Urban and rural medical insurance reimbursement scope and standards:

1. Outpatient reimbursement:

There is no deductible for general outpatient clinics. All insured residents enjoy general outpatient treatment. . Within a medical insurance year, there is no deductible for general outpatient services, and 60% of the medical expenses within the payment scope of the outpatient overall fund will be reimbursed. The maximum annual personal payment limit of the overall fund is 400 yuan;

2. Hospitalization reimbursement ratio:

The longer the continuous insured period, the greater the reimbursement ratio. For every five consecutive years of continuous payment by insured residents, the hospitalization reimbursement ratio of the medical insurance fund will increase by 5 percentage points, with a total of no more than 10 percentage points. If you participate in the insurance for 10 consecutive years from 2007, the hospitalization reimbursement ratio in third-level, second-level, and first-level hospitals will reach 70%, 80%, and 90% respectively;

3. Secondary reimbursement ratio:

For the medical expenses incurred by insured residents for multiple hospitalizations in an individual year, after payment of basic medical insurance and "secondary reimbursement", the accumulated hospitalization medical expenses incurred by the individual in the year (including the legal and reasonable self-pay part) For the portion exceeding 25,000 yuan, the excess portion will be reimbursed by the critical illness insurance fund at a rate of 55%. The annual maximum personal payment limit for critical illness insurance funds is 250,000 yuan.

The following medical expenses are not included in the payment scope of the basic medical insurance fund:

1. They should be paid from the work-related injury insurance fund;

2. They should be paid by a third party

3. Should be borne by the public health department;

4. Those seeking medical treatment abroad.

To sum up, according to the needs of management services, social insurance agencies can sign service agreements with medical institutions and pharmaceutical business units to standardize medical service behaviors. Medical institutions should provide reasonable and necessary medical services to insured persons.

Legal basis:

Article 28 of the "Social Insurance Law of the People's Republic of China"

Comply with the basic medical insurance drug catalog, diagnosis and treatment items, Standards of medical service facilities and medical expenses for emergency and rescue services shall be paid from the basic medical insurance fund in accordance with national regulations.

Article 29

The part of the medical expenses of the insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance agency and the medical institution and pharmaceutical business unit .