A: All employers within the administrative area of this Municipality include government agencies, institutions, social organizations and enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises and private enterprises). ), provincial units in Beijing and their employees, retirees, flexible employees without fixed jobs, file keepers and owners of private individual economic organizations and their employees.
2. What is the contribution rate of basic medical insurance? What is the proportion of payment for participating in civil service subsidies or supplementary medical insurance for employees?
Answer: The insured units pay the basic medical insurance premium according to 7% of the total wages of employees last month and 2% of the total wages of individuals last month.
When the insured reaches retirement age, if the original payment period is less than 15 years, it needs to be supplemented by 15 years.
Institutions and institutions participating in Medicaid for civil servants shall pay 4.5% of employees' salary last month (including work-related injury insurance). Units participating in supplementary medical insurance for enterprise employees shall pay 4% of the employees' salary last month.
3. What is the proportion of funds allocated to individual medical accounts?
Answer: 1.35 years old, 2.6% of the total wages paid by me;
2.36 to 45 years old, pay 3.2% of my total salary;
3.46 years old to retirement, 4% of my total salary;
4 retired (post) personnel according to my last year's pension 5% plan hair;
5. If government agencies and institutions have participated in civil service subsidies or enterprises and institutions have participated in supplementary medical insurance for employees, they will be credited to personal accounts according to the above age groups, respectively, by 0.8%, 1.4%, 2% and 2.5% of the payment wages.
Four, how to deal with the balance of personal accounts of insured employees in that year?
Answer: When the personal account of the insured employee has a balance within one year, it will continue to be used in the next year, and the interest will be calculated according to state regulations.
Five, the insured workers transferred from the city, termination (dissolution) of labor relations, death, etc. How to handle your personal account?
Answer: When the insured workers are transferred from this city, the employing unit should go to the municipal medical insurance agency to handle the medical insurance transfer procedures and transfer the funds in the personal account with the transfer procedures of the municipal personnel and labor departments within one week.
Insured employees and employers who temporarily suspend payment due to the dissolution or termination of labor relations shall be detained. Jacket? Br> After the death of the insured employee, the employing unit shall go through the formalities of stopping the insurance with relevant information to the medical insurance agency within one month, and the balance of the personal account will be transferred to the personal account of the legal heir after confirmation by the Municipal Medical Insurance Office. If the legal heir is a non-insured person, it shall be inherited by the legal heir; When no one inherits, the balance of his personal account will be included in the basic medical insurance pooling fund.
Six, the basic medical insurance fund does not pay the cost of the project?
Answer: The medical insurance fund will not pay for the following items:
1. Service Item Classification
(1) Social security card fee, registration fee, consultation fee outside the hospital, medical record fee, etc.
(2) Special medical service fees, such as visiting fees, urgent fees for examination and treatment, additional fees for roll call operation, high quality and good price, special nurses invited by themselves, etc.
2. Non-disease treatment projects
(1) Various beauty and bodybuilding projects as well as non-functional plastic surgery and orthopedic surgery.
(2) all kinds of weight loss, weight gain and height increase projects.
(3) various physical examinations.
(4) All kinds of preventive health care and diagnosis projects.
(5) all kinds of medical consultation and medical appraisal.
3. Diagnostic equipment and medical materials
(1) Inspection and treatment items of large medical equipment such as positron emission tomography (pet), electron beam ct, stereotactic emitter (γ knife, χ knife) and ophthalmic excimer laser therapeutic instrument.
(2) Rehabilitation appliances such as glasses, dentures, artificial eyes, artificial limbs and hearing AIDS.
(3) all kinds of self-use health care, massage, examination and treatment equipment.
(4) Disposable medical materials that cannot be charged separately as stipulated by the provincial price department.
4. Treatment programs
(1) Organ source or tissue source of various organ or tissue transplants.
(2) Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow.
(3) Orthopedic surgery for myopia.
(4) Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.
5. Others
(1) Diagnosis and treatment items of various infertility (pregnancy) and sexual dysfunction.
(2) all kinds of scientific research and clinical verification of diagnosis and treatment projects.
(3) All expenses incurred for disability due to fighting, alcoholism, suicide, traffic accidents, medical accidents, etc.
(4) Medical expenses during going abroad to visit relatives, study and give lectures.
(5) the cost of treating sexually transmitted diseases, drugs or drug addiction.
(six) the cost of treatment for work-related injuries, occupational diseases, collective food poisoning and sequelae of family planning operations.
Seven, insured workers how to see a doctor, buy medicine?
Answer: 1. Outpatient service.
Insured workers hold the Social Security Card and Jingjiang Medical Insurance Record for Urban Workers (hereinafter referred to as the "card" and "certificate") to visit the designated medical institutions in this Municipality. The expenses that meet the basic medical insurance payment scope shall be directly transferred from the hospital's personal account, and the part that is not paid by the personal account shall be taken care of by itself.
2. Emergency treatment
When the insured workers can't go to the designated hospital for treatment due to sudden illness, they can go to the nearest hospital for medical treatment, but they need to report to the medical insurance agency the next day, and transfer to the designated medical institution for medical treatment in time after the condition is stable. Medical expenses can be handled according to the specific circumstances in accordance with the relevant provisions of outpatient and hospitalization. Insured employees or their families can hold "cards", "certificates" and emergency medical records, prescriptions, effective medical expense receipts, etc. , and within ten days to the municipal medical insurance agencies for reimbursement procedures.
be hospitalized
Insured workers need to be hospitalized due to illness, with the "card" and "certificate" to the designated medical machine for hospitalization procedures, and the hospital to settle medical expenses.
4. Transfer from outside the city
(1) The insured workers shall go through the registration formalities at the municipal medical insurance agency with their own "Card", "Certificate" and the transfer certificate of designated secondary hospitals or designated specialized hospitals in this Municipality, and may be transferred to other hospitals for medical treatment upon approval.
(2) If the patients with acute and critical illness really need to be immediately transferred to a hospital outside the city for rescue, they shall not report and register with the municipal medical insurance agency in time according to the procedures, and be treated after being signed by the hospital leader (or the chief duty officer), but they shall go to the municipal medical insurance agency to re-submit the referral procedures in time afterwards.
(3) In principle, the referral outside the city should be transferred to the designated hospital confirmed by the municipal labor and social security department, and the referral procedure is effective once.
5. Self-purchased drugs
Insured employees can buy prescription drugs in designated retail pharmacies with prescriptions from designated medical institutions and social security cards, which are over-the-counter drugs in the medical insurance drug list, and insured employees can buy them by themselves with social security cards.
Eight, the city's overall fund to pay the insured employees hospitalization medical expenses Qifubiaozhun, the maximum payment limit is how to provide?
Answer: The threshold for hospitalization medical expenses of insured employees in our city is:
1. hospitalization in a first-class medical institution in this city, with the minimum payment standard of 500 yuan;
2 in the city's secondary medical institutions for medical treatment, Qifubiaozhun for 650 yuan;
3. When transferring to other places for medical treatment, the minimum payment standard is 900 yuan.
The maximum amount of hospitalization medical expenses paid by the insured employees from the municipal co-ordination fund is 4 times of the average salary of employees in this city last year.
For multiple hospitalizations in the same year, and the interval between admission and discharge in medical institutions at the same level exceeds 15 days, starting from the second hospitalization, the Qifubiaozhun for hospitalization expenses will be reduced by 20% in turn, and the minimum shall not be lower than that in 200 yuan.
9. What is the personal burden ratio of hospitalization expenses after Qifubiaozhun?
Answer: 1. On-the-job insured employees' personal burden ratio is:
0-5,000 yuan, paid by individuals16%;
500 1- 15000 yuan, paid by individuals12%;
1500 1-40000 yuan, 8% paid by individuals;
2. The proportion of individual segmented burden of retired (post) personnel is:
0-5,000 yuan, paid by individuals10%;
500 1- 15000 yuan, 8% paid by individuals;
15001-40,000 yuan, and the individual pays 5%.
3. To participate in the civil service Medicaid or supplementary medical insurance personnel in a medical insurance settlement year in line with the basic medical insurance payment range of hospitalization medical expenses, individual pays Qifubiaozhun to the top line within the individual pays part by the civil service Medicaid or supplementary medical insurance fund bear 50%.
X. How to raise medical assistance fund for serious illness? How to deal with the serious medical expenses that exceed the maximum payment limit of the basic medical insurance hospitalization pooling fund?
A: The medical assistance fund for serious illness is jointly paid by the insured unit and the insured. The insured unit pays 5 yuan per person per month, and the insured person pays 3 yuan per person per month. The employer will withhold and remit the annual 96 yuan in July each year. The part paid by the retirees' serious illness medical assistance fund unit shall be paid by the employer on an annual basis, and the part paid by the individual shall be deducted from the retirees' personal medical insurance account in July each year.
In a settlement year of the insured, if the hospitalization medical expenses (including special disease outpatient expenses for hospitalization settlement) in medical insurance coverage exceed the maximum payment limit of 40,000 yuan and 1500 yuan, it shall be applied by the unit where the insured works. After the examination and confirmation by the municipal medical insurance agency, the serious illness relief fund pays 90%, and the unit and individual bear 10%.
XI。 How do insured workers who live in other places for a long time see a doctor?
A: There are two types of insured employees who live in other places for a long time:
1. Retired (vocational) personnel resettled in different places.
2. Persons who have been working or studying in the field for more than 6 months (including 6 months) for a long time.
Insured workers who live in other places for a long time shall be designated for medical treatment. 2-3 designated medical institutions confirmed by local medical insurance agencies are selected as designated hospitals by the units or individuals where employees work, and the Application Form for Medical Treatment in Different Places in Jingjiang City is filled out and reported to the municipal medical insurance department for the record.
12. How to reimburse the medical expenses of employees living outside?
Answer: The medical expenses incurred by employees living outside the hospital shall be paid in advance by individuals, and then the medical expenses shall be reimbursed to the medical insurance agency according to the relevant provisions of the municipal medical insurance on the basis of the Application Form for Medical Treatment of Insured Employees in Jingjiang City, the medical records provided by the hospital, the medical expense settlement list, and the medical expense receipt that meets the requirements (inpatients must show the discharge summary and detailed settlement list). For the reimbursement of medical expenses transferred to hospitals outside the overall planning area where employees live, they must go through the relevant referral examination and approval procedures before reimbursement. For insured units with a large number of employees living outside, centralized verification can be adopted.
All medical expenses of employees seeking medical treatment abroad must be settled within this year.
Thirteen, insured workers suffering from special diseases and long-term chronic diseases, what are the provisions of outpatient expenses?
Answer: If the insured employee suffers from one of the following diseases and is confirmed according to the prescribed procedures, the outpatient medical expenses can be paid by the overall fund according to the following proportion after being audited by the medical insurance agency:
1. Manic psychosis and schizophrenia (excluding simple type), outpatient (including hospitalization) medical expenses that meet the scope of medical insurance reimbursement shall be paid in full by the overall fund.
2. Patients with malignant tumor chemotherapy, radiotherapy, severe uremia and renal failure need dialysis treatment, which is recommended by the resident physician and applied by the employee himself. After the outpatient medical expenses are reported to the municipal medical insurance agency for examination and approval, they shall be executed according to the settlement method of hospitalization expenses.
3. Take care of the hospitalization expenses of patients with malignant tumors who meet the basic requirements within the scope of medical insurance, and halve the proportion of individual segment self-payment.
4 patients need hemodialysis, after going through the examination and approval procedures, the cost of hemodialysis shall be paid by the individual first, and the rest shall be paid by the basic medical insurance fund according to regulations.
5. Patients with chronic diseases such as chronic viral hepatitis, diabetes, complications, hypertension (above phase II), chronic heart failure, renal failure, chronic obstructive pulmonary disease, systemic lupus erythematosus, aplastic anemia, macular degeneration, etc., in a medical insurance settlement year, the outpatient medical expenses that meet the payment scope of basic medical insurance, the cumulative number of employees exceeds that of 800 yuan, and the number of retirees exceeds that of 500 yuan, can be reported to the municipal medical insurance agency for review by medical records and laboratory tests. To participate in civil service subsidies or enterprise supplementary medical insurance, supplementary medical insurance fund to pay 20%.
The designated medical institutions shall separately prescribe, keep accounts and pay the fees for the therapeutic drugs suffering from the above diseases.
Fourteen, the general outpatient medical expenses are subsidies for civil servants or supplementary medical insurance for enterprises?
A: Civil servant subsidies or enterprise supplementary medical insurance can subsidize the general outpatient medical expenses paid by individuals within the scope of medical insurance that exceed a certain amount. The specific subsidy measures are: if the insured employees' personal accounts meet the requirements of basic medical insurance after being used up, they can pay more than 10% of the average salary of employees in the previous year to less than 3,000 yuan, and 60% can be paid by supplementary medical insurance pooling funds such as medical records, relevant checklists, prescriptions and effective charge invoices, and reported to the medical insurance agency for review.
Fifteen, how to stipulate the settlement year of medical insurance expenses?
A: July of that year 1 to June 30th of the following year is a medical insurance settlement year.
Sixteen, what are the responsibilities of the insured units in the social medical insurance system?
Answer: The employer must pay the insurance premium in full and on time, and withhold the part that the individual should pay, and regularly announce the payment of medical insurance premium to the employees. Due to the arrears of employee insurance premiums, the insured employees can't enjoy the medical insurance benefits normally, and continuous bowling can't be calculated, which affects the retirement benefits of employees. The unit is responsible. Assist medical insurance agencies to do a good job in the publicity and management of social medical insurance for employees.
Seventeen, the employer does not pay medical insurance premiums according to regulations, how to deal with it?
Answer: Employers and their employees should pay the basic medical insurance premiums in full and on time in accordance with the provisions of the Interim Regulations on the Collection and Payment of Social Insurance Fees in the State Council. If the payer fails to pay and withhold the basic medical insurance premium according to the regulations, the administrative department of labor and social security shall order it to pay within a time limit, and at the same time suspend the transfer of funds in employees' personal accounts and the payment of funds as a whole and the handling of medical insurance transfer procedures; Fails to pay, in addition to repay the amount owed, from the date of default, an additional 2‰ fine for delaying payment. If the payer refuses to pay the basic medical insurance premium and late payment fee within the time limit, the tax authorities or the administrative department of labor security shall apply to the people's court for compulsory collection according to law.
Eighteen, how to participate in the basic medical insurance for flexible employees?
Answer: Flexible employees need to fill out an application form for medical insurance, and after confirmation by their village (or neighborhood committee), they should bring their ID card and one-inch photo to the medical insurance agency to handle the basic medical insurance procedures. After the insured, in July each year, with the social insurance payment voucher, the medical insurance agency will pay the annual basic medical insurance premium according to 9% of the payment base (the average salary of employees in the province last year), and at the same time pay the annual serious illness relief fund. The waiting period for new employees with flexible employment is 6 months. After payment, you can use the social security card personal account in the next month, and enjoy the basic medical insurance pooling fund payment (hospitalization) from the seventh month. From the seventh month to 12 months, if you suffer from ten kinds of serious diseases, the overall fund will pay by half.
Nineteen, how to use the medical insurance card (social security card)?
Answer: 1. After the medical insurance is encrypted, the social security card of the insured person has an initial password. In order to ensure the safe use of funds for the social security card of the insured, the cardholder must change the initial password to his own password when using it for the first time.
2. Medical treatment and expense settlement When the insured person purchases medicine in designated hospitals and pharmacies, he can use the social security card to pay the medical expenses within the scope of medical insurance with the medical insurance record; When in hospital, you can register and settle the hospitalization expenses in the inpatient department of the designated hospital with the social security card and medical insurance records. When the insured is discharged from the hospital, if the balance of personal account can fully pay the hospitalization qifubiaozhun, you can choose to use personal account to pay.
3. Inquiring about the cardholder can hold the social security card to the medical insurance agency or designated hospitals and pharmacies to inquire about personal account balance, personal medical treatment and other information.
4. If the social security card is lost or damaged, you should report the loss to the medical insurance agency with your ID card and medical record, and pay the production cost of the social security card. If the personal account amount is stolen within three days from the date of reporting the loss, the cardholder shall be responsible. You can get a new card after reporting the loss for seven days.
5. Pay attention to keep the chip clean when maintaining the social security card. If there is dirt, you can gently wipe it off with a clean soft cloth. Don't scratch, fold, get wet or distort the social security card. Social security cards should be kept away from mobile phones and magnets.