Answer: The medical expenses incurred by the insured in the outpatient service of designated medical institutions, the expenses for purchasing medicines in designated retail pharmacies and the medical expenses for hospitalization and family beds that need to be paid by individuals should be paid in personal accounts.
Personal account funds are owned by individuals in the form of IC cards, which can be carried forward and inherited according to law.
2. What is the proportion of employees transferred to individual accounts?
Answer: The composition of personal account includes the basic medical insurance premium paid by employees, the basic medical insurance premium paid by employers for employees and the interest of personal account.
Among them, the basic medical insurance premium paid by the employer for employees under 45 years old (including 45 years old) is included in the proportion of 0.8% of the payment base, and the above 45 years old is included in the proportion of 65438+ 0.5% of the payment base.
3. What is the ratio of retirees to personal accounts?
A: Retirees use their actual retirement expenses as the base for transferring households, and make different transfer ratios according to their age groups. Under 50 years old (including 50 years old) is 4.6%; 5 1 5.2% for the age of 60; 6 1 to 70 years old is 5.8%; 765438+6.4% over 0 years old.
4. When will it be credited to personal account?
A: On the premise that the employees of the unit pay the fees in full and on time, the personal accounts of the employees of the unit will be transferred within 5 working days after the payment is made by the unit.
2. According to the Notice of Jiangxi Provincial Department of Finance and other four departments on Printing and Distributing the Implementation Opinions on the Connection between Free Medical Care of Provincial Organs and Institutions and Basic Medical Insurance for Urban Employees (Gan Cai She [2012] No.35) and the Notice of Jiangxi Provincial Department of Human Resources and Social Security on Printing and Distributing the Implementation Rules of Medical Insurance for Employees of Provincial Organs and Institutions (Gan Ren She Zi [2012]) 20/. All the working staff and retirees of provincial organs and institutions (hereinafter referred to as provincial units) participate in the basic medical insurance for urban workers, medical insurance for serious illness and supplementary medical insurance for the unit, which is undertaken by the provincial social security center. In order to facilitate the cadres and workers of provincial units to master and implement the Regulations on the Management of Medical Insurance, we have compiled this medical guide, which includes medical treatment guide, personal account use, referral, sporadic reimbursement, outpatient treatment for special chronic diseases, medical treatment for people resettled in different places, fertility treatment, designated medical institutions and retail pharmacies. , for the insured and related medical personnel and provincial unit management personnel to master and use.
First, about medical treatment.
1. Which hospitals and pharmacies can the insured choose for medical treatment and medicine purchase?
Medical insurance for employees of provincial units shall be managed by designated medical institutions and designated retail pharmacies. Insured persons holding social security cards (temporarily using Jiangxi medical insurance cards at the same level, the same below) can choose to purchase medicines at designated medical institutions and retail pharmacies (please see the latest detailed list for the list of existing designated institutions).
Workers of provincial units seek medical treatment and purchase medicines in designated medical institutions and retail pharmacies, and the immediate settlement of medical expenses is implemented, that is, the part that individuals only need to pay in cash should be paid by pooling funds and personal accounts, and the medical insurance office of cadres of provincial organs of the provincial social security center (hereinafter referred to as the medical insurance office of provincial organs) regularly settles with designated institutions.
2. What medical expenses of the insured person can be reimbursed by the medical insurance fund?
The basic medical insurance, serious illness medical insurance and unit supplementary medical insurance fund shall pay the following fees according to the regulations:
(1) hospitalization expenses;
(2) medical expenses before emergency rescue and transfer;
(3) Prescribed outpatient treatment expenses for 39 special chronic diseases.
In accordance with the provisions of the general outpatient and emergency expenses, hospitalization and chronic diseases, according to the provisions of the payment of basic medical insurance fund, serious illness medical insurance and supplementary medical insurance fund, the rest of the individual pays from the insured person's personal account, personal account balance is insufficient, by the insured person to pay in cash.
3. What expenses are not paid by the medical insurance fund?
The following medical expenses, medical insurance funds (including individual accounts, pooling funds, serious illness medical insurance funds and unit supplementary medical insurance funds) will not be paid:
(1) occurred in non-designated hospitals and non-designated retail pharmacies (except emergency and rescue);
(two) beyond the "Jiangxi Province basic medical insurance, industrial injury insurance, maternity insurance drug list" and "Jiangxi Province basic medical insurance diagnosis and treatment projects, medical service facilities and payment standard list" scope;
(3) It shall be borne by a third party;
(4) It should be borne by public health;
(five) other expenses that are not paid according to the policy.
4. How does the insured handle the admission and discharge procedures?
The insured should hold the admission notice issued by the hospital, my social security card and resident identity card (or other identification materials), go through the relevant procedures for admission at the special window of medical insurance in designated hospitals, and pay the deposit according to the regulations of the hospital, and the deposit shall not exceed 600 yuan. When the insured person is discharged from the hospital, he/she will go to the medical insurance settlement window with the discharge notice and his/her social security card, go through the discharge settlement procedures and implement immediate settlement. The insured person only needs to pay the expenses that the individual should bear in cash according to the regulations, and the personal account, overall fund, serious illness medical insurance fund and unit supplementary fund will be settled regularly by the medical insurance department of the provincial organ and the designated hospital.
5. How much is the reimbursement of hospitalization expenses in kind?
The reimbursement policies for hospitalization expenses of medical insurance for employees in provincial units are as follows:
(1) The hospitalization expenses of the insured must first bear the hospitalization deductible line. The qifubiaozhun for first-class, second-class and third-class hospitals is 200, 400 and 600 yuan respectively, and the qifubiaozhun will be reduced by 100 yuan for re-hospitalization within the year, but the minimum shall not be less than 100 yuan.
(2) The reimbursement rates of hospitalization expenses in the first-,second-and third-level hospitals above the Qifubiaozhun and below the maximum payment limit of the overall fund (currently 654.38+10,000 yuan) are 98%, 95% and 90% respectively.
(3) 90% of the hospitalization expenses above the maximum payment limit will be reimbursed by the serious illness supplementary medical insurance fund, and the reimbursement period is 654.38+ 10,000-300,000.
(4) The out-of-pocket expenses of individuals who meet the standards of medication, diagnosis and treatment scope and medical service facilities of the basic medical insurance for urban workers shall be paid according to the main hall 100%, the deputy hall 98%, the division level 96% and the sub-division level 95% in the unit supplementary medical insurance, and the retirees shall be reimbursed by 2% on this basis (no more than 100%).
(5) Expenses exceeding 300,000 yuan and meeting the standards of medication, diagnosis and treatment scope and medical service facilities of the basic medical insurance for urban workers shall be paid according to the main hall 100%, deputy hall 98%, division level 96% and division level below 95% in the supplementary medical insurance of the unit.
6. What hospitalization expenses will increase personal burden?
For class B drugs, class B diagnosis and treatment items and class B service facilities within the basic medical insurance drug list, diagnosis and treatment item list and service facilities (hereinafter referred to as the three lists), individuals must pay 8% first, and then enter the reimbursement procedure; For Class C diagnosis and treatment projects, individuals have to bear 10% before they can enter the reimbursement link. Drugs, medical care, materials and services outside the three catalogues belong to self-funded projects and must be paid by individuals in cash, and the medical insurance fund for employees of provincial units will not be paid.
7. What should the insured pay attention to when he is hospitalized?
(1) When the insured person is hospitalized, he should take the initiative to show his social security card and cooperate with the hospital to see if the check card is consistent. If the social security card is damaged or the network is abnormal, he should reissue it within 48 hours.
(2) When the hospital uses drugs, medical care and services at its own expense, it must obtain the consent and signature of the insured, otherwise the insured has the right to refuse to pay the relevant expenses;
(3) Prescription for taking medicines: emergency prescriptions generally do not exceed 3 days, outpatient prescriptions and discharged medicines generally do not exceed 7 days, and chronic diseases do not exceed 15 days. It is forbidden to give injections when leaving the hospital, and it is not allowed to buy drugs in principle during hospitalization;
(4) When the medical expenses of the insured cannot be settled immediately, the medical records, prescriptions, inspection reports, discharge summaries, expense documents and other valid bills shall be properly kept;
(5) When the insured is hospitalized due to trauma, he/she must report the certificate of eliminating work-related injuries issued by the unit and the certificate of eliminating third-party injuries (including the certificate of eliminating traffic accidents) issued by the public security department to the provincial medical insurance office within two working days after hospitalization, otherwise, the expenses will not be paid.
(6) If an employee needs to change his major or re-enter the hospital within 15 days, he/she should fill in the Application Form for Changing Major or Re-entering the Hospital in Jiangxi Province within 15 days after discharge, and provide a discharge summary and a copy of his/her ID card, and submit it to the Medical Insurance Office of the provincial organ for review. If the application is successful, he/she will be hospitalized again.
Two. Personal account use guide
1. How to transfer medical insurance personal accounts of provincial units?
Employees and retirees set up individual accounts respectively, and the transfer ratio is:
(1) On-the-job employees shall allocate 3.2% (including 2% paid by individuals) from the basic medical insurance fund and 3.1%from the unit supplementary medical insurance fund;
(two) retirees to my pension as the base, respectively, from the basic medical insurance fund by 3.8%. 3.5% from the unit supplementary medical insurance fund.
The amount allocated to the personal account shall be approved at the beginning of each year in one lump sum, and shall be allocated after the unit pays in full and on time.
2. Is interest charged on the balance of personal account?
The principal and interest (calculated once a year according to the bank deposit interest rate) of the personal account balance belong to the individual and can be transferred, carried forward and inherited.
3. What is the scope of personal account payment?
Personal account is mainly used to pay the insured person's drug purchase expenses in designated retail pharmacies, outpatient medical expenses in designated medical institutions and medical expenses within the policy that the insured person should bear the responsibility during hospitalization.
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