Mr. Guoxin gave a detailed answer to all the hot issues that medical insurance is generally concerned about.
1. What is the personal account of basic medical insurance?
Personal account is established by the medical insurance institution of the insured. The insured's personal account fund rights and interests, outpatient medical expenses and pharmacy purchase drugs. And can be carried forward and inherited.
2. What is a self-funded drug? What is the self-funded project?
drugs that do not belong to the essential drugs list, such as health care drugs, are self-funded drugs, not reimbursement scope.
The reimbursement process of basic medical insurance, the list of CPI drugs and Class B drugs, among which Class B drugs are listed, they need to spend 2% of the cost, which is a self-funded project. In addition, special medical expenses, such as CT and MRI, are also a self-funded project.
3. How is a natural year divided?
January 1st to December 31st is a calendar year. If you were hospitalized on December 3, 24 and discharged on January 5, 25, then the reimbursement amount involved in 25.
4. How to choose a designated hospital? If I choose to be treated in a hospital, does it mean that it is fixed after treatment in this hospital?
Designated hospitals are the review of cooperation agreements confirmed and signed by labor and social security departments and social security institutions of hospitals. You can choose a suitable designated hospital according to your own needs, there is no fixed one.
5. I need to be reimbursed after I leave the hospital. What kind of information do you need to provide? Is there a time limit?
if your hospital computer is connected to the social security bureau? The direct settlement and discharge through drawing card, and the comprehensive promotion of network hospital after discharge, are related to the reimbursement of social security bureau.
If you are admitted to a hospital in the city, you should go to the Social Security Bureau for reimbursement within two months after discharge; Outside the city, go to the social security bureau for reimbursement within 3 months after discharge. The reimbursement place is on the third floor of Chengdu Social Security Bureau. I need to bring my social security card, ID card, discharge certificate, list of expenses and invoices. Working hours are from 9: to 12:, every Monday to Friday, and from 13: to 5:.
Case analysis
It's more complicated. Because of the provisions of the basic medical insurance, in order to better understand the policy, we use case analysis to explain. The basic medical insurance is mainly divided into two parts: outpatient service and hospitalization. Let's explain separately.
A, hospitalization reimbursement
In general, living in a hospital, rather than living in a higher proportion, is reimbursed by a tertiary hospital, and the reimbursement is even greater.
less than 46, yuan, Chen, 4 years old, was hospitalized in a designated hospital for medical expenses, which cost 3, yuan at a time (regardless of his own expenses and special expenses). Well, Chen You has basic medical insurance, and the reimbursement amount at this time is:
(3-884× 12% )× [(75+4× .2) ÷ 1] = 2929.92× 83 (%) = 24. 94.83 yuan
The personal cost is:
3-2494.83 = 595.17
If you live in a designated hospital, the reimbursement amount is:
(3-884× 5% )× (75+4× .2). More than 46, yuan Liu 5 years old 3,-24,564.51 = 5,435.49 yuan
For example, one-time medical expenses in a designated hospital cost 6, yuan (excluding self-funded and special expenses). The formula should reimburse the basic medical expenses:
(6-884× 5% )× [(75+5× .2) ÷ 1 = 5929.92× 85% = 5175.43 yuan
BR /> However, according to the stipulated basic medical insurance, the total amount of reimbursement in a natural year can not exceed four times the average salary of the city last year, which is 46,336 yuan in Chengdu at present. The reimbursement cost of Liu's formula exceeds the upper limit.
So, at this time, the actual reimbursement expenses are 46,336 yuan, and the expenses to be borne by individuals are: < p p> 6-46336 =13664 yuan
B, outpatient reimbursement
Social security institutions, and individual accounts for basic medical insurance are established for each insured. The amount in my personal account is used to buy medicine at the pharmacy or outpatient medical expenses with my credit card and the hospital pays the part according to the regulations. Outpatient service, the balance of personal account is paid in cash, and my savings can be inherited according to law.
Next, we introduce the employees, retirees and freelancers.
On-the-job employees
First of all, my monthly salary is included in all personal payments (that is, 2%) in my personal account, so part of the premiums paid also includes my personal account. The formula for the monthly increase of personal account is:
5-year-old worker: (my monthly salary × 2%)+(my monthly salary * .2% * my age)
5-year-old worker's example (my monthly salary × 2%)+(my monthly salary is .35% x my age)
Wang. The total monthly amount should include Wang's personal account: (1,× 2%)+(1,× .2 %× 3) = 26 < P > Jiang is 52 years old with a monthly salary of 1,2 yuan. The total monthly amount should include Jiang's personal account: (12× 2%)+(12× .35 %× 52) = 24 21.84 = 45.84 yuan
The calculation formula for the monthly increase of retirement
is:
Last year, the average monthly salary of employees in the city× 2%+last year.
Zhang, 61 years old, has a monthly pension of 1 yuan (Chengdu, the average monthly salary of workers is more than 965 yuan, last year), which should be included in the monthly personal account:
(1,× 2%)+(1,× .35 %× 61) = 41.35 yuan
Huang's old basic old-age pension insurance. The monthly amount should be credited to Huang Yuxi's personal account:
(965× 2%)+(965× .35 %× 62) = 4.3 yuan
Free
The calculation method of the monthly increase in personal account is as follows:
5-year age: the average monthly salary of the city× 2%+the average monthly salary of the city× . (The average monthly salary in Chengdu is 965 yuan)
For example, Zhu, the total amount of the monthly personal account of a 4-year-old freelancer should be:
(965× 2%)+(965× .2 %× 4) = 19.37.72 = 27.2 yuan
Workers' health insurance guide.
1. Is this a designated medical institution?
designated medical institutions: local social insurance management, designated medical institutions determined by local labor and social security administrative departments, and places selected and announced by designated medical institutions.
2. How was the doctor's clinic?
Designated medical institutions:
Designated pharmacies of the Ministry of Social Security can purchase medical drugs directly by swiping their cards, and publish them online, thus reducing costs and directly transferring funds to personal accounts.
local designated medical institutions: the cost of medical treatment, medicine and first self-improvement in the designated medical institutions of social insurance of the local Ministry of Labor and Social Security is purchased into the personal account of the railway hospital in this area after reimbursement to offset the funds.
The medical process is as follows:
Medical institutions: → Cancel the personal medical insurance card and IC card, and enter the medical records registered by the computer, here →→→ Plan the price for surgery → Deal with it → Holder → Apply for check-in procedures, and pay for prescription drugs in the IC card account → Check, deal with and get medicines.
where the designated medical institution is located: → cash payment → pharmacy for sale → holding valid documents → unit area? The railway hospital in the jurisdiction reduces the individual plan price →→→ the holder checks the application form, and the prescription fee is registered in their medical record here →→→→ the clinic account.
Expense reimbursement:
Can medical institutions? With the credit card directly charged to the personal account, the expenses of local designated medical institutions put personal progress first, and then the institutions that write relevant bills, and the self-care that the funds in the personal account are insufficient to pay for as a whole is stipulated.
3. What should we pay attention to in severe crisis rescue?
treatment principle:
the treatment principle at that time, and the nearest designated and non-designated hospitals receive life-saving treatment.
after emergency rescue and temporary disposal, nearby non-designated hospitals and designated medical institutions should be reversed in time. Irreversible timely emergency department certificate, family members or units should be kept within 3 days (holidays postponed), and the conditions should be summarized to the Bureau of Social Insurance Management Office (Guiyang, Chongqing Medical Insurance Management Office) for approval and filing.
expense reimbursement: reimbursement calculation is the same as
hospitalization medical expenses. The cost of emergency rescue in hospital should be calculated into a unified hospitalization medical reimbursement.
4. What are the regulations for special outpatient diseases?
what is the outpatient special disease
what is the outpatient special disease
after the insured's disease, it needs long-term outpatient treatment, and under the condition of stable condition, the medical cost is higher and the disease occurs.
Patients' specific types of diseases
The regulations of each cooperative co-ordination area include:
Sichuan units are divided into two categories. The first category: after the diagnosis is clear, you can rely on drugs to treat outpatient diseases: (1) diabetes; ② Hypertension stage Ⅱ and Ⅲ; ③ Aplastic anemia; ④Graves disease; ⑤ Sequela of cerebrovascular accident; ⑥ psychosis (stationary phase); ⑦ Cirrhosis; 8 A, B, CD, hepatitis E; Pet-name ruby lung heart disease; Attending Parkinson's disease. The second category: diseases with stable condition treated in outpatient department: ① radiotherapy, chemotherapy and postoperative adjuvant treatment for malignant tumors; ② Chronic leukemia; ③ Systemic lupus erythematosus; ④ Dialysis treatment of chronic renal failure; ⑤ Drugs for immune rejection after kidney (liver) transplantation.
Money unit: dialysis treatment for various malignant tumors, aplastic anemia, hemophilia, systemic lupus erythematosus and chronic renal failure, and anti-rejection treatment after organ transplantation included in the diagnosis and treatment items.
Setting in Chongqing: 1. Radiotherapy, chemotherapy and analgesia for malignant tumor; 2. Dialysis treatment for patients with renal failure; 3. Anti-rejection therapy for type 1 diabetes, type 2,5 and systemic lupus erythematosus after kidney, heart valve and hematopoietic stem cell transplantation; 6, hypertension, hypertension, high risk and very high risk, grade 2 hypertension, hypertension 3, 7, coronary heart disease, rheumatic heart valve disease; 9, cerebrovascular accident, cerebral infarction, cerebral hemorrhage, sequela of subarachnoid hemorrhage, 1, bronchial asthma, chronic bronchitis, emphysema, patients with chronic pulmonary heart disease, 11, cirrhosis, decompensated period 12, aplastic anemia 13, schizophrenia, mood disorder, depression, mania, paranoid mental disorder; 14 TB。 The principle of
, the principle of outpatient special disease management: implementing a given disease, giving medical institutions, giving treatment plans, cost control standards within a given range of drugs, and subsidy period. ?
4.
1. The report in the unit hospital makes my illness diagnosis (examination, laboratory report, etc.) for hospitalization medical insurance. Where necessary, I need to fill in the application form for special diseases of my employees in Chengdu, Sichuan, and clearly declare the diseases (the units in Chongqing have received the application form).
2. Preliminary examination of the hospital, necessary examination and confirmation of diagnosis results, suggested treatment plan, drug name and time frame for treatment.
3. The personal information of the approval mark of the social insurance management consent is summarized and submitted by the individual who returns from the hospital every month, and the hospital will inform you of the benefits, so you can start to enjoy the outpatient treatment of special diseases.
different places? Personal records of retirees living in local designated hospitals receive treatment, but they need to get the return, social security, fill it in the hospital, and pay the relevant information approved by the Social Security Department.
5. How to reimburse the outpatient expenses for special diseases
In the former railway hospital, the personal part that should be paid directly by swiping the card first reduced the funds in the personal account, and a small amount of cash payment was reimbursed automatically through the network. BR /> Relocation of workers: quarterly reimbursement of hospitalization expenses in local cross-departmental social security offices.
VI. Expense reimbursement standard
Overall reimbursement of basic medical insurance fund:
(1) Units in Sichuan: Accumulate outpatient expenses for specific diseases according to natural years.
payment from the overall fund: the part of a class of diseases that exceeds 4 yuan's natural cumulative safety range will be paid by the overall fund for 4% of retirement and service at the rate of 6% every year, and the accumulated payment from the overall fund in natural years will not exceed 1, yuan for retirement and service. The two types of diseases are paid by the overall fund according to the proportion of 8% if the safety exceeds 9.7 million yuan in a natural year;
(2) Money unit: in each natural year, the outpatient medical expenses for special diseases shall be borne by individuals, and from 7 yuan to 5, yuan (including 5, yuan, the same below), the individual shall bear 2%; More than 5 yuan to 1 yuan, personal burden of 15%; Ten thousand yuan personal burden of 15, yuan or more 1%, 15, yuan or more below the top line, personal burden of 5%.
individuals have a 7% proportional burden.
(3) In Chongqing, the threshold standard fee and the same year of hospitalization are paid by the individual according to a calculation. When the outpatient medical expenses of special diseases exceed the threshold and are lower than the capping line, the proportion of the overall fund payment: 9% of the expenses of cancer patients and advanced chemotherapy, radiotherapy and analgesia, dialysis patients and organ transplant anti-rejection drugs; Pay 8% of other special diseases, the same patient is treated in two designated medical institutions, and the threshold fee determined by high-level medical institutions.
2. Reimbursement of supplementary medical insurance:
If more than 9% of those who retire from supplementary medical care are reimbursed as a whole, 7% will be reimbursed, and 9% will be reimbursed from the social pooling fund for the part above the maximum payment limit.
3, capping line: in a natural year, the cumulative total amount of specific diseases and hospitalization expenses paid by the overall fund and supplementary medical insurance funds for individual patients shall not exceed the capping line of basic medical insurance and supplementary medical insurance funds.
5. Provisions on hospitalization and reimbursement?
how to handle hospitalization and discharge?