Medical insurance reimbursement scope and standards for urban employees and urban and rural residents

Medical insurance generally refers to basic medical insurance, which is established to compensate workers for their economic losses caused by disease risks. A social insurance system. The following is the medical insurance reimbursement scope and standards for urban employees and urban and rural residents that I have carefully compiled. I hope it will be helpful to you!

1. Drug reimbursement scope: According to the "Sichuan Province Basic Insurance Plan" "Medical Insurance, Work Injury Insurance and Maternity Insurance Drug Catalog" (2010 edition) (including 2,373 types of Western medicines, Chinese patent medicines, and ethnic medicines, including 1,817 Category B drugs) standard reimbursement, divided into Category A and Category B, and is carried out regularly Adjustment. All Category A drugs are included in the scope of reimbursement, and Category B drugs are included in the reimbursement scope after paying a certain percentage out of pocket (10% for Category B drugs, and 15% for Category B drugs with a minimum package price of more than 100 yuan as special drugs).

2. Scope of reimbursement for diagnosis and treatment items: Reimbursement is based on the standard reimbursement of diagnosis and treatment items that are allowed to be paid, partially paid, and not paid by basic medical insurance determined in the "Catalogue of Diagnostic and Treatment Items of Basic Medical Insurance for Urban Employees in Sichuan Province" . Attached is the catalog of diagnosis and treatment items of Sichuan Province’s basic medical insurance:

Diagnosis and treatment items that are not covered by basic medical insurance

(1) Service item categories:

1. Registration fee, consultation fee, house call fee, outpatient diagnosis and treatment fee, remote diagnosis and treatment fee, medical guidance service fee, etc.

2. Special medical service fees such as expedited examination and treatment fees, roll call (appointment) medical service fees, ward rounds fees, self-recruited special nurse fees, door-to-door service fees, discharge follow-up fees, full mother-child system services, etc. .

3. Medical record production costs, computer query and management fees, various bill production costs, etc.

(2) Non-disease treatment items:

1. Various beauty treatments such as freckles, acne, dark spots, warts, acne, freckle removal, pigmentation and hair loss (including alopecia areata) , gray hair, mole removal, ear piercing, saddle nose, breast augmentation, single eyelid to double eyelid, massage and beauty and other projects.

2. Various plastic surgery, orthopedics (except for sequelae of poliomyelitis) and physical defects treatment such as body odor removal, hare lip repair, stuttering correction, squint correction, polydactyly (toe) removal, circumcision, " O" shaped legs, "X" shaped legs, refractive errors, vision correction and other surgical items.

3. Diabetes decision support system, sleep breathing monitoring system, trace element detection, bone density measurement, human body information diagnosis, computer selection of the best pregnancy period, fetal gender and fetal development examination and other diagnostic and treatment projects.

4. Various diagnosis and treatment projects for weight loss, weight gain, height gain, bodybuilding, and smoking cessation.

5. Various health examinations.

6. Various preventive and health-care diagnosis and treatment items.

7. Various medical consultations (including psychological prediction, health prediction, dietary consultation, disease consultation), various predictions (including stroke prediction, health prediction, disease prediction,) various identifications (forensic identification, Work-related injury identification, labor identification, medical identification, paternity identification), health guidance and other projects.

(3) Treatment equipment and medical materials:

1. Cytoknife, positron emission segment device PET, electron beam CT, ophthalmic excimer laser therapy device and other large medical Equipment inspection and treatment items.

2. Glasses, prosthetic eyes, dentures, prosthetic limbs, hearing aids, brain-boosting equipment, leather (steel) vests, steel waistbands, steel necks, stomach supports, kidney supports, scrotal supports, pessaries, crutches , wheelchairs, deformed insoles, medicated pillows, medicated pads, hot compress bags, tourniquets, infusion nets, cremasteric belts, hernia belts, knee braces, artificial anal bags and other equipment.

3. Various household inspection and testing instruments (devices), treatment instruments (devices), physical therapy instruments (devices), massagers, magnetic therapy supplies and other treatment equipment.

4. Diagnosis and treatment projects using medical instruments, equipment and medical materials that do not comply with national or provincial regulations on the management and supervision of medical instruments, equipment and medical materials.

5. Disposable medical materials that cannot be charged separately according to the provincial price department.

(4) Treatment item categories:

1. Organ sources or tissue sources for various types of organ or tissue transplantation and related operations to obtain organ sources and tissue sources, etc.

2. In addition to kidney, heart valve, cornea, skin, blood vessel, bone, and bone marrow transplantation, the reimbursement scope and standards of medical insurance for urban employees and urban and rural residents for other organ or tissue transplantation Insurance reimbursement scope and standards.

3. Diagnosis and treatment items such as microwave (radio frequency) treatment for prostatic hyperplasia, helium-neon laser intravascular irradiation (blood therapy), new analgesia technology after anesthesia and surgery (analgesic bed), endoscopic retrograde appendography, etc.

4. Dental dentures, dental implants, dental implants, orthodontics, yellow and black teeth, defective teeth, stained teeth, baked magnetic teeth and other diagnostic and treatment items.

5. Qigong therapy, music therapy, hypnotherapy, magnetic therapy, water bar therapy, oxygen bar therapy, posture therapy, psychotherapy and suggestion therapy (except for mental patients), dietary therapy, nutritional therapy and other auxiliary services treatment program.

6. Diagnosis and treatment items for various infertility (pregnancy) diseases, sexual dysfunction and ultra-family planning.

7. Various scientific research, teaching, and clinical verification diagnosis and treatment projects.

Diagnosis and treatment items for which basic medical insurance pays part of the cost

(1) Diagnosis and treatment equipment and medical materials:

1. Application of r-knife, x-knife Knife, , color Doppler, medical linear accelerator and other large medical instruments for inspection and treatment projects.

2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy projects.

3. Various clinical monitoring (except intraoperative and postoperative monitoring).

4. Disposable medical materials that can be charged separately as stipulated by the provincial price department.

(2) Treatment item categories:

1. Hemodialysis and peritoneal dialysis treatment items.

2. Perform kidney, heart valve, cornea, skin, blood vessel, bone, and bone marrow transplant operations.

3. Artificial organs and bodies for internal replacement such as pacemakers, artificial valves, artificial joints, intraocular lenses, various stents, various staplers, various catheters, implanted drug delivery devices, etc. Built-in placement materials and installation or placement of surgical items.

4. Surgical projects such as cardiac bypass, cardiac catheter balloon dilatation, and cardiac radiofrequency ablation.

5. Coronary angiography, laparoscopic and thoracoscopic surgery, cardiac laser drilling, T lymphocyte reinfusion method in tumor biological therapy, prostate resection, tumor thermal therapy and other diagnostic and treatment items.

6. Various microwave, spectrum, far-infrared, photon (liquid therapy) and other auxiliary treatment items.

3. Scope of reimbursement for medical service facilities: Reimbursement shall be made according to the standards stipulated in the "Interim Measures for Medical Service Facilities of Basic Medical Insurance for Urban Employees in Sichuan Province". Attached to the scope of medical service facility items of basic medical insurance

The scope of medical service facility items paid according to the provisions of basic medical insurance

(1) Payment scope:

1. General ward beds

2. Outpatient (emergency) outpatient observation beds

3. Isolation ward beds

4. Critical rescue ward beds (CCU, ICU)

(2) Payment standards:

1. Ordinary ward beds are paid according to the price of ordinary ward beds for 3 people or more as stipulated in the price policy. Specialty and grade hospitals can pay according to the rising proportion stipulated in the price policy.

2. Outpatient (emergency) outpatient observation beds are paid according to the price stipulated in the price policy. However, the maximum price does not exceed the payment standard for beds in ordinary wards.

3. The payment standards for beds in isolation and critical care wards are appropriately relaxed and determined by each coordinating region based on actual conditions.

Scope of medical service facilities that are not covered by basic medical insurance

1. Transportation expenses for (referral) treatment, emergency ambulance fees, etc.

2. Air conditioning, heating, television, telephone, electric stove, refrigerator, baby incubator, food incubator, compensation for damage to public property, water, electricity, gas and other expenses.

3. Accompanying fee, bed accompanying fee, nurse fee, cleaning fee, bathing fee, medicinal bath fee, disinfection fee, haircut fee, washing fee, etc. 4. Outpatient decoction fees and traditional Chinese medicine processing fees.

5. Fees for cultural and entertainment activities, newspapers and magazines, and fitness activities. 6. Meal expenses.

7. Flowers and flower arrangements.

8. The cost of disposable items such as sanitary tableware, wash basins, cups, toilet paper, sheets, pillowcases, bed towels, and diapers.

9. The cost of daily necessities such as soap water, detergent, garbage bags, mosquito killers, etc.

10. Encyclopedia of reimbursement scope and standards of medical insurance for urban employees and urban and rural residents for other living service expenses.

4. Reimbursement standards for special medical material fees, one-time medical material fees and hospitalization bed fees: According to the "Garze Prefecture Medical Insurance Standards for Payment of Hospital Bed Fees, Special Medical Material Fees and One-time Medical Material Fees" ( Ganren Medical Insurance Center [2006] No. 29) and the "Reply on the Opinions on Adjusting the Payment Standards for Medical Insurance Inpatient Bed Fees and Medical Material Fees" (Ganren Social Insurance [2014] No. 28) shall be implemented.

(1) Payment standards for inpatient bed fees

1. The payment standards for inpatient bed fees and the basic medical insurance co-ordinating fund are unified. The specific payment standards are as follows: Tertiary hospitals: 35 yuan/bed day; second-level hospitals: 25 yuan/bed-day; first-level and unclassified hospitals: 15 yuan/bed-day; beds in critical emergency wards (ICU, CCU): 60 yuan/bed-day. If the hospitalization bed fee for insured persons is lower than the payment standard, it will be calculated based on the actual bed fee, and if it is higher than the payment standard, it will be calculated according to the payment standard.

2. The excess hospitalization bed charges for county-level cadres who enjoy civil servant medical subsidies will be separately included in the public service medical subsidies and a price limit will be provided to make up for the difference (personnel at the deputy department level and above enjoy separate subsidy for local-level cadres).

The specific subsidy limit standards are as follows: no more than 30 yuan/bed day for third-level hospitals; no more than 20 yuan/bed day for second-level hospitals; no more than 15 yuan/bed-day for second-level hospitals; no more than 10 yuan/bed for hospitals below second-level Day; beds in critical emergency wards (ICU, CCU) shall not exceed 20 yuan/bed day

(2) Payment standards for special medical materials

1. Implantation of human materials and artificial organs The cost of special medical materials such as special medical materials shall be included in the payment scope of the basic medical insurance pooling fund according to the following standards:

(1) If the unit price is less than 100 yuan (including 100 yuan), it will be included 100%;

< p>(2) If the unit price is between 100 yuan and 10,000 yuan (including 10,000 yuan), 80% will be included, and 20% will be paid by yourself;

(3) The unit price is between 10,000 yuan and 50,000 yuan (including 50,000 yuan) (4) If the unit price is more than 50,000 yuan, it will be included at 60%, and 40% will be paid out of pocket.

2. Clarify the special medical materials such as implanted human materials and artificial organs that are currently included in the payment scope of the basic medical insurance fund. Unspecified special medical materials such as implanted human materials and artificial organs are not yet included. Included in basic medical insurance payment coverage.

(3) Payment standards for disposable medical materials

100% of the cost of disposable medical materials used for treatment in hospital medical materials with a unit price of less than 10 yuan is included in the basic medical insurance plan Fund payment scope: If the unit price is more than 10 yuan (including 10 yuan), it will be included in the payment scope of the basic medical insurance overall fund after 20% is paid out of pocket for special projects. The cost of one-time medical materials used for non-treatment purposes is not included in the payment scope of the basic medical insurance pooling fund.

5. According to the "Notice on Including the Expenses of New Diagnosis and Treatment Projects into the Reimbursement Scope of Basic Medical Insurance" (Ganlao Social Insurance [2010] No. 38): the expenses of new diagnosis and treatment projects that are clinically treated for diseases (including the cost of diagnosis and treatment surgery and corresponding diagnosis and treatment materials), shall be included in the reimbursement scope of special items of basic medical insurance in accordance with the relevant provisions of the current medical insurance policy.

Disclaimer: This article only represents the author’s personal views and has nothing to do with this website.

Reimbursement ratio

1. Outpatient and emergency medical expenses: During the year (January 1st to December 31st) for active employees, the total medical expenses that meet the scope of basic medical insurance exceed 2,000 Yuan and above.

2. Settlement ratio: During the contract period, 50% of the dispatched personnel's expenses exceeding 2,000 yuan will be reimbursed, and the individual will pay 50%; the maximum amount of outpatient and emergency reimbursement paid to dispatched personnel in one year is 20,000 yuan.

3. Insured persons must properly keep the outpatient medical receipts (including receipts for large amounts and below, the bottom of prescriptions, etc.) for medical treatment at designated hospitals as a voucher for medical expense reimbursement.

4. Outpatient medical treatment for three special diseases: When the insured person needs to seek medical treatment in the outpatient department after radiotherapy and chemotherapy for malignant tumors, renal dialysis, and kidney transplantation, the insured person shall The designated secondary and tertiary hospitals for medical treatment will issue a "Disease Diagnosis Certificate", fill out the "Medical Insurance Special Disease Application Approval Form", and report it to the district medical insurance center for approval and filing. Outpatient medical treatment and medicine collection for these three special diseases are only available in designated hospitals approved for treatment, and cannot be purchased at designated retail pharmacies. If the medical expenses incurred fall within the prescribed range for outpatient special diseases, they will be settled with reference to hospitalization.

5. Inpatient medical treatment.

Only if you have paid enough medical insurance for 20 years can you enjoy medical insurance reimbursement after retirement.

The reimbursement ratio range of medical insurance varies from place to place. Please refer to local policies for details.

Function

1. It is conducive to improving labor productivity and promoting the development of production.

Medical insurance is the inevitable result of social progress and production development. In turn, the establishment and improvement of the medical insurance system will further promote social progress and production development. On the one hand, medical insurance relieves workers from worries and allows them to work with peace of mind, thereby improving labor productivity and promoting the development of production; on the other hand, it also ensures the physical and mental health of workers and the normal reproduction of the labor force.

2. Adjust income differences and reflect social fairness.

Medical insurance adjusts income differences by collecting medical insurance premiums and reimbursing medical insurance service fees. It is an important means for the government to redistribute income.

3. An important guarantee for maintaining social stability.

Medical insurance provides financial assistance to sick workers and helps eliminate social instability caused by illness. It is an important social mechanism for adjusting social relations and social contradictions.

4. An important means to promote social civilization and progress.

The social system of medical insurance and social mutual assistance reflects the new social relationship of "when one party is in trouble, all parties support" by sharing the risk of disease costs among insured persons, which is conducive to Promote social civilization and progress.

5. An important guarantee for promoting the reform of the economic system, especially the reform of state-owned enterprises.

How individuals pay basic medical insurance premiums

First of all, each coordinating region must determine a personal basic medical insurance contribution rate suitable for the burden level of local employees, which is generally 2% of salary income. Secondly, individuals pay basic medical insurance premiums based on their salary income and according to the prescribed local individual contribution rates. The base of personal payment should be based on the statistical caliber of wage income stipulated by the National Bureau of Statistics, that is, all wage income, including all kinds of bonuses, labor income and in-kind income, etc., as the base, multiplied by the prescribed personal payment rate, This is the basic medical insurance premium that I should pay. Third, individual contributions generally do not require individuals to go to social insurance agencies to pay, but are withheld and paid by the unit from wages.

How to establish a basic medical insurance pooling fund and personal account

In accordance with the provisions of the "Decision of the State Council on Establishing a Basic Medical Insurance System for Urban Employees" (Guofa [1998] No. 44), The funds injected into a personal account come from two parts: personal payment and unit payment: all personal payment is credited to the personal account, and part of the unit payment is credited to the personal account. The unit payment is generally transferred to the personal account at about 30%. However, since there are great differences in the level of medical consumption expenditures of employees of each age group, when determining the proportion of unit contributions credited to each employee's account in the coordinating area, the age factor must be taken into consideration to determine the different proportions of different age groups. Determining the specific proportion of unit contributions transferred to individual accounts shall be determined by the coordinating region based on factors such as the payment scope of individual accounts and the age of employees.

The funds injected into the overall planning fund mainly come from unit payments. The remaining portion after the unit payment is transferred to the individual account is the funds of the overall fund.

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