First, students and children. In a settlement year, medical expenses below RMB 6,543,800+0,800 yuan that meet the scope of reimbursement occurred. The threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 55%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.
Second, the elderly over 70 years old. In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold of tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.
Third, other urban residents. In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold of tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The Qifubiaozhun for hospitalization in secondary hospitals is 300 yuan, and the reimbursement rate is 55%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 60%. Urban residents hospitalized for more than two times in a settlement year, starting from the second hospitalization, no longer charge Qifubiaozhun fees. Transfer or hospitalization for more than two times, make up the difference of Qifubiaozhun in accordance with the provisions of transfer or hospitalization again.
Proportion of rural medical insurance reimbursement in Hubei Province
First, the proportion of outpatient reimbursement
In a natural year, the average outpatient and emergency expenses incurred by on-the-job personnel exceed 1.800 yuan and 1.800 yuan's large medical mutual aid fund, and individuals pay 50%. Accumulated retirees 1.300 yuan or above, 70% of large medical mutual funds under 70 years old, 80% of large medical mutual funds over 70 years old and 20% of large medical mutual funds. The maximum payment limit in a natural year is 20000 yuan.
Second, the proportion of hospitalization reimbursement
Qifubiaozhun is 1300 yuan for the first hospitalization in a natural year, and 650 yuan for each subsequent hospitalization. The payment ratio is divided into three grades. Take a tertiary hospital as an example. The floating standards are: 30,000 yuan, 85% on the job, 9 1% for retirement, 90% for 30,000-40,000, 94% for retirement, more than 40,000, 95% for employment and 97% for retirement. 90 days of general hospitalization is a settlement cycle. Psychiatric hospitalization for 360 days is a settlement cycle, and the floating standard is halved. In a natural year, the maximum payment of the overall fund is 654.38+10,000 yuan. The maximum hospitalization limit is 200,000 yuan, and the hospitalization ratio is 85%.
Hubei rural insurance is not reimbursed.
I. Service items
(1) Registration fee, outpatient consultation fee, inter-hospital consultation fee, medical record fee, etc.
(2) Special medical service fees, such as visiting fees, urgent fees for examination and treatment, additional fees for roll-call surgery, high quality and good price fees, and self-invited special care fees;
③ Referral transportation fee and ambulance fee;
(4) compensation for damage to meals, air conditioning and refrigeration, heating, television, telephone, food heating and public property;
⑤ Life service items and facilities such as escort fee, nursing fee, washing fee and decocting fee.
Second, non-disease treatment projects
① All kinds of beauty and bodybuilding projects and non-functional beauty and plastic surgery projects, such as: treatment of freckles, senile plaque, pigmentation, nasal bridge filling, mole removal, verruca plana, double eyelid surgery, beauty massage, alopecia, bromhidrosis, tooth cleaning, dental inlay, orthodontics, treatment of stained teeth, correction of stuttering, breast augmentation surgery, etc.
(2) various weight loss, weight gain and height increase projects;
③ Various health checks;
(4) all kinds of prevention, health care and family planning diagnosis and treatment projects;
(5) all kinds of medical consultation and medical appraisal;
⑥ Recuperation expenses of various sanatoriums.
Three, diagnosis and treatment equipment and medical materials
(1) Inspection and treatment projects of large medical equipment such as positron emission computed tomography (PET) and ophthalmic excimer laser therapeutic apparatus;
② Rehabilitation appliances such as glasses, dentures, artificial eyes, artificial limbs and hearing AIDS;
(3) all kinds of personal health care, massage, examination and treatment instruments, such as massager, massage cushion, wheelchair for the disabled, transfusion thermostat, all kinds of personal detection and treatment instruments, all kinds of magnetic therapy instruments, all kinds of traction belts, crutches, leather steel carapace, waist circumference, steel head and neck, stomach support, kidney support, uterus support, hernia belt, kneepad belt, testicular belt and brain strengthening.
Disposable medical materials that cannot be charged separately as stipulated by the provincial and municipal price departments.
Iv. categories of treatment items
① Orthopedic surgery for vision and strabismus;
(2) Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.
Verb (short for verb) Other:
(1) The organ or tissue source of various organ or tissue transplants;
(2) the cost of blood and various plasma products;
(3) various infertility (pregnancy) and sexual dysfunction diagnosis and treatment projects;
4. Diagnosis and treatment projects such as transsexual surgery;
⑤ Various scientific research and clinical confirmatory diagnosis and treatment projects;
⑥ All insurance items added during hospitalization (including the insurance premium for various artificial organ transplant operations such as pacemaker installation);
All landowners medical malpractice or medical expenses that have been identified as medical malpractice disputes but have not yet been identified.
Today should enjoy the national and provincial special subsidy policy of disease treatment costs.
legal ground
People's Republic of China (PRC) social insurance law
Article 30
The following medical expenses are not included in the payment scope of the basic medical insurance fund:
(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.