetes;
8. Heart failure above degree II;
9. Chronic obstructive pulmonary disease;
10, myasthenia gravis;
1 1, systemic lupus erythematosus;
12, ankylosing spondylitis;
13, systemic sclerosis;
14, polymyositis;
15, rheumatoid arthritis;
16, primary Sjogren's syndrome;
17, laser treatment of fundus diseases;
18, anticoagulation therapy after arterial stent implantation;
19, anticoagulation therapy after heart valve replacement or bypass surgery;
20, decompensated cirrhosis;
2 1, autoimmune hepatitis;
22, cataract phacoemulsification and intraocular lens implantation;
23. Pituitary tumor;
24. hypothyroidism;
25, nephrotic syndrome;
26, chronic glomerulonephritis;
27. Interferon treatment of active hepatitis C:
28. Hypertension III;
29. Parkinson's syndrome;
30, outpatient rehabilitation treatment;
3 1, hand, foot and mouth disease in children;
32, outpatient rescue death;
33. Bipolar disorder;
34. Schizophrenia affective disorder;
35. Paranoid mental disorder;
36. Mental disorders caused by epilepsy;
37. Mental retardation with mental disorder;
38, myeloproliferative diseases.
Insured residents can enjoy outpatient medical treatment for special diseases according to regulations after being identified. According to different diseases, the identification of special disease clinics adopts two ways: centralized identification and non-centralized identification. The centralized identification of special disease clinics is organized by medical insurance agencies and determined by designated medical institutions on schedule. Non-centralized identification of patients, in the designated hospital at any time to apply for identification cards at any time.
Fourth, medical treatment for serious and serious diseases.
Urban and rural residents suffering from the following 38 kinds of serious diseases can enjoy the medical security treatment for serious diseases of urban and rural residents in our province according to the regulations, that is, they are hospitalized in designated medical institutions and reimbursed at a limited price without deductible; Among them, the reimbursement rates of medical expenses within the hospitalization policy of county, city and provincial medical institutions are 80%, 70% and 65% respectively. The specific diseases are as follows:
1, hospitalization insurance disease
2. Outpatient insurance diseases shall be subject to the policy adjustment of Henan Province. Specifically, you can consult the Medical Insurance Service Section of urban and rural residents and the medical insurance offices of major hospitals, relevant insurance policies, identification procedures, medical treatment settlement methods, etc. Or pay attention to the WeChat official account "Luoyang Medical Insurance" query.
Verb (abbreviation of verb) Obstetric medical treatment
Pregnant women who participate in medical insurance for urban and rural residents give birth in hospital, and the hospitalization medical expenses are limited to pay. The limit standards are: 600 yuan for natural delivery, 800 yuan for dystocia, cesarean section 1600 yuan.
Sixth, the newborn insurance preferential treatment
In the year when the newborn was born, the parents who participated in the basic medical insurance (including the troops stationed in Luo) automatically obtained the insurance qualification and enjoyed the medical insurance benefits for urban and rural residents. Newborn mothers or fathers who participate in the medical insurance for urban and rural residents in our city can enjoy the medical insurance benefits for urban and rural residents in the year of birth with their mother's or father's identity certificate and birth medical certificate. Parents did not participate in the medical insurance for urban and rural residents in our city, according to the provisions of the medical insurance agencies for insurance procedures.
Seven, serious illness insurance medical treatment
Luoyang city serious illness insurance funds allocated from the basic medical insurance fund for urban and rural residents, insured residents no longer pay. According to the unified standards of the whole province, the part of the medical expenses that the insured residents personally bear within the policy scope exceeds 1. 1 000 yuan shall be reimbursed according to the following proportion: 1. 1 000 yuan ~ 1 000 yuan (including 1. 65,438+70% for the part above 10,000 yuan; You can reimburse up to 400,000 a year.
During the connection between poverty alleviation and rural revitalization, preferential policies for serious illness insurance will be implemented for low-income people, poor people and people returning to poverty. The deductible was reduced from 1. 1.000 yuan to 0.55 million yuan, and the reimbursement rate was increased by 5 percentage points. There is no capping line for reimbursement of serious illness insurance during the year.
Eight, insured residents can apply for medical treatment in different places and different places.
Insured residents who need to be referred to the insured city for medical treatment shall go through the procedures of referral and transfer, and enjoy medical insurance benefits according to regulations; In addition to emergency and mental illness, if the referral and transfer procedures are not handled according to the regulations, the reimbursement ratio of the corresponding medical institutions will be reduced by 20 percentage points. The management of referral and referral in our city is implemented in accordance with the Notice of the Henan Provincial Department of Human Resources and Social Security on printing and distributing the Interim Measures for the management of referral and referral of basic medical insurance in Henan Province and medical treatment in different places. Long-term residents in different places can go through the medical record formalities in the local medical insurance agency and enjoy the direct settlement service of medical expenses at their place of residence.
Coverage:
Large-scale supplementary medical insurance for employees includes large-scale supplementary medical insurance and large-scale secondary subsidies, and the maximum compensation limit in the insurance year is 400,000 yuan.
The maximum payment limit of large supplementary medical insurance is 200,000 yuan, and the part exceeding the maximum payment limit of the basic medical insurance pooling fund for urban workers in that year will be reimbursed in proportion, and the compensation scope is consistent with the basic medical insurance pooling fund;
The maximum compensation limit of large-scale secondary subsidy insurance is 200,000 yuan, and the medical expenses incurred by large-scale insured employees in hospitalization, the part of which the individual pays more than 30,000 yuan, will be subsidized in proportion;
Suffering from 20 kinds of major diseases in hospital, the individual pays less than 30,000 yuan, and the individual's conceit exceeds the average salary of employees in the previous year 10%, and the subsidy is 50%.
The payment scope of large supplementary medical insurance is consistent with that of the basic medical insurance pooling fund;
Large supplementary medical insurance is consistent with the settlement year of basic medical insurance.
Nine, medical insurance reimbursement materials:
1, original ID card or social security card;
2, the original certificate of disease diagnosis issued by the designated medical institutions;
3, outpatient medical records, inspection, test results report and other original medical information;
4. Original receipt of outpatient charges of medical institutions with unified finance and taxation;
5. The detailed list of outpatient expenses printed by the hospital computer or the original payment of prescriptions issued by doctors;
6. Designated pharmacies: unified original invoices and computer-printed sales lists of taxable goods;
7. If it is an agent, you need to provide the original ID card of the agent.
X. Medical insurance reimbursement process:
Bring all the above information to the relevant departments of the local social security center. Upon examination, if the information is complete and meets the requirements, it can be handled immediately.
When applying for reimbursement of outpatient medical expenses, the applicant should first deduct the amount allocated to the personal account of medical insurance in this social security year, and then verify the amount to be reimbursed.
The scope of medical insurance reimbursement includes: medical expenses paid by insured persons who meet the basic medical insurance drug list; Medical expenses that meet the diagnosis and treatment items; Medical expenses that meet the standards of medical service facilities; And medical expenses for first aid and rescue.
Eleven, medical insurance reimbursement matters needing attention:
1. When the insured is admitted to or discharged from the hospital, they must go through the registration formalities at the medical insurance management window of the designated medical institution with the medical insurance card. If you need to be hospitalized, you need to pay a medical deposit first, and pay more and less after discharge.
2. If the insured person needs to be referred or transferred due to illness, he shall submit the referral opinions agreed by the attending physician of the hospital, and the unit where he works shall fill in the application form, report to the municipal (district) social security agency for approval and go through the referral (hospital) procedures. Among them, the referral is limited to provincial specialized hospitals, and the expenses need to be paid in advance. The reimbursement standard should be 10% first, and then the reimbursable amount should be calculated according to local regulations.
3. After discharge, the hospital will calculate the amount of medical insurance reimbursement and personal payment according to relevant policies. The amount of medical insurance reimbursement can be directly reimbursed at the hospital medical insurance settlement office, and the part paid by individuals needs to be settled by the insured.
4. The standard part of the deductible line for pooling funds after hospitalization will be different according to different local policies. Under normal circumstances, based on 10% of the average annual salary of employees in this city last year, the medical expenses for multiple hospitalizations are accumulated in a basic medical insurance settlement year.
Medical insurance generally refers to basic medical insurance, which is a social insurance system established to compensate workers for economic losses caused by disease risks. The medical insurance fund is established through the contributions of employers and individuals. After the insured person has medical expenses, the medical insurance institution will give certain economic compensation.
The establishment and implementation of the basic medical insurance system has gathered the economic strength of units and social members. With the government's funding, sick social members can get necessary material help from the society, reduce the burden of medical expenses, and prevent sick social members from "poverty due to illness".
Legal basis:
People's Republic of China (PRC) social insurance law
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.
Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:
(a) shall be paid by the industrial injury insurance fund;
(2) It shall be borne by a third party;
(three) shall be borne by public health;
(4) Go abroad for medical treatment.
Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.
Thirty-second individuals across the overall regional employment, the basic medical insurance relationship with my transfer, the cumulative payment period.