Employee medical insurance

The funds in the personal account in the current year are used to pay the following expenses incurred by the insured:

(a) medical expenses incurred in designated medical institutions in accordance with the scope of medical insurance expenses (including emergency, the same below);

(2) the cost of drugs purchased in designated retail pharmacies that meet the scope of medical insurance expenses;

(three) serious illness insurance premiums and medical difficulties relief funds that should be paid by individuals.

basic medical insurance for rural and non-working urban residents

Personal account funds over the years are used to pay the following expenses incurred by the insured:

(a) medical expenses incurred in designated medical institutions that should be paid by individuals at their own expense, self-care and self-payment;

(two) the cost of using the preventive immunization vaccine outside the national expanded immunization program;

(three) the service fee for the signing of community doctors who should be borne by individuals;

(four) other projects stipulated by the state and the province.

basic medical insurance for rural and non-working urban residents

Unless otherwise stipulated by the national, provincial and municipal basic medical insurance policies, the specific financing and distribution standards of various funds and funds shall be determined by the overall planning areas themselves.

critical illness insurance

Critical illness insurance consists of two parts: large medical subsidy and special drug critical illness insurance.

Large-scale Medicaid refers to the medical expenses (hereinafter referred to as large-scale medical expenses) within the scope of medical insurance expenses above the maximum hospitalization limit of insured persons.

Special drug critical illness insurance refers to the protection of Zhejiang province critical illness insurance for the insured to use special drugs (including rare drugs, the same below).

Proportion of medical insurance reimbursement in Hangzhou

Employee medical insurance

In a settlement year, the hospitalization expenses incurred by the insured in accordance with the scope of medical insurance payment shall be handled in accordance with the following provisions:

(1) One-time hospitalization Qifubiaozhun expenses borne by individuals. For those who have been hospitalized twice or more, the Qifubiaozhun is calculated according to the standard of the highest-level medical institution, specifically: tertiary and corresponding medical institutions (hereinafter referred to as tertiary medical institutions) are not higher than 800 yuan, other medical institutions (including secondary and corresponding medical institutions, the same below) are not higher than 600 yuan, and community health service institutions are not higher than 300 yuan. Specific standards shall be determined by all localities as a whole.

(two) the maximum amount of hospitalization expenses paid by the employee medical insurance fund (based on the date of discharge, hereinafter referred to as the maximum hospitalization limit) is 360 thousand yuan.

(three) the medical expenses above Qifubiaozhun and below the maximum hospitalization limit, which are shared by the overall fund and the individual. Among them, the proportion of medical expenses incurred by community health service institutions borne by the overall fund is not less than 80% before retirement and not less than 85% after retirement, and the specific proportion is determined by overall planning.

(four) medical expenses above the maximum amount of hospitalization in accordance with the provisions of the serious illness insurance shall be borne jointly by the individual and the serious illness insurance fund.

In a settlement year, the general outpatient medical expenses incurred by the insured in accordance with the scope of medical insurance payment shall be handled in accordance with the following provisions:

(a) first paid by the personal account in the current year, when the personal account is insufficient to pay, the individual shall bear the medical expenses of a outpatient qifubiaozhun. Among them, it is not higher than 1 1,000 yuan before retirement and not higher than 500 yuan after retirement. The specific standards are determined by the master plan.

(two) when the insured retires, the outpatient Qifubiaozhun is calculated according to the actual number of months before and after retirement, and then combined to determine.

(three) outpatient Qifubiaozhun above part of the medical expenses, by pooling funds and individuals * * *. Among them, the proportion of medical expenses incurred by community health service institutions borne by the overall planning fund is not less than 75% before retirement and not less than 80% after retirement, and the specific standards are determined by overall planning.

(four) according to local conditions, determine the maximum amount of outpatient medical expenses paid by the employee medical insurance pooling fund, and the medical expenses pooling fund that exceeds the maximum amount will not be paid.

basic medical insurance for rural and non-working urban residents

In a settlement year, the hospitalization expenses incurred by the insured in accordance with the scope of medical insurance payment shall be handled in accordance with the following provisions:

(1) The individual shall bear the medical expenses of Qifubiaozhun for one hospitalization. For those hospitalized for two or more times, the Qifubiaozhun shall be calculated according to the highest medical institution standards, specifically: tertiary medical institutions shall not be higher than 800 yuan, other medical institutions shall not be higher than 600 yuan, and community health service institutions shall not be higher than 300 yuan, and the specific standards shall be determined by overall planning.

(two) the maximum amount of hospitalization paid by the medical insurance fund for urban and rural residents is 250 thousand yuan.

(three) the medical expenses above the hospitalization Qifubiaozhun and below the maximum hospitalization amount shall be shared by the overall fund and the individual. Among them, the proportion of medical expenses incurred by community health service institutions is not less than 75%, and the specific proportion is determined by overall planning.

(four) medical expenses above the maximum amount of hospitalization in accordance with the provisions of the serious illness insurance shall be borne jointly by the individual and the serious illness insurance fund.

In a settlement year, the general outpatient medical expenses incurred by the insured in line with the scope of medical insurance expenses shall be borne by the individual first, and the medical expenses above the outpatient Qifubiaozhun shall be borne by the urban and rural residents' medical insurance pooling fund according to a certain proportion.

According to the local conditions, each co-ordination place can determine the Qifubiaozhun for urban and rural residents' medical insurance outpatient service, the proportion of co-ordination funds participating in payment and the maximum amount of outpatient medical expenses. The medical expenses above the maximum limit shall not be paid by the overall fund.

critical illness insurance

In a settlement year, the large medical expenses incurred by the insured shall be settled according to the following provisions:

(a) the proportion of large medical expenses incurred by employees' medical insurance participants borne by the serious illness insurance fund is 90%.

(two) the proportion of large medical expenses incurred by urban and rural residents insured by medical insurance is 70%.

In a settlement year, the special drug expenses incurred by the insured shall be settled according to the following provisions:

(1) Individuals shall bear the minimum payment standard, specifically: 5,000 yuan for the holder and 20,000 yuan for other insured persons.

(two) the annual maximum payment limit of the serious illness insurance fund is 450 thousand yuan.

(3) The expenses above the minimum deductible and below the maximum payment limit shall be settled by the serious illness insurance fund according to the excess progressive system, and the specific proportion is 50% from 5,000 yuan to 20,000 yuan (inclusive); 20,000 yuan to 200,000 yuan (inclusive) is 60%; 200,000 yuan to 450,000 yuan (inclusive) is 70%.