Basic medical care
(1) According to the outpatient service and hospitalization, the Qifubiaozhun of the overall fund is set respectively. The outpatient co-ordination Qifubiaozhun is based on the "lower limit of provincial social insurance payment base" published by the provincial government every year, and a dynamic adjustment mechanism is established according to the proportion. On-the-job employees account for 5% of the minimum annual social insurance payment base in Jiangsu Province, and retirees account for 3% of the minimum annual social insurance payment base in Jiangsu Province.
(2) The outpatient medical expenses of the insured person shall be paid by the personal account of that year; If the personal account in the current period is insufficient to pay, the personal account accumulated in the previous year or cash will pay the expenses of "outpatient co-ordination Qifubiaozhun"; The accumulated part that exceeds the "overall Qifubiaozhun" will be reimbursed by the overall fund according to different levels of medical institutions. The personal account funds accumulated by the insured in previous years can be used to pay the expenses that should be paid by individuals and reduce the personal cash burden.
(3) If the total amount of outpatient basic medical expenses exceeds the overall Qifubiaozhun during the year, it shall be paid by the overall fund and individual according to the level of designated medical institutions. That is, in tertiary hospitals, social pooling funds pay 50% and individuals pay 50%; Secondary hospitals, social pooling funds pay 70%, and individuals pay 30%; In the first-class hospitals and other designated medical institutions except designated community health service institutions, the social pooling fund pays 75% and the individual pays 25%; In my designated community health service institutions, the social pooling fund pays 90% and the individual pays 10%.
(4) the basic medical expenses incurred by the insured shall be paid by the personal account fund of that year; When the personal account fund is used up, the expenses within the hospitalization qifubiaozhun shall be paid with personal cash or the remaining personal account fund of the previous year;
(5) Co-ordinate hospitalization Qifubiaozhun: The Qifubiaozhun for the first hospitalization of on-the-job personnel is calculated according to the 3 rd, 2 nd and other 3 rd, 1 ST and other medical institutions with 4%, 3% and 2% of the "lower limit of the annual social insurance payment base in Jiangsu Province" respectively; If the patient is hospitalized for the second time during the year, the overall Qifubiaozhun will be reduced by 50% according to the level standard of the corresponding medical institution; From the third hospitalization, exempt from the overall Qifubiaozhun. Qifubiaozhun for retirees in hospital is 50% of the standard for on-the-job personnel.
(6) If the hospitalization basic medical expenses exceed the overall Qifubiaozhun, they shall be paid by the overall fund and individuals in proportion. On-the-job personnel are paid 85% by the overall fund and15% by individuals; Retirees are paid 90% by the overall fund, and individuals pay 10%.
First, the payment standard of employee medical insurance municipal co-ordination
1。 The basic medical insurance premium for employees shall be paid by both the employer and the employees. The employer shall pay 9% of the specified base; On-the-job employees shall pay 2% of the specified base; Flexible employees shall pay 1 1% of the specified base. The "serious illness pooling fund" is included in the personal account of the insured 1% and allocated from the pooling fund. Individuals do not need to pay fees.
2。 Self-funded supplementary insurance shall be paid by on-the-job employees and flexible employees according to the specified base of 0. 5%, the employee expenses are withheld and remitted by the employer; Retirees will not pay for the time being.
Second, the minimum payment period of employee medical insurance
The insured shall pay the insurance premium continuously. When reaching the statutory retirement age, if the minimum payment period is not less than 25 years for men and 20 years for women, and the actual payment period in this province has accumulated to 10 years or more (including 10 years), the basic medical insurance premium for employees will not be paid after retirement.
Insured persons who have reached the statutory retirement age but have not reached the prescribed payment period can pay the fees to the prescribed period year by year; You can also pay the basic medical insurance premium for the missing years in one lump sum according to 1 1%, and then you can enjoy the basic medical insurance benefits for retirees.
Third, how to transfer personal accounts after market unification.
On-the-job personnel under the age of 45 (including flexible employees) are included in 3% of the actual annual payment base of individuals; On-the-job personnel aged 45 and above (including flexible employees) are paid at 4% of the actual annual payment base.
4. What are the functions of personal accounts after market unification?
Personal accounts are divided into current personal accounts and previous personal accounts.
In that year, the personal account can be used to pay the compliant basic medical insurance premiums, and the balance can be used to pay the personal prepaid part of the drug expenses and the personal prepaid part of the medical treatment project expenses.
In previous years, personal accounts can deduct the expenses within the minimum threshold and the expenses paid by individuals in overall payment, and can also expand the use, such as purchasing designated commercial health insurance products.
Five, after the reunification of the city, what are the provisions for community health service institutions?
Every employee with medical insurance can designate two community health service institutions (including community health service centers, township health centers, Yunyang People's Hospital and Maternal and Child Health Hospital) as their designated community health service institutions.
Six, insured outpatient and emergency expenses how to reimbursement?
The outpatient and emergency medical expenses of the insured shall be paid by the personal account of that year; If the personal account in the current period is insufficient to pay, the personal account accumulated in the previous year or cash will pay the expenses of the "outpatient and emergency co-ordination Qifubiaozhun"; The accumulated part that exceeds the "overall Qifubiaozhun" will be reimbursed by the overall fund according to different levels of medical institutions.
7. How to settle the hospitalization expenses of the insured?
The hospitalization expenses of the insured shall be paid by the personal account of the current year; When the personal account is insufficient to pay, the "hospitalization Qifubiaozhun" fee is paid by the personal account and the cash accumulated in previous years; Beyond the "overall Qifubiaozhun" part, 85% will be reimbursed by the overall fund; Retirees are reimbursed 90% by the overall fund.
The hospitalization Qifubiaozhun is also based on the "lower limit of provincial social insurance payment base" announced by the provincial government every year, and a dynamic adjustment mechanism is established in proportion. Qifubiaozhun for on-the-job personnel's first hospitalization as a whole is calculated according to the three levels, two levels and other three levels, one level and other medical institutions, respectively, with 4%, 3% and 2% of the lower limit of the annual payment base of social insurance in Jiangsu Province; The second hospitalization in that year was halved; From the third hospitalization, exempt from the overall Qifubiaozhun. Qifubiaozhun for retirees in hospital is 50% of the standard for on-the-job personnel.
8. What are the overall benefits of the insured's serious illness?
1。 During the year, the basic medical expenses for outpatient, emergency and hospitalization paid by individuals in cash exceeded the "lower limit of provincial social insurance payment base"15% (6,000 yuan in 2022), and 60% was reimbursed by the serious illness pooling fund; Accumulated more than150% (60,000 yuan in 2022), 70% will be paid by the serious illness medical pooling fund.
2。 The basic medical expenses of the insured for the treatment of Class A infectious diseases and some mental diseases stipulated by the state shall be paid by the overall fund. The insured suffers from chronic renal failure, and the basic medical expenses for renal dialysis exceeding the overall Qifubiaozhun shall be paid by the overall fund. The insured person suffering from cancer, cancer treatment exceeds the basic medical expenses of the overall Qifubiaozhun, and the annual accumulated basic medical expenses are less than 50,000 yuan, which will be paid by the overall fund.
9. What aspects are reflected in the link between payment and treatment?
1。 For the insured whose continuous payment period is less than 5 years, the maximum amount of medical expenses settlement is 50,000 yuan, and the maximum amount decreases by 5,000 yuan every full year/kloc-0.
2。 The accumulated payment period of the insured during employment exceeds the minimum payment period (25 years for men and 20 years for women). For each additional year, the treatment of "serious illness medical co-ordination" after medical insurance retirement will increase by 1 percentage point, with a maximum of 5 percentage points (the reimbursement treatment for serious illness will reach 6 1%-75%).
X. How is the scope and standard of self-funded supplementary insurance stipulated?
1。 The hospitalization expenses incurred by the insured during the year in accordance with the provisions of the "three catalogues" of self-funded supplementary insurance shall be paid by the self-funded supplementary insurance fund for 45%.
2。 Due to malignant tumor, outpatient treatment really needs to use targeted drugs in the self-funded supplementary insurance catalogue, and 25% will be paid by the self-funded supplementary insurance fund.
3。 Out-patient positron emission computed tomography examination is paid by self-funded supplementary insurance fund for 25%.
I hope the above content can help you. If in doubt, please consult a professional lawyer.
Legal basis:
The "Interim Measures" of Zhenjiang social medical insurance sixth
Establish a social medical assistance system that focuses on supporting disadvantaged groups and faces social diversified sources of funds.
Article 7
Encourage units and individuals to participate in commercial health insurance on the basis of participating in social medical insurance.
Article 8
Medical insurance bureau (hereinafter referred to as the Municipal Medical Insurance Bureau) is entrusted by the Municipal Labor and Social Security Bureau as the administrative department of social medical insurance in this Municipality, and is responsible for the unified management of social medical insurance in this Municipality.
Municipal health, finance, education, auditing, drug supervision, civil affairs, industry and commerce, taxation, price and other departments shall, in accordance with their respective responsibilities, coordinate in the management of social medical insurance.
The establishment of social medical insurance agencies, responsible for urban social medical insurance business. According to the needs of the work, the medical insurance agency can set up a work site in the overall planning area to form a service network.
Article 9
Combined with the establishment of social medical insurance system, actively promote the reform of medical and health system, provide better services for the people at lower cost, and meet the people's demand for basic medical services.