1. Scope of implementation: All employers in cities and towns in this city, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, enterprises invested by Hong Kong, Macao and Taiwan investors, private enterprises, etc.), government agencies, and public institutions , social groups, private non-enterprise units and their employees must participate in basic medical insurance. Central, provincial and municipal units and their employees in Zhifu District, Laishan District, Fushan District, Muping District and Economic and Technological Development Zone participate in municipal basic medical insurance. Other employers participating in local overall planning, qualified township enterprises and urban individual economic organization owners and their employees must gradually be included in the scope of basic medical insurance. At present, Yantai City is first piloting it in enterprises and public institutions under corporate management, and then gradually rolling it out.
2. Medical insurance fund raising ratio: Basic medical insurance premiums are paid jointly by the employer and employees: the employer pays 8% of the total wages of active employees (7% in some counties and cities), Current employees pay 2% of their salary income, and the employer withholds it from their salary. Individual retirees do not pay basic medical insurance premiums. If the employee's contribution salary is lower than 60% of the average salary of local employees in the previous year, 60% will be used as the base for payment. The basic medical insurance fund consists of a pooled fund and an individual account fund, which are accounted for separately and are not allowed to crowd each other out. Of the basic medical insurance premiums paid by the employer, 65% is transferred to the overall fund and 35% is transferred to the individual account.
3. Medical expense reimbursement ratio for insured employees: In a medical year (from April 1st of the current year to March 31st of the following year), the insured person’s medical expenses for each hospitalization due to illness will be The portion above the payment standard shall be paid in installments from the overall fund: the portion above the minimum payment standard to 5,000 yuan shall be paid at 70%; the portion above 5,000 yuan to 10,000 yuan shall be paid at 75%; the portion above 10,000 yuan to the maximum payment limit shall be paid Pay at 80%. For retirees, based on the above payment ratio, it will be increased by 10%. For the daily outpatient medical expenses of patients with 12 types of coordinated diseases, 80% will be paid from the unified fund, and retirees will pay 85%. Among them, the reimbursement rate for outpatient hemodialysis, peritoneal dialysis and the cost of taking cyclosporine A after kidney transplantation for uremic patients will be increased by 10% on the above basis. The cost of taking cyclosporine A after kidney transplantation will be reimbursed to individuals first. Burden 5%.
4. The concept of deductible payment standard and cap line: The deductible payment standard refers to the amount of medical expenses incurred by insured employees who are sick and hospitalized, and the basic medical insurance coordinating fund begins to pay. The minimum payment standard stipulated by Yantai City is: 8% of the average salary of employees in the city in the previous year for first-level hospitals; 10% for second-level hospitals; and 12% for third-level hospitals. The maximum payment limit (capping line) of the overall pool fund is four times the average salary of local employees in the previous year.
During the period from April 2003 to March 2004, the minimum payment standards for the overall fund were: 500 yuan for first-level hospitals; 600 yuan for second-level hospitals; and 700 yuan for third-level hospitals. Designated hospitals that have not yet undergone hospital grade assessment will be temporarily implemented according to the standards of second-level hospitals. The maximum payment limit of the overall pool fund is 32,200 yuan.
5. Coordinated diseases: The following diseases are temporarily listed as co-ordinated diseases: (1) Leukemia; (2) Uremia; (3) Acute stage of cerebral hemorrhage (including those who require special care after the acute stage) ); (4) Intracranial space-occupying lesions; (5) Intraspinal space-occupying lesions; (6) Malignant tumors in various systems of the body; (7) Large-area burns (more than 50% of the whole body is II°, and 30% is III° The acute phase above); (8) Decompensated phase of liver cirrhosis; (9) Chronic pulmonary heart disease (pulmonary function symptoms, combined with cardiac insufficiency); (10) Heart function level III or above (including level III) ; (11) Diabetes complications; (12) Cerebral thrombosis (causing limb dysfunction and requiring special care).
6. Medical insurance policy for retired cadres (including veteran workers who participated in revolutionary work before the founding of the People's Republic of China, the same below) and revolutionary disabled servicemen of Class B and above:
(1) Retired The medical insurance benefits of personnel and disabled revolutionary servicemen of Class B and above remain unchanged, and their medical expenses are raised based on the per capita medical expenses of all retired personnel and disabled revolutionary servicemen of Class B and above within the scope of the previous year's overall planning. Medical insurance agencies maintain separate accounts and use special funds for their own purposes. Their medical expenses are within the scope stipulated by the basic medical insurance and will be reimbursed according to the facts.
From April 2002 to March 2003, the standard for raising medical insurance premiums for retired personnel was 6,700 yuan per person; the standard for raising medical insurance premiums for revolutionary disabled servicemen above Class B was 6,000 yuan per person. Yuan.
(2) Reimbursement standards for hospital bed expenses for retired personnel. Reimbursement will be made according to the general bed fee standards of hospitals at all levels. "Shandong Province Medical Institution Charging Items and Charging Standards" stipulates that first-level hospitals are 6 yuan per bed day; second-level hospitals are 10 yuan per bed day; and tertiary hospitals are 15 yuan per bed day. Retired cadres who enjoy medical and health care benefits will have their hospitalization bed fees reimbursed according to the standards stipulated in relevant documents of the Municipal Health Care Commission.
(3) Selection of designated hospitals for retirees. In order to facilitate medical treatment, retired personnel can go to designated hospitals for medical treatment according to their condition needs, or they can go to designated pharmacies to purchase medicines with prescriptions from designated hospitals. Those who are resettled in other places can choose one or two nearby public hospitals as designated hospitals. In principle, the selected hospital cannot be changed within one year.
(4) Medical treatment for retired personnel.