direct medical insurance in the district

1. Basic medical insurance benefits

(1) Sources of funds in personal accounts

1. All the basic medical insurance premiums paid by employees and 2% of their total wages are transferred to personal accounts.

2. 8% (6% in 22) of the total salary of basic medical insurance premium paid by the employer is included in the personal account according to the regulations, and the specific calculation method is .5% for people aged 45 and under; 1% from 46 to 59; 1.5% aged 6 and above.

(II) Sources of pooling funds

The basic medical insurance premium paid by the employer will enter the basic medical insurance pooling fund, except for the part that is included in the individual account according to the regulations.

(III) Payment scope of personal account

Personal account is mainly used to pay the medical expenses that meet the basic medical insurance drug list and diagnosis and treatment items; Pay the medical expenses that should be paid by the individual in hospital; Pay the cost of special examination and special treatment and the outpatient medical expenses of some patients with chronic diseases.

(IV) Payment scope of the overall fund

1. Payment of hospitalization medical expenses: Medical expenses that meet the requirements of basic medical insurance during hospitalization: above the Qifubiaozhun, and below the maximum payment limit are paid by the overall fund according to the subsection accumulation method. Individuals should also pay a certain proportion:

proportion of overall fund payment% proportion of individual payment %

hospitalization medical expenses, on-the-job retirement, on-the-job retirement

the minimum payment is more than 5, yuan, 7 75 2 15

5,-1, yuan, 75,81,51

1, yuan to the maximum limit of 8,851 5

2, The maximum payment limit of the overall fund in a year is 4 times the annual salary of employees. The medical expenses exceeding the maximum limit will not be paid by the overall fund. The insured will pay in cash and be solved through commercial medical insurance.

II. Interim Provisions of the State on Medicaid for Civil Servants

(1) Scope of subsidies

1. List of medical expenses and drugs that meet the standards of basic medical insurance diagnosis and treatment items and medical service facilities.

2. part of the medical expenses that exceed the maximum payment limit of the basic medical insurance fund.

3. The individual pays more than a certain amount of medical expenses within the scope of basic medical insurance payment.

4. Medical expenses incurred by medical care personnel who enjoy medical care according to regulations.

5. Medical expenses for work-related (work-related) injuries and maternity that meet the national civil servant medical subsidy.

(II) Outpatient medical subsidy

It meets the requirements of basic medical insurance, and one-time medical expenses occur:

55% of the employees are subsidized (the total outpatient medical expenses exceed 1,6 yuan in one year), and they will not be subsidized.

65% of retirees' subsidy (the total outpatient medical expenses exceed 1,8 yuan in one year) is no longer subsidized.

9% of the medical care personnel will be subsidized (the total outpatient medical expenses will exceed 2, yuan in one year), and they will no longer be subsidized.

(III) Hospitalization subsidy

1. Hospitalization bed fee subsidy: For the part that exceeds the bed fee of basic medical insurance in 15 yuan, the daily subsidy is: 1 yuan for employees, 15 yuan for retirees and 25 yuan for medical care personnel.

2. For the medical expenses incurred in hospitalization within one year, the subsidies are: 85% for on-the-job employees, 9% for retirees, 95% for medical care personnel and 1% for health care objects, which are borne by individuals above the minimum payment limit of the basic medical insurance pooling fund.

3. The subsidies for using drugs that are not listed in the basic medical insurance drug list during critical rescue are: 5% for employees, 6% for retirees and 9% for medical care personnel. This subsidy method is that the doctor fills in the application form, reports it to the medical insurance center for approval, and then settles the account in cash, and submits the hospitalization invoice and application consent form to the medical insurance center for reimbursement according to regulations.

III. Medical treatment for some chronic outpatients

1. The chronic diseases listed in outpatient clinics include coronary heart disease, diabetes, various malignant tumors, chronic obstructive emphysema, hypertension, Parkinson's syndrome, decompensated cirrhosis, uremia, chronic heart failure and anti-rejection immunomodulation therapy after organ transplantation.

2. Each insured person can declare up to 3 diseases.

3. According to the regulations, outpatient chronic diseases can only enjoy the list of medical insurance drugs within the prescribed scope of the chronic diseases.

4. Before entering the chronic disease subsidy, the individual pays the drug fee below the minimum threshold, that is, the average annual salary of employees is 8%, and the rest of the drug fee is paid in proportion to the overall fund.

IV. Payment proportion of special inspection and special treatment items

1. According to the regulations, 4% of the expenses for special inspection and special treatment will be paid by individuals first, and the remaining expenses will be paid according to the proportion stipulated in the basic medical insurance, and the personal payment will be subsidized according to the proportion and limit of civil servants' subsidies.

2. Individuals shall pay 5% of the imported materials in cash first, and the remaining expenses shall be subsidized according to the method specified in Article 1.

v. Medical treatment for employees (public injuries) in institutions directly under the Central District

According to the spirit of Document No.9 of Medical Insurance of Guilaoshe (22):

1. Employees in institutions directly under the Central District who are eligible to enjoy the national civil servant medical subsidy shall be reimbursed for their medical expenses for work-related injuries that meet the requirements.

2. Workers (workers) injured in institutions and institutions directly under the Central District must report to the Medical Insurance Department of the District Labor Department by telephone within 48 hours, and fill in the report form of workers (workers) injured in institutions directly under the Central District within 15 days. Workers who are identified as work-related injuries by the administrative department of the Labor and Social Security Department of the autonomous region shall enjoy medical treatment for work-related injuries according to regulations.

3. Employers and employees with work-related injuries must provide the following certificates

Work-related (public) injury accident report form, diagnosis certificate of designated hospital or confirmed certificate of occupational disease, relevant inquiry transcripts and circumstantial materials; In the event of a traffic accident, provide the traffic police department with a letter of responsibility for handling the accident and other materials.

4. After the employees of the central government and institutions directly stationed in Yong suffered work-related (work-related) injuries, the designated hospital is now designated as the First Affiliated Hospital of Guangxi Medical University (including the Second Affiliated Hospital, namely the West Hospital). Guangxi People's Hospital, Guangxi Workers' Hospital and Nanning Second People's Hospital. The critically wounded can be rescued in the nearest hospital, and then transferred to the designated hospital for further treatment after the injury is stable.

5. The basic medical insurance for urban workers in Guangxi Zhuang Autonomous Region, the scope of medical service facilities and payment standards, and the list of basic medical insurance drugs in Guangxi Zhuang Autonomous Region shall be implemented during the medical treatment of workers with work-related (work-related) injuries. During the rescue period, the scope of drug use may be appropriately relaxed, but it must be reported to the Social Security Bureau of the autonomous region for approval.

6. Hospitalization medical expenses that meet the relevant provisions of basic medical insurance during the treatment of work-related injuries shall be fully reimbursed in the national civil service Medicaid.

7. The expenses incurred by employees who are identified as work-related (work-related) injuries during outpatient and hospitalization shall be paid in cash by the unit first, and then they shall be submitted to the Social Security Bureau of the autonomous region for review and reimbursement with the work-related injury approval form, medical insurance certificate, hospital certificate, medical expense list, etc.

VI. Management of personal medical insurance IC card

1. Personal medical insurance IC card records the medical insurance files of the insured, personal account funds and usage status, and is kept and used by individuals.

2. The principal and interest of an individual account are owned by the individual, and cash cannot be withdrawn in principle.

3. If the IC card is lost or damaged, you should report the loss to the district medical insurance center with your personal ID card. If you can't report the loss for a while, you can call the district medical insurance center in advance to avoid unnecessary losses. The telephone number for reporting the loss is 2853836.

medical insurance directly under the municipal government

1. medical treatment for specific outpatient items

1. the scope of specific items is: radiotherapy and chemotherapy for malignant tumors, dialysis treatment for uremia, and anti-rejection treatment after organ transplantation.

2. For the insured who meet the specific project, the doctor shall submit a written application every time he visits a doctor, and the expenses incurred after going through the examination and approval procedures shall be borne by the on-the-job personnel at 15%; Retirees will bear 8% of their personal expenses, and the rest will be paid by pooling funds.

3. Insured persons over the age of 5 who suffer from serious chronic diseases in outpatient clinics exceed 5 yuan within 3 days, shall be reimbursed according to the regulations after reporting the drug expense reimbursement form at the municipal medical insurance center with the outpatient drug invoice and medical records.

2. Management and payment of special inspection and special treatment

1. For the special inspection and special treatment project approved by the application, the on-the-job staff pays 3%; Retirees pay 15%.

2. For the imported artificial organs approved for use by inpatients due to illness, the expenses for placing materials in the body shall be paid in cash by individuals first, and then reimbursed by other relevant materials to the municipal medical insurance center according to regulations.

III. Treatment of medical mutual assistance payment

1. If the employees who participate in medical mutual assistance exceed the maximum payment limit of the overall fund, the excess medical expenses will be paid in cash, and they will be reimbursed from the medical mutual assistance fund in accordance with the regulations with the ticket to the municipal medical insurance center.

2. The maximum amount paid by the overall fund is 4 times of the average total wages of employees in the previous year.

3. 7% of the expenses incurred in hospitalization are paid by the medical mutual aid fund when the average salary of employees is less than 9 times (including 9 times) in the first half of the overall planning area, and 3% is paid by the individual; 8% of the average salary is more than 9 times and less than 13 times (including 13 times), and the individual pays 2%; 9% of the average salary is more than 13 times to 15 times, and the individual pays 1%.

The scope of medical treatment items that are not paid by the basic medical insurance can be divided into the following categories

1. Service items

1. Registration fee, consultation fee outside the hospital, visit fee, expedited fee for examination and treatment, surcharge for operation by name, and special medical services for self-invited nurses.

2. Various cosmetic, bodybuilding and non-functional plastic surgery.

3. various weight loss, weight gain and height increase projects.

4. All kinds of health examination and medical appraisal fees.

2. Diagnosis and treatment equipment and medical materials

1. Electron emission tomography (PET) and ophthalmic excimer laser therapy.

2. Glasses, dentures, artificial eyes and hearing AIDS.

3. Various self-use health care, massage, examination and treatment instruments.

III. Treatment items

1. Organ source or tissue source of various organ or tissue transplants.

2. Transplantation of organs or tissues other than kidney, pericardium, cornea, skin, blood vessels, bone and bone marrow.

3. Orthopedic surgery for myopia.

4. Qigong, music therapy, spectrum therapy, laser therapy and light quantum therapy.

5. Expenses for diagnosis and treatment of infertility (pregnancy) and sexual dysfunction, and for examination and treatment of sexually transmitted diseases.

iv. Life service items

1. Transportation expenses for medical treatment and referral and first aid.

2. Hospitalization air conditioning fee, escort fee and nursing fee.

3. Expensive special services.

5. Others

1. Medical expenses (except rescue) incurred in not attending designated medical institutions.

2. expenses incurred in going to other places for medical treatment without the approval of relevant departments.

3. Medical expenses incurred abroad, Hong Kong, Macao and Taiwan.

4. Medical expenses of female workers in childbirth (to be reimbursed separately according to relevant policies on childbirth).

5. expenses incurred due to work-related (work-related) injuries (to be reimbursed separately according to relevant regulations on work-related injuries).

6. Medical expenses incurred due to traffic accidents, medical accidents, suicide, self-mutilation, alcoholism and fighting.

7. Cleaning teeth, inserting teeth, assembling artificial eyes and limbs.

8. Drug expenses outside the basic medical insurance drug list in Guangxi Zhuang Autonomous Region.

9. Hospital-made drugs, self-defined items and new inspection and treatment items that have not been approved by the health, drug supervision and administration, price departments and district social security bureau.

After paying medical insurance, anyone who is hospitalized can be reimbursed as long as it meets the fluctuation standard, and the average reimbursement rate can reach more than 8%.

according to the national regulations, the threshold of hospitalization medical expenses paid by social pooling funds is set at about 1% of the average salary of local employees. The original provisions of the first, second and third-level medical institutions in our city were 6%, 8% and 1% of the average wage of employees in the previous year respectively. With the increase of the average wage of employees year by year, it should be adjusted every year. However, considering that it will not increase the burden on employees, our city has been implementing the standard of calculating the social flat wage in 2, and it has not been adjusted with the increase of the social flat wage. The Qifubiaozhun is 5 yuan, 67 yuan and 84 yuan respectively. In order to reduce the burden on employees, this revision will decouple the Qifubiaozhun from the average salary of employees, and the first, second and third-level medical institutions will still maintain the current standards: 5 yuan, 67 yuan and 84 yuan, and make appropriate adjustments according to the salary income of employees and the income and expenditure of medical insurance funds in the future. For the first hospitalization within a medical year, the Qifubiaozhun is 1%, for the second hospitalization, the Qifubiaozhun is 5%, and for the third and above hospitalization, the Qifubiaozhun is no longer set.