1. Reimbursement ratio of outpatient medical insurance in Nanjing:

For outpatient (emergency) medical expenses in a treatment year, the fund will pay 5% for those who go to community medical institutions, 3% for those who go to non-community medical institutions, and the annual fund payment limit is 3 yuan; After enjoying the overall treatment of outpatient service, the individual pays more than 2, yuan for the outpatient medical expenses that continue to occur. For those in community medical institutions, the fund pays 5%, for those in non-community medical institutions, the fund pays 3%, and the annual fund payment limit is 2,6 yuan.

For seriously ill outpatients, 8% of the elderly residents and other residents' funds are paid, and 85% of the students' children's and college students' funds are paid.

2. Reimbursement ratio of chronic diseases in Nanjing Medical Insurance:

For the insured persons who receive dialysis treatment (including hemodialysis and peritoneal dialysis) in outpatient clinics of chronic renal failure, the limit of dialysis medical expenses incurred in the designated medical institutions is 63, yuan/year, and the limit of fund payment is 8, yuan/year.

3. Reimbursement proportion of Nanjing medical insurance hospitalization:

The proportion of fund payment for elderly residents and other residents is: 65% for tertiary medical institutions, 85% for secondary medical institutions, 9% for first-class and below medical institutions, and the proportion of fund payment for elderly people over 8 years old at all levels is increased by 5 percentage points; The proportion of funds paid by medical institutions at all levels for students, children and college students is 8%, 9% and 95% respectively.

referring to article 16 of the detailed rules for the implementation of the measures for the basic medical insurance for urban and rural residents in Nanjing, the fund will pay the medical expenses that meet the scope of medical insurance payment for urban and rural residents within one treatment year, and the part above the minimum threshold will be paid according to the regulations, as follows:

(1) Overall treatment for outpatient service. Qifubiaozhun 2 yuan, the outpatient (emergency) medical expenses occurred in a treatment year, 5% of which are paid by the fund in community medical institutions, 3% of which are paid by the fund in non-community medical institutions, and the annual fund payment limit is 3 yuan. The proportion of fund payment for elderly residents over 8 years old will increase by 5 percentage points on the basis of the above payment ratio, and the annual fund payment limit will increase by 1%.

(2) compensation for high outpatient expenses. In a treatment year, after enjoying the overall treatment of outpatient service, the outpatient medical expenses that continue to occur, the individual pays more than 2, yuan, and the fund pays 5% for treatment in community medical institutions, 3% for treatment in non-community medical institutions, and the annual fund payment limit is 2,6 yuan.

(3) outpatient treatment of serious illness. Serious diseases in outpatient department include malignant tumor, hemodialysis (including peritoneal dialysis) treatment of severe uremia, anti-rejection treatment after organ transplantation, hemophilia, aplastic anemia and systemic lupus erythematosus. In a treatment year, the proportion of special outpatient medical expenses for diseases in designated medical institutions is 8% for elderly residents and other residents, and 85% for students, children and college students. Provisions and limits of fund payment are as follows:

1. Outpatient treatment of malignant tumor. The insured with malignant tumor, the outpatient radiotherapy and chemotherapy (intravenous or interventional chemotherapy) medical expenses occurred in the designated medical institutions, the fund payment limit is 12 thousand yuan/year;

The fund will pay 8, yuan/year for the targeted drug treatment expenses such as endocrine therapy for breast cancer and prostate cancer, immunotherapy for renal cancer and melanoma, oral chemotherapy (including molecular targeted drugs) for malignant tumor, bladder perfusion, anti-bone metastasis or late analgesic treatment within five years from the date of diagnosis. If the treatment is still needed after five years, the treatment period can be extended after evaluation by the designated medical institutions;

The expenses incurred for adjuvant therapy other than radiotherapy and chemotherapy and targeted drug therapy are limited to 1, yuan/year for the first to third years, 5, yuan/year for the fourth to fifth years, and 2, yuan/year for the sixth year and beyond.

2. Outpatient dialysis treatment for chronic renal failure. For the insured who are treated with dialysis in outpatient department of chronic renal failure (including hemodialysis and peritoneal dialysis), the limit of dialysis medical expenses incurred in the designated medical institutions is 63, yuan/year, and the limit of fund payment for the medical expenses of auxiliary examination drugs is 8, yuan/year.

3. Anti-rejection treatment in outpatient department after organ transplantation. The fund payment limit for anti-rejection drug treatment expenses incurred in designated medical institutions is: 8, yuan in the first year, 75, yuan in the second year, 7, yuan in the third year, and 65, yuan/year in the fourth year and beyond. The fund payment limit for the auxiliary treatment expenses is: < P > 8, yuan in the first year; 6 yuan in the second year; 4, yuan in the third year; 2 yuan for the fourth year and beyond. The treatment period of outpatient anti-rejection treatment after hematopoietic stem cell (allogeneic) transplantation is the year of operation and the first year after operation, and the treatment standard is implemented with reference to the corresponding years of outpatient anti-rejection treatment after transplantation.

the fund will pay the medical expenses for outpatient serious illness that occurred in the year after the diagnosis of insured persons suffering from serious outpatient diseases or after surgery according to the first-year treatment standard.

4. Treatment of hemophilia. For hemophilia (hereditary coagulation factor ⅷ, ⅸ deficiency) patients, the corresponding medical expenses for examination and alternative treatment in designated medical institutions are respectively 1, yuan, 5, yuan and 1, yuan according to the light, medium and heavy hemophilia.

5. Treatment of aplastic anemia and systemic lupus erythematosus. The medical expenses for diseases occurred in the designated medical institutions shall be the minimum payment standard of 1 yuan, and the annual fund payment limit shall be 1, yuan.

(4) outpatient psychiatric treatment. Suffering from schizophrenia, schizoaffective disorder, paranoid psychosis, bipolar disorder, epileptic psychosis, mental retardation with mental disorder, depressive episode (moderate or severe), obsessive-compulsive disorder and other mental diseases, the proportion of medical expenses incurred in outpatient clinics is 8% for elderly residents and other residents, and 85% for students, children and college students.

(5) outpatient AIDS treatment. HIV-infected people and AIDS patients enjoy free anti-HIV and opportunistic infection treatment and related examinations in outpatient clinics, which are used by designated medical institutions according to the quota standard of 1 yuan per person per quarter.

(6) Hospitalization treatment. In the designated medical institutions for hospitalization medical expenses, Qifubiaozhun for tertiary medical institutions in 1 yuan, secondary medical institutions in 5 yuan, level 1 and below medical institutions in 3 yuan. For the part above Qifubiaozhun, the proportion of fund payment for elderly residents and other residents is: 65% for tertiary medical institutions, 85% for secondary medical institutions, 9% for first-class and below medical institutions, and the proportion of fund payment for elderly people over 8 years old at all levels is increased by 5 percentage points on the above basis; The proportion of funds paid by medical institutions at all levels for students, children and college students is 8%, 9% and 95% respectively.

if you are hospitalized for the second time or more in a treatment year, the hospitalization qifubiaozhun shall be calculated according to 5% of the stipulated hospitalization qifubiaozhun. There is no hospitalization Qifubiaozhun for patients hospitalized due to serious diseases, mental diseases and AIDS. The insured person is referred from the first-level designated medical institution to the next-level designated medical institution for hospitalization, and the hospitalization Qifubiaozhun of the next-level designated medical institution is cancelled; Cumulative calculation of qifubiaozhun when transferring.

(7) Maternity medical treatment. The medical expenses for prenatal examination and childbirth in line with the national family planning policy will be included in the payment scope of urban and rural residents' medical insurance fund. For the prenatal examination expenses incurred in a treatment year, the fund will pay 4%, and the fund will pay the limit of 3 yuan; The expenses for childbirth in hospital shall be implemented with reference to the hospitalization payment policy, of which 75% shall be paid by the fund for medical treatment in tertiary medical institutions.

expanded information

referring to article 2 of the detailed rules for the implementation of the measures for the basic medical insurance for urban and rural residents in Nanjing, all urban and rural residents who meet the requirements of the city for participating in insurance can bring their household registration books, identity cards and other related materials to the relevant institutions responsible for social insurance in the street (town) and community (village) where they live (hereinafter referred to as "grass-roots agencies") for registration. The following personnel also need to provide relevant materials:

1. Those who are over 18 years old and insured as students and children need to provide the student status materials issued by the education department or school in our city's high school (including high school equivalent);

2, according to the provisions of the city's residence permit to participate in the insurance, you need to provide a residence permit within the validity period;

3. If the newborn (born within 12 months) is insured, it is necessary to provide birth medical certificate and parents' ID card;

4. If the prospective newborn is insured, it is necessary to provide the parents' household registration book and ID card;

5. During the year, retired soldiers, employees whose medical insurance was interrupted and released from prison should provide relevant materials such as certificates of retirement, employees' medical insurance interruption and release.

referring to article 3 of the detailed rules for the implementation of the measures for the basic medical insurance for urban and rural residents in Nanjing, the age determination of each insured person shall be based on his/her ID card, and the determination time shall be as of December 31st of the year when he/she registered for insurance, and the determination time of the insured person in the middle of the year shall be as of December 31st of the previous year.

referring to article 4 of the detailed rules for the implementation of the measures for the basic medical insurance for urban and rural residents in Nanjing, the medical insurance for urban and rural residents is paid annually, and the payment period is from November 1st to December 25th each year. If the insurance procedures are completed and the full payment is made within the specified payment period, the treatment period is from January 1st to December 31st of the following year.

in principle, college students pay according to the academic system, and pay the medical insurance premium in one lump sum according to the academic system according to the payment standard of the year when they enter school. The payment period is from September 1 to October 25 each year, and the treatment enjoyment period is from September 1 in the academic year to August 31 of the following year. Colleges and universities should organize and handle college students' insurance registration, payment and other related businesses in the payment period. The above treatment enjoyment period is collectively referred to as "a treatment year".

= Nanjing Municipal Bureau of Human Resources and Social Security-Detailed Rules for the Implementation of Measures for Basic Medical Insurance for Urban and Rural Residents