1. Outpatient fee: 1. Tertiary hospitals: 60% paid by social pooling funds and 40% paid by individuals; 2 Secondary hospitals: 70% paid by social pooling funds and 30% paid by individuals; First-class hospitals: 75% paid by social pooling funds and 25% paid by individuals; 4 Designated community health service institutions: 85% paid by social pooling funds and 15% paid by individuals.
2. Hospitalization expenses: within1/0000 yuan (including 10000 yuan): 80% paid by social pooling funds and 20% paid by individuals (85% paid by social pooling funds and15% paid by individuals in designated community health service institutions); 265438+100,000 yuan to 50,000 yuan (including 50,000 yuan): 90% paid by social pooling funds and 10% paid by individuals. The proportion of retirees' hospitalization medical expenses paid by individuals is half of the above proportion.
More than 35,000 yuan: 95% paid by social pooling funds and 5% paid by individuals.
4. The employing unit (below 10), its employees and other individuals who pay for insurance for the first time can only pay the medical expenses that meet the requirements with personal accounts within 6 months from the date of payment, and all the unpaid parts of personal accounts are paid by individuals. After 6 months, you can enjoy basic medical insurance benefits according to regulations.
5. In the same year, the maximum amount of medical expenses paid by social pooling funds and individuals for each insured person is 50,000 yuan. For the insured whose payment period is less than five years, the maximum amount of medical expenses will decrease by 5,000 yuan every year, and the difference between the actual limit and the maximum amount will be 50,000 yuan paid by the individual.
Serious illness medical co-ordination fund payment period in more than 5 years (including 5 years) of the insured, in line with the provisions of the medical expenses during the year, by the serious illness medical co-ordination fund to pay 95%, individuals pay 5%; The serious illness pooling fund was not capped in that year. If the payment period is less than 5 years, the maximum is 50,000 yuan, and the maximum reduction is 1 year.
6. Individual annual maximum payment limit: the medical expenses paid by the insured in the basic medical insurance (excluding drugs and medical treatment items advanced by individuals, out-of-range drugs, out-of-pocket reimbursement items, out-of-pocket medical expenses exceeding the maximum limit and insufficient payment period) shall not exceed 4,500 yuan in that year, and the part exceeding 4,500 yuan shall be paid by the social pooling fund.
7. Suffering from Class A infectious diseases and some mental diseases stipulated by the state (schizophrenia: paranoid, adolescent, neurotic, simple; Paranoid mental disorder; Mood disorder: manic episode, bipolar disorder), family planning operation and its sequelae (confirmed by the family planning department at or above the county level in conjunction with relevant departments) and courageous injury (confirmed by relevant government departments), the medical expenses that meet the requirements shall be paid by the social pooling fund.
The insured suffers from cancer and chronic renal failure, and the medical expenses that meet the requirements of cancer treatment and renal dialysis and exceed the Qifubiaozhun shall be paid by the social pooling fund.
8. Long-term working staff and people living in different places may apply for medical treatment in local secondary hospitals (including secondary hospitals) and the nearest primary hospitals, and the medical expenses incurred shall be audited and reimbursed by the municipal medical insurance settlement center with valid vouchers.
The medical expenses incurred during the insured's business trip and visiting relatives can be reimbursed by the medical insurance settlement center with valid vouchers.
9. For the medical expenses incurred by the insured in public hospitals and clinics when going abroad on business and arriving in Hong Kong, Macao and Taiwan, the individual shall pay 30% of the total medical expenses first, and then be reimbursed according to relevant regulations.