General outpatient service: (1) First of all, the individual bears the minimum qifubiaozhun for one-time outpatient medical expenses, specifically for 300 yuan. (two) the part of the medical expenses exceeding the outpatient Qifubiaozhun shall be shared by the overall fund and the individual. The proportion of the overall fund is: 40% for tertiary and corresponding medical institutions (hereinafter referred to as tertiary medical institutions), 60% for other medical institutions (including secondary and corresponding medical institutions, the same below) and 70% for community health service institutions. (3) If the insured children contracted by general practitioners seek medical treatment in the outpatient service of contracted community health service institutions, the proportion of overall fund commitment shall be increased by 3 percentage points on the basis of the provisions in Item (2) of this article. For the first time, the insured children see a doctor in a contracted community health service institution, or are referred to other medical institutions for further treatment by the contracted community health service institution, and the qifubiaozhun for outpatient medical insurance is reduced or exempted in 300 yuan. Second, hospitalization reimbursement: (1) The maximum hospitalization expenses paid by children's medical insurance pooling fund is 250,000 yuan. (two) to undertake a hospitalization Qifubiaozhun, two or more hospitalizations, Qifubiaozhun is calculated according to the highest level of medical institutions. Specifically: 800 yuan, a tertiary medical institution, 500 yuan, other medical institutions, and 300 yuan, a community health service institution. (three) the medical expenses above the hospitalization Qifubiaozhun and below the maximum amount shall be shared by the overall fund and the individual. The overall proportion of rent and regret payment is 70% for tertiary medical institutions, 75% for other medical institutions and 80% for community health service institutions. (four) more than 250 thousand medical expenses, in line with the provisions of the serious illness insurance, by the serious illness insurance fund in accordance with the proportion of 70%.
Legal basis:
People's Republic of China (PRC) social insurance law
Article 2 The state establishes social insurance systems such as basic old-age insurance, basic medical insurance, industrial injury insurance, unemployment insurance and maternity insurance, so as to guarantee citizens' right to receive material assistance from the state and society in accordance with the law in case of old age, illness, industrial injury, unemployment and maternity.
Twenty-sixth basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.
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.
Derivative problem:
What is the proportion of medical insurance reimbursement for over-transfer personnel?
Reimbursement ratio: if the emergency expenses of general outpatient service exceed 2,000 yuan in a natural year, 50% of the large medical mutual funds above 2,000 yuan will be sold first and then paid, and 50% will be paid by individuals themselves. The expenses not reimbursed by medical insurance are as follows: 1, service items: registration fees, out-of-hospital consultation fees, medical records fees, etc. Special medical services such as visiting fees, expedited fees for examination and treatment, additional fees for name-calling surgery, additional fees for name-calling surgery, high-quality and good-price fees, and self-invited special care. 2. Diagnosis and treatment equipment and medical useful materials: examination and treatment items of large medical equipment such as positron emission tomography (pet), electron beam ct and ophthalmic excimer laser therapeutic apparatus. Glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation appliances. All kinds of self-use health care, massage, examination and treatment equipment. Disposable medical materials that are not charged separately as stipulated by the provincial price department. 3. Treatment items: organ sources or tissue sources of various organ or tissue transplants; Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow; Orthopedic surgery for myopia; Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.