The medical insurance policy and reimbursement ratio of urban workers in Xi city were compiled. This article is for reference only. If there is any change, please refer to the announcement of official website.
Medical insurance for urban workers shall be coordinated at the municipal level, and policies, standards and procedures shall be unified.
Xi medical insurance policy for urban workers
Xi medical insurance reimbursement ratio
; Insurance reimbursement method:
Medical insurance for ordinary urban residents: 50% for urban residents with household registration in Xi city and 18 years old or older, with the maximum reimbursement limit of 500 yuan. The maximum reimbursement amount is1.4000, excluding the deductible line, which is 55% for tertiary hospitals, 75% for secondary hospitals and 85% for hospitals at or below the first level.
Reimbursement of children: the proportion of children's overall fund payment is increased by 5% according to the corresponding standard of urban non-employed residents.
Medical insurance for urban employees: part of the medical insurance premiums paid by urban employees and individual employees are credited to personal accounts (medical insurance cards) for purchasing medicines. The maximum reimbursement for hospitalization is 400,000 yuan.
The target of the new rural cooperative medical system: The maximum reimbursement for each farmer in Xi 'an is 6.5438+0.5 million yuan per year, of which the maximum compensation for hospitalization is 6.5438+0.3 million yuan, and the remaining 20,000 yuan is for outpatient and chronic diseases.
_ employee _
In a statistical year, the Qifubiaozhun of the overall fund shall be determined according to a certain proportion of the average salary of employees in the previous year of this Municipality and according to the hospital level and the number of employees hospitalized. The hospitalization expenses incurred by employees (including retirees) participating in the basic medical insurance for urban workers in our city in designated medical institutions shall be adjusted from more than 50,000 yuan to 5% of the maximum payment limit.
Qifubiaozhun for first-class hospitals:
The first time: level III hospital 10%, level II hospital 8%, level I hospital 6%;
The second time: 7% in tertiary hospitals, 5% in secondary hospitals and 4% in primary hospitals;
Third time and above: 5% in tertiary hospitals, 4% in secondary hospitals and 3% in primary hospitals.
The part of hospitalization medical expenses below each Qifubiaozhun shall be paid by personal account or by myself.
Employee individual payment ratio:
The minimum threshold is above 1 10,000 yuan: level-1 hospital 10%, level-2 hospital 12%, level-3 hospital15%;
10000 yuan to 50000 yuan: 6% in a first-class hospital, 8% in a second-class hospital, and11%in a third-class hospital;
More than 50,000 yuan to the maximum payment limit: 5%;
The proportion of individual contributions of retired (post) personnel is reduced by three percentage points according to the corresponding standards of on-the-job employees.
Retirees' individual self-payment ratio:
The minimum threshold of 1 10,000 yuan or more: level-1 hospital 12%, level-2 hospital 9%, level-3 hospital 7%;
10000 yuan to more than 50000 yuan: 3% in first-class hospitals, 5% in second-class hospitals and 8% in third-class hospitals;
More than 50,000 yuan to the maximum payment limit: 5%;
; Special outpatient items:
1. Outpatient treatment of special diseases (radiotherapy and chemotherapy for malignant tumor, outpatient renal dialysis, taking anti-rejection drugs after organ transplantation): 50% from the overall fund and 50% from individuals.
2. Outpatient treatment of chronic diseases (hypertension, coronary heart disease, diabetes): In one year, if the medical expenses for outpatient treatment of chronic diseases in designated medical institutions exceed 350 yuan, the excess will be paid by the overall fund according to the standard of 50%, and the maximum payment limit of the overall fund is 2,000 yuan.
; Hospitalization:
Township and first-class designated hospitals, compliance costs below 300 yuan, no deductible, reimbursement of 60%; If the total fee is above 300 yuan (including 300 yuan), the deductible line is 80 yuan, and the compensation ratio is 90%.
District-level and secondary designated medical institutions (including municipal designated secondary medical institutions) within the territory of the district (county), 200 yuan as the deductible line and 500 yuan outside the district (county), and the compensation ratio is 70%-80%.
The deductible line of municipal designated tertiary medical institutions is 1000 yuan, and the compensation ratio is 50%-60%.
Reimbursement ratio
; Reimbursement scope:
1, insured residents are treated in designated medical institutions (including family beds).
2, the insured in the designated medical institutions, retail pharmacies.
; Seven situations cannot be reimbursed.
1, medical expenses incurred in non-designated medical institutions without approval.
2, except suicide, self-mutilation (mental illness).
3, fighting, fighting, alcoholism, drug abuse and other criminal acts that cause injuries or violate the "Public Security Administration Punishment Law"
4. Traffic accidents, accidental injuries, medical accidents, etc.
5, due to beauty, plastic surgery, physical defects and other treatment.
6. Belonging to the scope of work-related injury insurance (including occupational diseases) or maternity insurance.
7, the national and provincial medical insurance policies and other non payment.
; Reimbursement conditions:
1, normal insurance payment (indicating the insurance payment status at the time of hospitalization) and the treatment review expires (unit insurance payment is 30 days, and individual insurance payment is 6 months).
2, the disease conforms to the "basic medical insurance inpatient disease directory"
3. Complete information
; Reimbursement materials:
1, "Xi basic medical insurance general hospitalization certificate"
2. Home page of inpatient medical records (stamped with the seal of the hospital and kept the original)
3, discharge records (stamped with the seal of the hospital, leave the original)
4, diagnosis certificate (stamped with the seal of the hospital, leave the original)
5, financial bills (stamped with the hospital financial chapter, leave the original)
6, the cost list (stamped with the seal of the hospital, leave the original)
7. My ID card (check the original and keep a copy)
8. Prepare the applicant's own bank card or passbook (it must be a local card or passbook, and you should know the accurate bank information, check the original and keep a copy).
9. Entrusted to provide the ID card of the trustee (original inspection)
; Medical insurance settlement in different places:
Shaanxi province has basically realized the settlement of medical insurance in different places in the province. At present, workers from all cities in the province have achieved direct settlement in different places when they go to An for medical treatment, and some have achieved direct settlement in different places from An to Xianyang and Ankang. In the next step, they will also realize direct settlement in different places according to their needs.
Xi female maternity insurance
; Xi maternity insurance reimbursement conditions have the following two situations:
(a) in line with the national family planning policy or the implementation of family planning surgery.
(two) the unit in accordance with the provisions for employees to participate in maternity insurance and full payment for more than one year.
The reimbursement scope of maternity insurance includes the following aspects:
If the employer participates in maternity insurance in accordance with the regulations and pays in full and on time, the employees (female employees) who meet the relevant family planning policies can enjoy the following maternity insurance benefits, and the maternity medical expenses are subject to fixed subsidies.
1, maternity medical expenses (including prenatal check-up, delivery, blood transfusion, operation, hospitalization and medicine) subsidy standard:
For more than 7 months of pregnancy (including 7 months) delivery or premature delivery less than 7 months of pregnancy, the subsidy standard for medical expenses for hospitalization delivery is:
1 The maximum subsidy for medical expenses of cesarean section shall not exceed 6000 yuan.
The maximum subsidy for medical expenses of vaginal delivery shall not exceed 4000 yuan.
For spontaneous abortion and artificial termination of pregnancy for more than 3 months (including 3 months) and less than 7 months, the maximum subsidy for maternity medical expenses shall not exceed 1000 yuan.
For spontaneous abortion and artificial termination of pregnancy for less than 3 months, the maximum subsidy for maternity medical expenses shall not exceed that of 350 yuan.
2, and other expenses related to maternity insurance subsidy standards:
The spouses of male employees participating in maternity insurance are non-urban employees who have not participated in maternity insurance, and the maternity medical expenses of female employees are subsidized by the maternity insurance fund by 50%.
Female workers who participate in maternity insurance, after the implementation of conservative treatment of ectopic pregnancy, the maximum subsidy standard is not more than 4000 yuan; The maximum subsidy standard for surgical treatment does not exceed 6000 yuan.
3, maternity complications subsidies:
Workers who have one of the following complications due to childbirth shall be given medical assistance of no more than 2,000 yuan while enjoying maternity insurance benefits. At the same time suffering from two or more birth complications, Medicaid does not exceed 3000 yuan.
Reproductive complications (26 kinds): pregnancy-induced hypertension syndrome, intrahepatic cholestasis of pregnancy, placenta previa, placental abruption, maternal-infant blood group incompatibility, gestational diabetes, uterine rupture, amniotic fluid embolism, postpartum hemorrhage, puerperal infection, postpartum urinary retention, mastitis, hyperemesis gravidarum, contour placenta, vascular previa, polyhydramnios, oligohydramnios, premature rupture of membranes, intrauterine growth retardation of fetus, cervix.
4, the implementation of family planning operation subsidy standard:
The maximum subsidy for placing (removing) intrauterine devices and subcutaneous implants (removing subcutaneous implants) shall not exceed that of 300 yuan.
The maximum subsidy for sterilization shall not exceed 1000 yuan.
The maximum subsidy for fallopian tube or vas deferens recanalization shall not exceed 1500 yuan.
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Proportion and scope of medical insurance reimbursement:
1, outpatient and emergency medical expenses: the medical expenses that met the requirements of the basic medical insurance in that year (1 10/February/31February) exceeded 2,000 yuan.
2. Settlement ratio: 50% of the part of the dispatched personnel above 2,000 yuan will be reimbursed during the contract period, and 50% will be paid by the individual; Within one year, the maximum amount of accumulated reimbursement for outpatient and emergency services of dispatched personnel is 20,000 yuan.
3. The insured shall properly keep the medical documents (including receipts and prescriptions for large amounts) in the outpatient department of the designated hospital. ), as a medical expense reimbursement certificate.
4. Outpatient treatment of three kinds of special diseases: when the insured person needs to take anti-rejection drugs after radiotherapy and chemotherapy for malignant tumor, renal dialysis and renal transplantation, the second-and third-level designated hospitals where the insured person is treated will issue the Certificate of Disease Diagnosis, fill in the Application and Approval Form for Special Diseases of Medical Insurance, and report it to the district medical insurance center for approval and filing. Outpatient treatment and drug collection for these three special diseases are limited to designated hospitals that have approved treatment, and cannot be purchased in designated retail pharmacies. The medical expenses incurred meet the prescribed scope of outpatient special diseases, with reference to hospitalization settlement.
5, hospitalization, medical insurance paid for 20 years, can enjoy medical insurance reimbursement after retirement.