The proportion of hospitalization reimbursement for children's medical insurance in Shenzhen is as follows:
1. Outpatient medical expenses: 80% and 60% of drugs belonging to Class A and Class B in the drug list of basic medical insurance shall be paid by the community outpatient co-ordination fund respectively;
Individual diagnosis and treatment items or medical materials belonging to the basic medical insurance catalogue shall be paid by the community outpatient co-ordination fund for 90%, but the maximum payment amount shall not exceed 120 yuan.
The outpatient medical expenses paid by the community outpatient co-ordination fund to each insured person in the second grade of basic medical insurance within a medical insurance year shall not exceed 1000 yuan at most.
Second, the outpatient expenses for serious illness: insured children can enjoy the outpatient treatment for serious illness, with the highest reimbursement rate reaching 90%.
The proportion of outpatient serious illness treatment is linked to the number of years of continuous insurance. The continuous participation time is less than 12 months, less than 36 months and more than 36 months, and the proportion of medical insurance fund payment is 60%, 75% and 90% respectively.
Third, hospitalization expenses.
1, deductible: the basic medical expenses and local supplementary medical expenses incurred by the insured during hospitalization shall be paid by the insured if the deductible is not exceeded; The part exceeding the deductible shall be paid by the basic medical insurance fund and the local supplementary medical insurance fund in accordance with the regulations.
The deductible line is set according to the hospital level: the hospital below the first level of the city 100 yuan, the second-level hospital 200 yuan, and the third-level hospital 300 yuan;
400 yuan, a medical institution outside the city that handled referral or filing according to regulations, failed to handle referral or filing according to regulations 1 000 yuan. If the insured person is referred to different hospitals for hospitalization, the deductible line shall be calculated respectively.
2. Payment ratio: 90% if the second-class insured of basic medical insurance fails to receive the pension insurance benefits for employees in this city on a monthly basis;
The part of the basic medical expenses paid by the basic medical insurance fund that exceeds its payment limit shall be paid by the local supplementary medical insurance fund within its payment limit;
The basic medical expenses and local supplementary medical expenses incurred by the insured in the designated medical institutions in this Municipality exceed the payment limit of the local supplementary medical insurance fund, and the local supplementary medical insurance fund pays 50%.
legal ground
Article 23 of the Social Insurance Law stipulates that employees should participate in the basic medical insurance for employees, and employers and employees should pay the basic medical insurance premiums in accordance with state regulations. Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.