Guide to Medical Insurance Reimbursement for Urban and Rural Residents in Zhenjiang (Zhenjiang Medical Insurance Card)

I. Reimbursement conditions

1, the applicant has gone through the insurance formalities and paid the medical insurance premium in full;

2, cooperative medical designated medical institutions for medical treatment;

3. The medical expenses incurred by the insured in hospitalization in medical institutions shall be paid in cash in advance, and relevant documents and materials shall be kept.

Second, the handling of materials

Hospitalization: original or photocopy of medical insurance calendar, medical insurance card, expense receipt, detailed list of hospitalization expenses, outpatient medical records and discharge records;

Outpatient service: the insured's medical insurance, medical insurance card, complete emergency observation medical records and outpatient invoices.

Third, the handling process

The insured person chooses the above materials to go through the reimbursement procedures with the medical insurance agency.

Fourth, medical care.

Medical insurance and basic medical insurance benefits for urban and rural residents

1. Outpatient medical co-ordination.

The general outpatient service shall co-ordinate the medical insurance for urban and rural residents and implement the first consultation system at the grass-roots level. I pay 50% of the general outpatient and emergency medical expenses incurred by the insured in the medical insurance system of the community health service institution designated by me, and the maximum payment limit of the fund in the year is 1000 yuan.

Outpatient co-ordination of chronic diseases. The medical expenses for chronic diseases incurred by the insured in the community health service institutions designated by me shall be paid by the basic medical insurance fund for urban and rural residents by 50%, and the maximum payment limit of the basic medical insurance fund for urban and rural residents within the year is 2500 yuan. The scope of chronic diseases in community health service institutions and township hospitals is tentatively set as: hypertension, diabetes, benign prostatic hyperplasia, coronary heart disease, chronic obstructive pulmonary disease, pulmonary heart disease, convalescence and sequelae of cerebrovascular accident, Parkinson's disease, Parkinson's syndrome, systemic lupus erythematosus, rheumatoid arthritis, chronic glomerulonephritis, nephrotic syndrome, Chronic renal failure and other insured persons in designated secondary and above medical institutions within the prescribed scope of medical expenses for chronic diseases, urban and rural residents' basic medical insurance fund to pay 50%, urban and rural residents' basic medical insurance fund annual maximum payment limit of 4500 yuan. The range of chronic diseases in designated secondary and above medical institutions is tentatively defined as five diseases: psychosis, chronic hepatitis, epilepsy, tuberculosis and aplastic anemia.

Outpatient co-ordination of special major diseases. The basic medical insurance fund for urban and rural residents pays different treatment and treatment standards according to different diseases when the insured suffers from particularly serious diseases within the prescribed scope. For patients with end-stage renal disease receiving dialysis treatment, 70% of outpatient medical expenses are paid by the basic medical insurance fund for urban and rural residents within the medical insurance system, and there is no maximum payment limit for the fund; For outpatient diagnosis and treatment of other major diseases within the prescribed scope, the basic medical insurance fund for urban and rural residents pays 50% of the outpatient medical expenses within the medical insurance system, and the maximum annual payment limit of the fund is 4,500 yuan. The scope of outpatient diagnosis and treatment of special major diseases is tentatively set as: severe psychosis, multidrug-resistant tuberculosis, end-stage renal disease, cancer, hemophilia, anti-rejection treatment after organ transplantation, congenital heart disease, hyperthyroidism and phenylketonuria in children.

2. Hospital medical coordination.

The hospitalization expenses incurred by the insured in the medical insurance system shall be settled by stages.

The insured in my designated community health service institutions or township hospitals in 500 yuan above part of the medical insurance system hospitalization expenses, the basic medical insurance fund for urban and rural residents to pay 75%. Starting from the second hospitalization in the year, the Qifubiaozhun is reduced by 50% according to the grade standard of the corresponding medical institution.

The hospitalization expenses of the insured in the medical insurance system of the secondary hospitals in this city shall be paid in proportion: if it exceeds 1 10,000 yuan but is less than 1 10,000 yuan, the basic medical insurance fund for urban and rural residents shall pay 55%; 65438+100000 yuan and 50000 yuan are 65%; 50,000 yuan and above, pay 75%. In the medical insurance system of tertiary hospitals in this city, the proportion of hospitalization expenses paid by the basic medical insurance fund for urban and rural residents is 5 percentage points lower than that paid by secondary hospitals. Starting from the second hospitalization in the year, the Qifubiaozhun is reduced by 50% according to the grade standard of the corresponding medical institution.

3. Maternity expenses.

The basic medical insurance fund for urban and rural residents will subsidize the maternity expenses that meet the requirements of family planning according to the standards of flat delivery 1.000 yuan and caesarean section 1.200 yuan.

4. Maximum payment limit for basic medical care.

The maximum amount of basic medical expenses paid by the basic medical insurance fund for urban and rural residents during the year is 300,000 yuan, and it will not be paid if it exceeds part of the basic medical insurance fund for urban and rural residents. There is no maximum payment limit for medical expenses for special major diseases within the scope specified in hemodialysis treatment and other parts.

Medical insurance and serious illness insurance for urban and rural residents

1. If the medical expenses paid by the insured individuals within the medical insurance system during the year reach15,000 yuan but less than 50,000 yuan, the serious illness insurance fund will pay 50%; More than 50,000 yuan, 6.5438+10,000 yuan, and the serious illness insurance fund pays 60%; 654.38 million yuan, 70% of the serious illness insurance fund.

2. The insured suffers from special major diseases within the prescribed scope, and on the basis of enjoying the basic medical insurance benefits for urban and rural residents, the serious illness insurance fund for urban and rural residents pays a certain proportion according to different diseases and cost ranges:

Dialysis treatment for patients with end-stage renal disease, outpatient medical expenses are paid by individuals in the medical insurance system, and 70% is paid by urban and rural residents' serious illness insurance fund.

Suffering from other special major diseases within the prescribed scope, the outpatient medical expenses in the medical insurance system are paid by individuals, and the urban and rural residents' serious illness insurance fund pays 20%.

If the first diagnosis is a disease covered by special major diseases of urban and rural residents, and the treatment is carried out in a designated hospital with medical insurance at or above the second level and the whole process is standardized, the personal payment of hospitalization medical expenses within the medical insurance system will be paid by the urban and rural residents' serious illness insurance fund. The hospitalization scope of special major diseases is tentatively defined as: childhood leukemia, congenital heart disease in children, cerebral infarction, psychosis, multidrug-resistant tuberculosis, AIDS opportunistic infection, acute myocardial infarction, cleft lip and palate, primary lung cancer, esophageal cancer, gastric cancer, colon cancer, rectal cancer, breast cancer, cervical cancer, chronic myeloid leukemia, type I diabetes, hypospadias and other 18 diseases.

3. After the insured suffers from some special and serious diseases within the prescribed scope and enjoys the basic medical insurance for urban and rural residents and serious illness insurance, the personal medical burden is still high, which leads to difficulties in family basic life. Social medical assistance funds and "charitable medical assistance" funds can be given certain subsidies, and the specific subsidy standards and measures will be separately studied and formulated by the Municipal Charity Federation. Medical insurance and basic medical insurance benefits for urban and rural residents

1. Outpatient medical co-ordination.

2. Hospital medical coordination.

The hospitalization expenses incurred by the insured in the medical insurance system shall be settled by stages.

3. Maternity expenses.

4. Maximum payment limit for basic medical care.

Medical insurance and serious illness insurance for urban and rural residents

Verbs (short for verb) deal with addresses.

Medical insurance reimbursement for urban and rural residents shall be handled in the designated community health service center.

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The pinyin combinations and radicals of Ji