Conditions and procedures for reimbursement of medical insurance in Beijing
I. Outpatient expenses
(1) Reimbursement scope: the insured persons are in designated hospitals or specialized hospitals of medical insurance selected by individuals, Chinese medicine hospitals and Class A hospitals (Friendship, Xuanwu, Guang 'anmen Chinese Medicine, Tongren, Xiehe, Beijing Third Hospital of Medical Sciences, Peking University People, Peking University No.1, Jishuitan, Chaoyang, Peking University No.1).
(2) reimbursement ratio: in a natural year, the average outpatient emergency expenses incurred by on-the-job personnel have accumulated more than 2, yuan, 5% of which is paid by some large medical mutual funds with more than 2, yuan, and 5% is paid by individuals themselves. Retirees have accumulated more than 1,3 yuan, and the part with more than 1,3 yuan is covered with 7-year-old large-scale medical mutual funds, with 7% paid by individuals and 3% paid by individuals, 8% paid by large-scale medical mutual funds over 7 years old and 2% paid by individuals. The maximum payment limit in a natural year is 2, yuan.
(3) Medical treatment management: individual cash payment for general outpatient and emergency expenses, and the medical expenses incurred shall conform to the scope of the three major catalogues of medical insurance. When purchasing drugs, special prescriptions shall be issued in designated hospitals and stamped with the special seal for medical insurance outsourcing, and then drugs shall be purchased at designated pharmacies.
(4) reimbursement process: in a natural year, if the accumulative amount exceeds the minimum payment standard, the insured person will submit the documents to the unit or social security office, and the unit or social security office will enter the documents into the enterprise version and declare the electronic information and documents to the medical insurance center. The medical insurance center will complete the examination, settlement and payment within 15 working days.
(5) application materials: general outpatient and emergency receipts, medical insurance prescriptions (double-price prescriptions), and detailed inspection and treatment expenses.
(6) declaration date: January 2th, the expenses of the current month shall be declared the next month, and the expenses of the current year shall be declared before January 2th of the next year.
II. Hospitalization expenses
(1) Reimbursement scope: hospitalization expenses incurred by insured persons in designated hospitals or specialized hospitals of medical insurance, Chinese medicine hospitals and Class A hospitals selected by individuals.
(2) reimbursement ratio: the minimum payment for the first hospitalization in a natural year is 1,3 yuan, and every time after that, 65 yuan. The payment ratio is divided into three grades. Take the tertiary hospital as an example. The fluctuation standard is: 3, yuan, 85% on the job, 91% on the job, 9% on the job from 3, to 4,, 94% on the job, 95% on the job and 97% on the job. 9 days of general hospitalization is a settlement cycle. Psychiatric hospitalization for 36 days is a settlement cycle, and the fluctuation standard is halved. In a natural year, the overall fund will pay up to 7, yuan. The maximum amount of hospitalization is 1, yuan, and the proportion of hospitalization is 7%.
(3) Medical treatment management: Please use the Beijing Medical Insurance Manual when seeking medical treatment. If the unit pays the fee in full, the individual can go through the hospitalization formalities only by paying part of the hospitalization advance payment. The medical expenses incurred should conform to the scope of the three major catalogues of medical insurance.
(4) reimbursement process: when discharged from hospital, the hospital and the individual will settle the self-funded and self-funded amount, and the reimbursement amount of the overall fund will be settled by the hospital and the district medical insurance center.
III. Outpatient special diseases
(1) Reimbursement scope: the outpatient medical expenses incurred by the insured who took anti-rejection drugs after malignant tumor radiotherapy and chemotherapy, renal dialysis and kidney transplantation after going through the examination and approval procedures for special diseases.
(2) reimbursement ratio: reimbursement ratio is the same as hospitalization. The settlement period of outpatient special diseases is 36 days.
(3) management of medical treatment: the insured can only choose one hospital as the designated hospital for special diseases. Please use the Beijing Medical Insurance Manual when seeking medical treatment. If the unit pays the fee in full, the individual only needs to pay the individual's own expenses and the self-funded part, and the reimbursement amount of the overall fund is settled by the hospital and the district medical insurance center.
(4) reimbursement process: the insured person submits the documents to the unit or social security office, and the unit declares the documents to the medical insurance center. The medical insurance center completed the examination, settlement and payment on the same day
IV. Scope of reimbursement for medical insurance in Beijing
(1) Western medicines and Chinese patent medicines shall be reimbursed according to the Municipal Health Bureau's "On Printing and Distributing < Scope of reimbursement for free medical care and labor insurance medical drugs in Beijing > Notice "(Jing Wei Gong Zi [1997] No.15) and" Guan Gan Implementation <; Scope of reimbursement for free medical care and labor insurance medical drugs in Beijing > Supplementary opinions "(Jing Wei Gong Zi [1998] No.2) file execution.
The expenses marked as "to be partially borne by individuals" in drugs should be borne by individuals at first, and the rest should be included in the payment scope of the basic medical insurance fund.
(2) hospital preparations; According to the municipal health bureau "on the implementation of <: Scope of preparation reimbursement in Beijing free medical care and labor insurance medical hospital > Notice "(Jing Wei Gong Zi [1999] No.2) file execution.
(III) Scope of payment and use of Chinese herbal pieces
1. For Chinese herbal pieces that need personal burden, according to the Municipal Health Bureau's < Provisions of Beijing Municipality on the scope of self-funded drugs for medical personnel who enjoy free medical care and labor insurance > Notice of the "(Jing Wei Cai Zi [77] No.267) file the first execution.
2. Chinese herbal pieces that are used singly and used reasonably in the compound prescription due to illness (not exceeding the normal dosage) shall be treated according to the Municipal Health Bureau's <: Provisions of Beijing Municipality on the scope of self-funded drugs for medical personnel who enjoy free medical care and labor insurance > Notice of "(Jing Wei Cai Zi [77] No.267) file second execution.
3. The expenses for the reasonable use of Chinese herbal pieces in the above paragraphs 1 and 2 during the rescue period of critically ill patients shall be included in the payment scope of the basic medical insurance fund.
(IV) Payment scope of radiotherapy and chemotherapy drugs for malignant tumor outpatient service
When the insured persons are treated with radiotherapy and chemotherapy for malignant tumor in outpatient service, the following drugs can be included in the payment scope of the basic medical insurance pooling fund:
1. Tumor drugs
The "Eleventh Class of Tumor Drugs" of Chinese and Western medicines in the Reimbursement Scope of Free Medical Care and Labor Insurance Medical Drugs in Beijing is excluded.
2. Leukopoiesis promoting drugs
Granulocyte colony stimulating factor [special] injection (imported), Lixuesheng tablet, shark liver alcohol tablet and inosine tablet injection.
3. Anti-infective drugs
"Antibiotics" (45 kinds) and "Antifungal drugs" (5 kinds) in "Class I Anti-infective Drugs" in the Reimbursement Scope of Free Medical Care and Labor Insurance Medical Care in Beijing. ***5 kinds of drugs.
(V) Anti-rejection drugs used in renal transplant clinics
There are five kinds of drugs: cyclosporine, prednisone, dexamethasone, methylprednisolone and azathioprine.
II. Scope and standard of basic medical insurance service facilities
(1) Ordinary bed fee
Ordinary bed fee is included in the payment scope of the basic medical insurance pooling fund. Without the overall transformation of the ward for each bed day 16 yuan; After the overall transformation, the ward is 24 yuan per bed day; If the actual fee is lower than the above standard, it shall be paid according to the actual fee.
(2) The bed fee for emergency observation room, rescue ward and blood ward shall be included in the payment scope, and the charging standard approved by the Municipal Price Bureau shall be implemented.
(3) The expenses for bone marrow transplantation and chemotherapy for hematological diseases due to illness need to be admitted to laminar flow ward can be included in the payment scope.
(4) strengthen the ward, according to the Municipal Health Bureau's "Intensive Ward (ICU) Admission Standard" (Jing Weigong [1996] No.8) document.
(5) The bed building fee and bed checking fee for therapeutic family beds established by community health service centers (stations) are included in the payment scope.
(6) heating expenses during hospitalization; By the insured unit according to the relevant provisions to be paid.
III. Basic medical insurance diagnosis and treatment items
(1) The maximum expenses for artificial organs installed in the body are as follows:
1. Pacemakers: 14, yuan per set for single cavity, 18, yuan per set for dual cavity and 6, yuan per set for temporary use;
2. heart valve: 7, yuan for each set of biomembrane and 8, yuan for each set of mechanical membrane;
3. Each intraocular lens is 668 yuan;
4. Artificial joint: 4,5 yuan for each set of artificial hip joint, 5, yuan for each set of artificial knee joint and 3,3 yuan for each set of artificial femoral head;
5. The highest payment standard for installing other artificial organs in vivo is 18, yuan;
if the above actual charges are lower than the above standards, they shall be paid according to the actual charges.
(II) Organ transplantation and tissue transplantation are included in the scope of payment and the cost standards are as follows:
1. The scope of payment is implemented according to Article 3 of the Notice of the Municipal Labor and Social Security Bureau on Further Deepening the Reform of Free Medical Care (No.86 [2] of Beijing Labor and Social Security Bureau);
2. Individuals should pay 2% of the hospitalization expenses for organ transplantation and tissue transplantation, and the rest will be included in the payment scope.
(III) Large-scale medical equipment and medical materials
The reimbursement scope and use of large-scale medical equipment shall be implemented according to Articles 1 to 6 of the Interim Provisions on the reimbursement scope of large-scale medical equipment and expensive medical materials (Jing Weigong [1998] No.14) issued by the Municipal Health Bureau.
Due to illness, the expenses for examination and treatment (including the items approved to be included in the reimbursement scope for single examination and treatment expenses above 2 yuan) using the equipment in Article 2 of the above-mentioned document (included in the reimbursement scope for large medical equipment) shall be borne by the individual first, and then included in the payment scope of the basic medical insurance fund.
(IV) Community Health Service Centers (Stations)
The scope and standard of payment for medical expenses of community health service centers (stations) shall be implemented according to the Notice of the Municipal Labor and Social Security Bureau on Relevant Issues Concerning the Management of Community Health Services for Free Medical Care and Serious Illness Medical Insurance (No.16 [2] of Beijing Labor and Social Security Bureau).
(5) Other
1.X-ray computed tomography and magnetic * * vibration imaging shall be carried out according to the file "X-ray computed tomography technology and magnetic * * * vibration imaging specification" (J.W.G. Zi [1996] No.9) issued by the Municipal Health Bureau;
2. Hyperbaric oxygen therapy shall be implemented according to the document Scope of Medical Reimbursement for Hyperbaric Oxygen Therapy at Public expense (Jing Wei Gong Zi [1996] No.7) issued by the Municipal Health Bureau;
3. The surgical expenses for the treatment of poliomyelitis sequelae are included in the basic medical insurance fund.
(6) related expenses that are not included in the scope of payment by the basic medical insurance fund:
For items that are not paid by the basic medical insurance fund, according to the "On Printing and Distributing < Measures of Beijing Municipality on the Administration of Free Medical Care > Article 4 of the Annex of Notice ([9] Jing Wei Gong Zi No.1) and Article 2 of the Notice of the Municipal Labor and Social Security Bureau on Strengthening the Management of Free Medical Care and Serious Illness Medical Insurance (Jing Lao She Yi Fa [2] No.9).
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