The qifubiaozhun of primary medical and health institutions is 150 yuan, and the reimbursement ratio is 90% for on-the-job employees and 95% for retired employees;

The Qifubiaozhun for secondary medical institutions is 87% for employees and 92% for retired employees within 600 yuan.

The qifubiaozhun of tertiary medical institutions is 900 yuan, and the reimbursement rate is 85% for on-the-job employees and 90% for retired employees.

Qifubiaozhun for referral outside the city is 1200 yuan, and normal referral (including emergency and mental illness) is paid according to the payment ratio of medical institutions at the same level;

Employees in the city need not go through referral and filing procedures when they are hospitalized in designated medical institutions in the city. The hospitalization medical expenses incurred within the scope of the policy shall be implemented according to the current Qifubiaozhun and reimbursement ratio of the corresponding medical institutions. The maximum annual payment limit of the overall fund is 80,000 yuan.

Proportion of maternity payment for female employees: prenatal examination: 1200 yuan/case; Natural delivery: 3,000 yuan/case; Midwifery: 3600 yuan/case; Cesarean section: 4500 yuan/case; Cesarean section and related gynecological surgery: 5000 yuan/case.

During the hospitalization of the insured patient, the deductible is calculated continuously within 72 hours due to illness. If the insured patient is referred to a higher-level designated medical institution for treatment by a lower-level designated medical institution, the deductible is charged according to the difference between the lower-level designated medical institution and the higher-level designated medical institution;

If the insured patient is referred between medical institutions at the same level in the city or referred by a designated medical institution at a higher level to a designated medical institution at a lower level for treatment, the deductible will no longer be charged. The insured is hospitalized for the second time this year and later, and the deductible is reduced by 50%.

Outpatient co-ordination (implemented from July 1 day, 2022): Insured persons who meet the requirements of employee medical insurance hospitalization co-ordination can enjoy general outpatient co-ordination treatment. Qifubiaozhun is set according to time, and there is no Qifubiaozhun for tertiary medical institutions in 50 yuan, secondary medical institutions in 40 yuan and primary medical institutions (including township hospitals and community health service centers).

The maximum monthly payment limits for employees and retirees are 150 yuan and 200 yuan respectively, and the maximum annual payment limits are 1500 yuan and 2,000 yuan respectively. On-the-job employees need to pay 50% for medical treatment in the outpatient department of tertiary designated medical institutions, 55% for medical treatment in the outpatient department of secondary designated medical institutions and 60% for medical treatment in the outpatient department of primary designated medical institutions.

The contribution rate of retirees is higher than that of employees 10 percentage point. Insured persons can enjoy general outpatient co-ordination and outpatient chronic diseases, outpatient specific drug treatment at the same time, but do not enjoy general outpatient co-ordination treatment during hospitalization, and general outpatient expenses are not included in the scope of civil servants' Medicaid.

The general outpatient expenses incurred by the insured during the period of arrears shall not be paid by the overall fund, and the general outpatient treatment shall not be supplemented if the arrears are paid.

Outpatient chronic diseases: medical institutions designated by the municipal and county (district) medical security departments recognize each other, and the insured person can directly settle the purchase of medicines.

The employees of this Municipality who are insured by medical insurance can choose designated medical institutions to use personal accounts to seek medical treatment and purchase medicines in this Municipality, and make real-time settlement. Not restricted by the insured place, enjoy the same treatment in the same city.

Outpatient patients with chronic diseases are treated in outpatient service, and there is no deductible line, and the payment limit management is implemented. The proportion of fund payment is 70% (the handling method is the same as that of residents).

Chronic diseases in outpatient department of basic medical insurance for urban workers in Kaifeng: 1, sequelae of cerebrovascular accident; 2. Allogeneic organ transplantation; 3. Heart failure; 4. Cirrhosis; 5. After stent implantation in vivo (payment 1 year); 6. Systemic lupus erythematosus; 7. Tuberculosis (paid for 2 years); 8. Rheumatoid arthritis; 9. Myasthenia gravis; 10, femoral head necrosis; 1 1, stage III hypertension; 12, myelodysplastic syndrome; 13, lumbar spinal stenosis (payment 1 year); 14, coronary heart disease; 15, obstructive emphysema; 16, malignant tumor (except serious diseases); 17, complications of chronic diabetes; 18, epilepsy; 19, ankylosing spondylitis; 20. Parkinson's syndrome; 2 1, after heart bypass surgery (payment 1 year); 22, rehabilitation (central nervous system injury, shoulder, hip, knee fracture); 23. Schizophrenia; 24. Mental disorders caused by epilepsy; 25. Mental retardation with mental disorder; 26, bipolar disorder; 27. Depression; 28, schizophrenia; 29. Persistent delusional disorder; 30. autoimmune hepatitis; 3 1, primary Sjogren's syndrome; 32. Chronic renal failure (non dialysis treatment); 33. Hypothyroidism;

Outpatient critical illness: 85% (90% of retirees) is paid by the urban workers' outpatient critical illness fund, and 90% (95% of retirees) is paid by peritoneal dialysis.

The original "serious illness insurance for urban employees" was renamed as "subsidy for large medical expenses for employees", and the financing standard was 180 yuan per person per year. The proportion of payment within insurance liability is 90% for hospitalization and 90% for outpatient chronic diseases, and the annual maximum payment limit is 420,000 yuan.

Persons with poor population status, low-income households, returning to poverty, members of marginal families with low-income allowances, people who are easy to return to poverty in rural areas, and those who are seriously ill due to illness and participate in the basic medical insurance for urban workers are included in the scope of medical assistance, and the policies they enjoy refer to urban and rural residents.

The financing standard of long-term care insurance is 120 yuan per person per year, in which the unit bears 60 yuan and the individual pays 60 yuan. Insured persons who meet the following conditions at the same time and are identified as severely disabled after application can enjoy long-term care insurance benefits according to regulations.

When applying for long-term care insurance benefits, the insured shall pay the basic medical insurance premium for employees in full for more than 2 years, and have participated in long-term care insurance and paid in full.

Medical institutions and rehabilitation institutions have standardized diagnosis and treatment, and the disability has lasted for more than 6 months, requiring long-term nursing services. Long-term care insurance is divided into institutional care, home care and home independent care.

(1) Institutional nursing refers to the service form in which the insured enjoys basic living care and closely related medical care in the nursing beds of medical institutions and pension institutions. The proportion of fund payment is 65%, and the monthly payment limit is 1900 yuan/person.

(2) Home-based care for the aged refers to medical institutions, old-age care institutions and nursing service institutions that provide basic life care and closely related medical care services for the insured at home through home-based care for the aged. The proportion of fund payment is 75%, and the monthly payment limit is 1500 yuan/person.

(3) Home-based self-care refers to the service form that the relatives of the insured provide care for the insured together with the on-site nursing staff of the nursing service institution after passing the training. The monthly payment limit of the fund is 900 yuan/person, in which the monthly payment limit of the insured person is 450 yuan/person, and the monthly payment limit of the nursing service institution is 450 yuan/person. The insured person can choose a form of nursing service during the period of enjoying the treatment, and the service form can be converted. The insured person does not enjoy long-term care insurance during hospitalization.

Fully support the poor, and give quota support to low-income people, severely disabled people and people returning to poverty. The subsidy standard is 80 yuan per person per year, and the rural population that is easy to return to poverty is given a fixed amount of support. The subsidy standard is 50 yuan per person per year.

(1) Basic medical insurance

1. hospitalization qifubiaozhun and payment proportion: the qifubiaozhun for primary medical and health institutions is 150 yuan, and the payment proportion is 85%; The qifubiaozhun of secondary medical institutions is 600 yuan, and the payment ratio is 70%; The qifubiaozhun of tertiary medical institutions is 900 yuan, and the payment ratio is 60%; Referral: Qifubiaozhun in the province 1200 yuan, Qifubiaozhun outside the province is 2000 yuan. Normal referral (including emergency and mental illness) is paid according to the proportion of medical institutions at the corresponding level; Abnormal referral is reduced by 20% according to the corresponding level of medical institutions.

2. Insured residents are hospitalized in designated medical institutions in the city, and there is no need to go through referral and filing procedures. The hospitalization medical expenses incurred within the scope of the policy are implemented according to the current Qifubiaozhun and reimbursement ratio of the corresponding medical institutions. The maximum annual payment limit of the overall fund is 6,543,800 yuan+0.5 million yuan.

3. The first-level hospital for normal delivery shall be reimbursed according to 600 yuan, the second-and third-level hospitals shall be reimbursed according to the quota 1.200 yuan, and the caesarean section shall be reimbursed according to 1.600 yuan.

4. During the hospitalization of the insured patients, the deductible is calculated continuously within 72 hours due to illness. If the insured patient is referred to a higher-level designated medical institution for treatment by a lower-level designated medical institution, the deductible is charged according to the difference between the lower-level designated medical institution and the higher-level designated medical institution; If the insured patient is referred between medical institutions at the same level in the city or referred by a designated medical institution at a higher level to a designated medical institution at a lower level for treatment, the deductible will no longer be charged. The insured is hospitalized for the second time this year and later, and the deductible is reduced by 50%.

(2) Serious illness insurance for urban and rural residents

Medical expenses with large medical insurance costs for urban and rural residents can also enjoy medical insurance benefits for urban and rural residents after reimbursement of basic medical insurance. Those who bear the hospitalization expenses of 1 10,000 yuan or more that meet the requirements shall be reimbursed according to the following standards, of which 1 10,000 yuan-6,543.8+10,000 yuan (including 6,543.8+10,000 yuan) will be partially reimbursed, and 70% will be reimbursed for the part above 6,543.8+10,000 yuan. You can reimburse up to 400,000 a year. For the poor population, low-income population and poor people returning to poverty, we will implement inclined security policies such as reducing the deductible line of serious illness insurance by 50%, increasing the payment ratio by 5 percentage points, and canceling the annual maximum payment limit.

(3) Medical assistance

Medical assistance expenses mainly cover the hospitalization expenses incurred by the aid recipients in designated medical institutions, the expenses that need long-term medication due to chronic diseases or long-term outpatient treatment due to major diseases. Out-of-pocket medical expenses within the following policies of basic medical insurance and critical illness insurance deductible line shall be included in the scope of rescue expenses according to regulations.

1. Hospitalization assistance. For poor people, low-income households and people returning to poverty, there is no minimum threshold for hospitalization assistance (during the five-year transition period). The minimum threshold for hospitalization assistance for rural marginal family members and poor people is 2,000 yuan, and the minimum threshold for hospitalization assistance for poor patients with serious illnesses is 5,000 yuan. For the hospitalization expenses incurred in designated medical institutions, 90% of the poor people are given assistance, 70% of the low-income people and the extremely poor people are given assistance, and 65% of the low-income marginal family members, rural poor people who are easy to return to poverty and seriously ill patients are given assistance according to their applications.

2. Outpatient assistance. Outpatient rescue diseases include the following nine categories: end-stage renal disease (outpatient hemodialysis or peritoneal dialysis treatment), hemophilia (coagulation factor treatment), chronic myeloid leukemia (outpatient tyrosine kinase inhibitor treatment), type I diabetes (outpatient insulin treatment), multidrug-resistant tuberculosis (outpatient anti-tuberculosis drug treatment), aplastic anemia (outpatient drug treatment), outpatient radiotherapy and chemotherapy for malignant tumors, anti-rejection treatment after organ transplantation, and severe mental patients. There is no threshold for outpatient assistance. The outpatient treatment expenses of the above nine diseases in designated medical institutions are paid by residents' basic medical insurance and serious illness insurance, and they are paid within the scope of the policy. 50% assistance is given to poor people, low-income objects and people returning to poverty, and 30% assistance is given to marginal family members of low-income families, people who are easy to return to poverty in rural areas and seriously ill people who are poor due to illness.

3. decompression limit. Hospitalization assistance and outpatient assistance * * * use the annual maximum assistance limit. The maximum annual relief limit for destitute people, low-income households and people returning to poverty is 30,000 yuan, and the maximum annual relief limit for marginal family members of low-income families, people who are easy to return to poverty in rural areas and seriously ill patients who are poor due to illness is 6,543,800 yuan.

4. Tilt rescue. For those who have been referred to hospitals in the province for medical treatment, the amount of assistance has reached the annual maximum assistance limit, and 90% of out-of-pocket expenses within the policy scope after the comprehensive guarantee of the triple system exceed 1 10,000 yuan, and the annual maximum assistance limit is 1 10,000 yuan.

(a) general outpatient and outpatient medical insurance benefits.

1. The reimbursement rate of basic medical insurance for urban and rural residents in general outpatient clinics is 60%, and there is no deductible line, and the highest reimbursement can be made to 440 yuan in the whole year.

2. Patients with hypertension and diabetes can enjoy the highest medical reimbursement treatment in 200 yuan during the year. (Do not repeat the treatment of chronic diseases and special diseases in outpatient department)

(2) Outpatient medical treatment for chronic diseases

Disease range: 1. Organ transplantation; 2. Complications of chronic diabetes; 3. Malignant tumor (except serious illness); 4. Sequela of cerebrovascular accident; 5. Liver cirrhosis; 6. Obstructive emphysema; 7. Systemic lupus erythematosus; 8. After in vivo stent implantation (payment 1 year); 9. Heart failure; 10. Parkinson's syndrome; 1 1. Tuberculosis (paid for 2 years); 12. Ankylosing spondylitis; 13 rheumatoid arthritis; 14. epilepsy; 15. Schizophrenia; 16. Persistent paranoid disorder; 17. Mental disorders caused by epilepsy; 18. Schizophrenia; 19. Depression (new); 20. Mental retardation with mental disorder; 2 1. Bipolar disorder; 22. Rehabilitation of children with cerebral palsy; 23 chronic renal failure (non dialysis treatment); 24. Coronary atherosclerotic heart disease; 25. Lumbar spinal stenosis (payment 1 year); 26. autoimmune hepatitis; 27. Primary Sjogren's syndrome; 28. Rehabilitation treatment (central nervous system injury, shoulder, hip and knee fractures).

The reimbursement rate of chronic diseases in urban and rural clinics is 65%, and there is no deductible line and fixed-point treatment, and quota management.

Treatment method:

1. The insured applies to the designated medical institution (hereinafter referred to as the appraisal institution) above the second level that undertakes the appraisal of chronic diseases in outpatient service (tuberculosis is appraised by the county CDC), and submits the following materials when applying: (1) Application Form for Chronic Diseases in Outpatient Service of Kaifeng Basic Medical Insurance; (2) A copy of my ID card or social security card; (3) Apply for outpatient medical records of chronic diseases in recent two years or half a year, including special treatment records or operation records, relevant inspection and inspection reports (including inspection reports of complications). If the application materials have been included in the medical record management of medical institutions, a copy of the seal of the medical institution can be provided; (4) Two recent 1 inch bareheaded photos.

2. identification. The appraisal institution shall immediately accept the application of the insured, and timely organize experts to conduct appraisal in accordance with the "Kaifeng outpatient chronic disease appraisal standard", and the longest time shall not exceed 20 working days. Seven kinds of mental diseases (including schizophrenia, schizoaffective disorder, persistent delusional disorder, bipolar disorder, mental disorder caused by epilepsy, mental retardation with mental disorder and depression) within the scope of outpatient chronic diseases that insured patients apply for do not need to be identified. After being reported by a designated medical institution with corresponding qualifications, they can directly enjoy outpatient chronic disease treatment with the diagnosis certificate issued by a psychiatric hospital or the Certificate of Management and Treatment of Severe Mental Disorder (established by the County Health and Health Commission).

3. publicity. Appraisal institutions will publicize the appraisal results and accept social supervision.

4. enter. Identification agencies will timely input patients with chronic diseases into the medical insurance information management system, and make a "Kaifeng outpatient chronic disease medical card" to the insured.

(1) Hospitalization for serious and serious diseases

1. Standard risk group and moderate risk group of childhood acute lymphoblastic leukemia; 2. Acute promyelocytic leukemia in children: 3. Congenital atrial septal defect in children; 4. Congenital ventricular septal defect in children; 5. Congenital patent ductus arteriosus in children; 6. Congenital pulmonary valve stenosis in children; 7. Congenital endocardial cushion defect; 8. Partial endocardial cushion defect; 9. Aortic valve stenosis; 10. Tetralogy of Fallot; 1 1. Atrial septal defect with ventricular septal defect; 12. Ventricular septal defect with right ventricular outflow tract stenosis; 13. Ventricular septal defect with patent ductus arteriosus; 14. Ventricular septal defect, patent ductus arteriosus with pulmonary valve stenosis; 15. Atrial and ventricular septal defects with patent ductus arteriosus; 16. Cleft lip; 17. Cleft palate; 18. Breast cancer; 19. Cervical cancer; 20. Lung cancer; 2 1. Esophageal cancer; 22. Gastric cancer; 23. Colon cancer; 24. Rectal cancer; 25. Acute myocardial infarction; 26. Chronic myeloid leukemia (hospitalization) 27. Severe mental illness (including bipolar disorder, schizophrenia, persistent delusional disorder, schizoaffective disorder and depression); 28. Multidrug-resistant tuberculosis (hospitalization); 29. Bilateral severe sensorineural deafness; 30. Hypospadias; 3 1. Congenital hypertrophic pyloric stenosis; 32. Developmental dislocation of hip joint; 33. Tethered spinal cord syndrome/myelocele;

(2) Outpatient medical treatment for major diseases.

1. End-stage renal disease; 2. Hemophilia; 3. Chronic myeloid leukemia (outpatient treatment); Type 2 diabetes; 5. hyperthyroidism; 6. Multidrug-resistant tuberculosis (outpatient treatment); 7. Aplastic anemia; 8. Non-small cell lung cancer; 9. Gastrointestinal stromal tumor; 10. Acute promyelocytic leukemia; 1 1. Colon cancer; 12. mantle cell lymphoma; 13. Gastrointestinal pancreatic endocrine tumor; 14. Breast cancer; 15. Advanced gastric cancer; 16. Nasopharyngeal carcinoma; 17. Peripheral T cell lymphoma; 18. Advanced renal cell carcinoma; 19. Neuroendocrine tumor of pancreas; 20. Liver cancer; 2 1. Multiple bone marrow cancers; 22. Phenylketonuria (classic phenylketonuria, tetrahydrobiopterin deficiency); 23. Rectal cancer; 24. Small lymphocytic lymphoma; 25. Chronic lymphocytic leukemia; 26. Multiple sclerosis; 27. Macular degeneration; 28. Amyotrophic lateral sclerosis; 29. Primary immunoglobulin deficiency; 30. Idiopathic pulmonary fibrosis; 3 1. Renal angiomyolipoma; 32. Thyroid cancer; 33. Prostate cancer; 34. Melanoma; 35. Acromegaly;

(3) Reimbursement policy of medical insurance for serious and serious diseases

There is no deductible for serious illness hospitalization of urban and rural residents, and the reimbursement rate of secondary medical institutions is 80%, and that of tertiary medical institutions is 70%; The reimbursement rate of outpatient peritoneal dialysis is 85%, and that of other outpatient diseases is 80%.

First, follow the principle of coordinating funds, finance and individuals, and raise funds according to the standard of 40 yuan/person/year. Among them, the basic medical insurance fund for urban and rural residents is transferred to 20 yuan/person/year; Financial subsidy 10 yuan/person/year, which shall be arranged by the finance at the same level; Individual contributions 10 yuan/person/year, which will be collected when paying the basic medical insurance for urban and rural residents; The medical insurance and financial departments shall dynamically adjust the fund-raising methods, fund-raising standards and treatment levels according to the economic and social development and fund operation. Financing measures for poor people and other groups with special difficulties shall be formulated separately;

Two. Treatment standard During the period when the insured enjoys the treatment, the nursing expenses that meet the requirements shall be paid by the fund according to the facts, and the part exceeding the limit shall be borne by the insured. The specific standards are as follows: the monthly payment limit of institutional nursing fund is 1.300 yuan/person; The monthly payment limit of home-based pension fund is 1300 yuan/person; The monthly payment limit of the home self-care fund is 540 yuan/person, of which the monthly payment limit of the insured is 270 yuan/person; The monthly limit for paying nursing service institutions is 270 yuan/person.