(a) outpatient fee (outpatient fee Qifubiaozhun in 800 yuan) x50%.
(2) Hospitalization expenses (hospitalization expenses in 800 yuan or deductible line 1.300 yuan or 1.700 yuan) x (85% (on-the-job) or 90% (retired) medical expenses for some serious diseases except self-funded drugs are reimbursed:
(1) 80% of employees' medical treatment is paid by the overall fund and 20% by individuals;
(2) For retirees seeking medical treatment, the overall fund pays 85%, and the individual pays 15%.
Large medical insurance:
(1) 30,000 yuan to110,000 yuan (inclusive) for medical expenses, 94% for large medical insurance premiums, and 6% for individuals;
(2) For medical expenses ranging from 6,543,800 yuan to 200,000 yuan (inclusive), 96% of the large medical insurance premium is paid, and 4% is paid by the individual;
(3) For medical expenses of more than 200,000 yuan, 98% is paid for large medical insurance premiums, and 2% is paid for individuals.
Hospitalization medical insurance treatment standard: the hospitalization medical expenses incurred by students and children within one year are less than 6.5438+0.8 million yuan, and 75% will be reimbursed in a first-class hospital (community health service center); The second-level hospital, starting from 400 yuan, has a reimbursement rate of 65%; A tertiary hospital, with a threshold of 500 yuan, has a reimbursement rate of 55%. Among them, the first-level hospital Qifubiaozhun is 300 yuan, the second-level hospital Qifubiaozhun is 400 yuan, and the third-level hospital Qifubiaozhun is 500 yuan. If urban and rural residents are hospitalized for more than two times in a settlement year, starting from the second hospitalization, the Qifubiaozhun fee will no longer be charged. Transfer or hospitalization for more than two times, make up the difference of Qifubiaozhun in accordance with the provisions of transfer or hospitalization again. Reimbursement standard for large medical expenses of outpatient and emergency departments: within one year, the threshold for outpatient and emergency medical expenses incurred by urban and rural residents in first-class hospitals and community medical institutions is 600 yuan, with the maximum payment limit of 3,000 yuan and the reimbursement ratio of 50%.
Legal basis: opinions of Tianjin Municipal People's Government on further improving the medical insurance system 1. Give play to the basic role of medical insurance in deepening the reform of medical and health system. (1) Safeguarding and safeguarding the rights and interests of the insured. Promote the full coverage of medical insurance participants, consolidate the achievements of universal medical insurance in our city, improve the reimbursement policy, ensure that the medical expenses incurred by the insured within the scope of the policy are compensated in time according to regulations, and protect the people's medical insurance rights and interests. Give full play to the basic role of medical insurance, guide medical service institutions to actively control the excessive growth of medical expenses, and effectively reduce the medical burden of the people. (2) Promoting the comprehensive reform of public hospitals. According to the overall deployment of comprehensive reform of public hospitals in the city, Ministry of Human Resources and Social Security City took the lead in formulating and implementing supporting policies for medical insurance, and gave support in terms of budget quota of medical insurance fund, reform of payment methods, information technology support, multi-point practice of doctors, and price adjustment of drugs and diagnosis and treatment projects. (three) to support the development of graded diagnosis and treatment. Medical institutions shall conduct graded diagnosis and treatment, and medical insurance shall implement differentiated payment policies. The proportion of medical insurance reimbursement for employees in primary medical institutions is higher than that in high-level medical institutions, and the hospitalization qifubiaozhun is lower than that in high-level medical institutions. Outpatient service, outpatient specific disease, hospitalization referral and deductible line are calculated continuously. The scope of drug reimbursement in primary medical institutions is extended to the product specifications in the basic medical insurance drug list. Doctors in primary medical institutions issue long-term prescriptions and pay for basic medical insurance. To carry out multi-point practice of doctors, the medical insurance management department shall timely maintain the multi-point practice information of medical insurance service doctors to ensure that they can provide medical insurance services for the insured in various practice places. (four) to explore the establishment of a social insurance system that meets the requirements of the combination of medical care and nursing. In accordance with the requirements of the state and this Municipality to promote the integration of medical and health care and old-age care services, we should explore diversified insurance financing models, establish a long-term care insurance system, ensure the long-term care service needs of the elderly, and share residents' economic risks and family care costs.