Grassroots designated medical and health institutions can report 70% without Qifubiaozhun.

The outpatient medical expenses incurred by the provincial-level insured workers in the designated medical institutions that have been directly settled by Unicom's outpatient clinics are included in the outpatient reimbursement as a whole. The specific reimbursement ratio is: the first-level designated medical institutions and grassroots designated medical and health institutions have no Qifubiaozhun and are reimbursed at 70%; Two designated medical institutions Qifubiaozhun 200 yuan, according to 60% reimbursement; The qifubiaozhun of tertiary designated medical institutions in 300 yuan is reimbursed at 60%. Reimbursement amount = (outpatient expenses within the scope of reimbursement-Qifubiaozhun) × reimbursement ratio.

1. What is an outpatient clinic?

The reform of outpatient service mechanism of medical insurance is an important measure to deepen the reform of medical security system. Through the establishment of general outpatient co-ordination system and the reform of individual accounts of medical insurance for employees, the outpatient security of medical insurance for employees will be changed from individual accumulation mode to mutual aid mode, and the burden of outpatient medical expenses for insured personnel will be gradually reduced, so as to realize a fairer and sustainable development of medical insurance system. The main contents include: establishing general outpatient co-ordination, including general outpatient expenses in the scope of medical insurance reimbursement for employees, reducing the burden of outpatient medical treatment for insured persons, and giving full play to the economic role of the co-ordination fund; Reform the way of personal accounts, so that spouses, parents and children of the insured can use them to improve the efficiency of personal accounts.

2. What is the reimbursement standard for general outpatient service?

Every year, 65438+1 October1to 65438+February 3 1 is the year of treatment enjoyment. The annual minimum payment standard (commonly known as "threshold fee") does not exceed that of 300 yuan (there is no minimum payment standard above 300 yuan during the year), and the maximum annual reimbursement amount for employees is 1.500 yuan, and the maximum annual reimbursement amount for retirees is 2,000 yuan. The specific reimbursement ratio is: the first-level designated medical institutions and grassroots designated medical and health institutions have no Qifubiaozhun and are reimbursed at 70%; Two designated medical institutions Qifubiaozhun 200 yuan, according to 60% reimbursement; The qifubiaozhun of tertiary designated medical institutions in 300 yuan is reimbursed at 60%.

Reimbursement amount = (outpatient expenses within the scope of reimbursement-Qifubiaozhun) × reimbursement ratio.

3. What are the scope of general outpatient reimbursement?

The outpatient medical expenses of the insured in the designated outpatient medical institutions are included in the scope of outpatient reimbursement. The scope of reimbursement is consistent with the basic medical insurance, that is, the list of basic medical insurance drugs, the list of medical services and the list of medical consumables stipulated by the state and the province. Those beyond the scope of reimbursement of basic medical insurance will not be reimbursed.

Four, how to settle the expenses of the general outpatient service?

The insured person only needs to pay the personal burden for seeing a doctor in a designated medical institution, and the outpatient expenses for seeing a doctor in a non-designated medical institution or not directly settled in a designated medical institution cannot be reimbursed.

5. How to reimburse emergency expenses?

If emergency rescue requires hospitalization within 72 hours, the emergency rescue medical expenses and hospitalization expenses shall be calculated together; Emergency rescue of death, with reference to hospitalization policy reimbursement; Other emergency expenses are reimbursed according to the general outpatient co-ordination standard.

6. Can outpatient medical expenses be reimbursed repeatedly?

I can't. The insured can't enjoy general outpatient co-ordination or outpatient reimbursement for chronic diseases and special diseases during hospitalization; Medical expenses have been reimbursed for the "dual-channel" management of drug treatment and outpatient treatment for chronic diseases and special diseases, but not for the general outpatient department.

7. What should I pay attention to in the overall settlement of outpatient service across the overall planning area?

Insured people need not apply for medical registration in different places in advance to buy medicines in outpatient clinics of designated medical institutions in Changsha, Zhuzhou and Xiangtan. Insured persons in cross-regional designated medical institutions for medical treatment, should take the initiative to show the insured identity and the type of medical treatment, produce medical insurance electronic documents, resident identity cards or social security cards for medical treatment and drug purchase, and abide by the procedures and norms for medical treatment and drug purchase; When the insured settles the outpatient co-ordination expenses in different places across the co-ordination areas, the Qifubiaozhun, payment ratio and maximum payment limit of the outpatient co-ordination fund specified by the insured place shall be implemented; In principle, it does not support the demand for refund of general outpatient expenses after the insured person directly settles across the overall planning area.

Legal basis:

"Guiding Opinions of the General Office of the State Council on Establishing and Improving the Economic Security Mechanism for Outpatients with Basic Medical Insurance for Employees"

Second, the main measures

(three) to enhance the outpatient service * * * economic security function. Establish and improve the overall guarantee mechanism for the general outpatient expenses of employee medical insurance, and gradually include the general outpatient expenses of frequently-occurring diseases and common diseases into the payment scope of the overall fund on the basis of doing a good job in the medical security work for chronic diseases and special diseases (hereinafter referred to as outpatient chronic diseases and special diseases) with heavy burden on the masses such as hypertension and diabetes. The general outpatient service covers all insured employees in medical insurance as a whole, and the payment ratio within the policy scope starts from 50%. With the strengthening of the affordability of the medical insurance fund, the level of protection is gradually improved, and the payment of benefits can be appropriately tilted towards retirees. According to the characteristics of outpatient medical service, scientifically calculate the minimum payment standard and maximum payment limit, and make a good connection with the hospitalization expense payment policy. Simultaneously improve the outpatient co-ordination of basic medical insurance for urban and rural residents, and gradually improve the level of protection.

According to the affordability of the medical insurance fund, the scope of chronic diseases and special diseases paid by the overall fund will be gradually expanded, and the outpatient expenses of some diseases with long treatment cycle, great harm to health and heavy cost burden will be included in the * * * economic security, and some special treatments that are suitable for outpatient service and more economical and convenient than hospitalization can be managed with reference to hospitalization. Constantly improve the outpatient service economic security mechanism, and gradually transition from disease security to cost security. Will meet the conditions of the designated retail pharmacies to provide drug protection services into the scope of outpatient services, support the settlement and adjustment of external prescriptions in designated retail pharmacies, and give full play to the convenience and accessibility of designated retail pharmacies. Explore the inclusion of qualified "internet plus" medical services in the scope of protection.