First, hospitalization medical insurance benefits, basic medical expenses above Qifubiaozhun, pooling funds to pay according to the following proportion:

(1) Minors and students at school are paid according to the proportion of 85% in first-class medical institutions, 75% in second-class medical institutions and 65% in third-class medical institutions.

(2) Other urban and rural residents pay 85% in primary medical institutions, 70% in secondary medical institutions and 55% in tertiary medical institutions.

Two, outpatient treatment of chronic diseases, the insured in accordance with the provisions of the outpatient designated chronic disease outpatient specialist drug costs, the overall fund according to the proportion of primary medical institutions to pay 70%, other designated medical institutions to pay 50%. Co-ordinate the fund to pay the highest 50 yuan per person per disease month, and the excess will be paid by the insured.

Three, outpatient medical insurance benefits, the insured in accordance with the provisions of the general outpatient drug costs, paid by the overall fund in accordance with the following provisions:

(a) minors and students in the selected primary medical institutions for medical treatment according to the proportion of 80% payment; Within 30 days after referral from designated medical institutions at the grass-roots level, other designated medical institutions and designated specialized medical institutions pay 50% for medical treatment; Without referral from designated medical institutions at the grass-roots level, 40% will be paid directly to other designated medical institutions and designated specialized medical institutions for medical treatment.

(two) other residents in the selected primary medical institutions outpatient treatment according to the proportion of 60% payment.

(three) the insured in the implementation of the basic drug system approved by the health department, and the implementation of the zero-difference sales of basic drugs in designated medical institutions for medical treatment, the general medical expenses paid 70%.

(four) the overall fund to pay for the general outpatient medicine, minors and students per year does not exceed 65,438+0,000 yuan, other urban and rural residents per year does not exceed 600 yuan. ：

Implementation Plan for Establishing and Perfecting the Outpatient Security Mechanism of Basic Medical Insurance in Shandong Province

Article 2 Objectives and tasks

(a) to establish and improve the overall security mechanism for general outpatient service. Gradually include the general outpatient expenses of frequently-occurring diseases and common diseases into the scope of payment of the overall fund. In cities that have not yet carried out general outpatient co-ordination, before the end of 2022, it is necessary to comprehensively establish a general outpatient co-ordination system covering all employees' medical insurance, and ensure the basic outpatient medical needs of the people in a fair and inclusive manner; Cities that have carried out general outpatient co-ordination should further refine and improve policies and standardize outpatient security management measures. Municipalities should combine the implementation of the province's unified medical security treatment list system to ensure the unity of the general outpatient service in terms of security content and treatment payment within the city, and do a good job in connecting with the outpatient chronic diseases and hospitalization payment policies.

(2) Scientifically formulate the payment policy for general outpatient treatment of employees. Scientifically set the annual minimum payment standard, payment ratio and maximum payment limit of the employee medical insurance outpatient co-ordination fund. Qifubiaozhun accumulated in the current year, not higher than 2% of the average wage of employees in full-caliber urban units in the province (hereinafter referred to as the average annual wage of employees in the province). Different levels of medical institutions should set differentiated qifubiaozhun. Within the scope of the policy, the proportion of payment shall be no less than 50% for employees, and the retirees shall be determined by an average of 5 percentage points higher than the employees; Differentiated payment ratios can be set for different levels of designated medical institutions, and they should be appropriately inclined to primary medical institutions, and the difference in payment ratios should not be less than 10 percentage point. In principle, the annual maximum payment limit is controlled at about 5% of the average annual salary of employees in the province. With the strengthening of the medical insurance fund's affordability, the level of protection will be gradually improved.