In an insurance year, except for critical illness insurance, the total reimbursement expenses of each insured resident is up to 6,543,800 yuan+0.5 million yuan. Insured residents hospitalized, in line with the residents' medical insurance policy reimbursement within the scope of hospitalization expenses, deductible, reimbursement ratio according to the following table:

The proportion of reimbursement for referral step by step in the city, but not referral step by step or first visit to the third-level designated medical institutions in the city (except for acute and critical diseases and infectious diseases with special designated treatment) decreased 10 percentage point.

Second, the hospital delivery reimbursement

The medical expenses for hospitalization delivery of insured residents shall be reimbursed by quota, and the quota subsidy standards are: natural delivery 1000 yuan, cesarean section 1500 yuan. For multiple births, 200 yuan will be increased for each additional baby. 13 kinds of pathological cesarean section are implemented according to the hospitalization reimbursement policy of ordinary residents, and no longer enjoy fixed subsidies.

Third, reimbursement for serious illness.

After being reimbursed by the basic medical insurance, if the out-of-pocket expenses of medical insurance for urban and rural residents in the insured year exceed the policy range of 1.3 million yuan (6,500 yuan for poor people, orphans and low-income recipients), they will be reimbursed by stages in proportion; There is no top line for reimbursement. The reimbursement rate of serious illness insurance for poor people, orphans and low-income people will be increased by 5% on a segmented basis.

Fourth, outpatient medical reimbursement.

There is no deductible for general outpatient medical expenses of insured residents. In a natural year, the reimbursement limit is 150 yuan/person, which is for personal use only. The unused part of the quota in the current year will not be carried forward in the new year and cannot be used by family members. Designated medical institutions in the city (excluding outpatient clinics), 70% of the first-level and below designated medical institutions, and 60% of the second-level and above designated medical institutions; Designated medical institutions outside the city (excluding outpatient clinics) will be reimbursed by 50%.

Insured residents suffering from hypertension and diabetes are recognized by public medical institutions designated by districts and towns (streets) and included in the "two diseases management", with the reimbursement rate of 70%. The annual reimbursement limit for hypertension is 200 yuan/person, and the annual reimbursement limit for diabetes is 300 yuan/person. The maximum payment limit for hypertension and diabetes is calculated together.

Five, special outpatient reimbursement

The scope of special diseases in residents' outpatient service is divided into three categories and 48 diseases. The first category (19 diseases) will be reimbursed 70% within the policy scope, with an annual limit of 1000 yuan; The second category (18 diseases) will be reimbursed 70% within the policy scope, with an annual limit of 3,000 yuan; The third category (1 1 disease) is reimbursed 75% within the scope of the policy, and the accumulated reimbursement expenses do not exceed the personal annual maximum.

Six, a single drug payment

The insured uses 124 drugs negotiated by the state and 18 high-value drugs paid for single diseases, and the total drug expenses paid by the basic medical insurance fund in a natural year shall not exceed 654.38+10,000 yuan. After the use of 18 high-value drugs exceeds the payment limit of 65,438+10,000 yuan, the expenses will continue to be included in the scope of supplementary insurance payment such as serious illness insurance and medical assistance for urban and rural residents, and will be reimbursed according to regulations.