Personal account is an account set up by medical insurance institutions for the insured. Personal account funds and their interest are owned by the insured individuals and used for outpatient medical expenses and drug purchase in designated pharmacies. And can be carried forward and inherited.
2. What is a self-funded drug? What is out-of-pocket expenses?
Drugs such as health care drugs that do not belong to the basic medical drug list are self-funded drugs and will not be reimbursed.
In the process of reimbursement of basic medical insurance, it is divided into two categories: the first-class drug list and the second-class drug list. Those who belong to the Class B drug list need to bear 20% of the expenses, that is, out-of-pocket expenses. In addition, special medical expenses, such as CT and MRI, are also self-funded items.
3. How is a natural year divided?
Every year from 65438+1 October1to 65438+February 3 1 is a natural year. If you were hospitalized on February 30th, 2004 and discharged on October 5th, 2005, the reimbursement amount involved will be calculated in 2005.
4. How to choose a designated hospital? If I choose to be treated in the hospital this time, does it mean that I will be treated in this hospital in the future?
Designated hospitals are hospitals that have been examined by labor and social security departments, confirmed by social security institutions and signed cooperation agreements. You can choose a suitable designated hospital according to your own needs, and there is no fixed one.
5. Where do I need to reimburse after discharge? What information do I need to provide? Is there a time limit?
If the computer in your hospital is connected to the Social Security Bureau, you can directly settle accounts with the hospital by swiping your card when you leave the hospital; If there is no internet hospital, you will pay in full, and you will be reimbursed by the Social Security Bureau with relevant information after discharge.
If you are hospitalized in the city, you will be reimbursed by the Social Security Bureau within two months after discharge; If it is outside the city, go to the social security bureau for reimbursement within 3 months after discharge. The reimbursement place is in the infirmary on the third floor of Chengdu Social Security Bureau. You need to bring your social security card, ID card, discharge certificate, expense list and invoice. Working hours are from 9: 00 am to 12 pm and from 6: 00 pm to 5: 00 pm every Monday to Friday.
case analysis
Because the terms of basic medical insurance are more complicated, in order to make it easier for everyone to understand the policy, we use case analysis to interpret it. The basic medical insurance involves outpatient service and hospitalization. Here are a few examples.
First, hospitalization reimbursement
Generally speaking, the reimbursement rate of living in 1 hospital is higher than that of living in a tertiary hospital, and the higher the age, the greater the reimbursement rate.
For example, within 46,000 yuan.
Chen Mou, 40 years old, was hospitalized in a designated tertiary hospital and spent 30,000 yuan on medical expenses at one time (regardless of his own expenses and special expenses). Then, through the basic medical insurance, the amount of reimbursement that Chen Mou can enjoy this time is:
(30000-8084×12% )× [(75+40× 0.2) ÷100] = 29029.92× 83% = 24094.83 yuan.
The expenses that individuals need to bear are:
30000-24094.83 = 5905. 17 yuan
If you live in a designated 1 level hospital, the amount you can reimburse is:
(30000-8084× 5% )× [(75+40× 0.2) ÷100] = 29595.8× 83% = 24564.5438+0 yuan.
The expenses that individuals need to bear are:
30000-2456438+0 = 5435.49 yuan
Example 2: More than 46,000 yuan.
Liu, aged 50, was hospitalized in a designated tertiary hospital and spent 60,000 yuan on medical expenses (excluding self-funded and special needs). Then, the basic medical expenses that should be reimbursed calculated by the formula are:
(60000-8084× 5% )× [(75+50× 0.2) ÷100] = 59029.92× 85% = 50175.43 yuan.
However, according to the regulations, the accumulated reimbursement amount of basic medical insurance in a natural year cannot exceed four times the average salary of employees in this city in the previous year, and Chengdu is currently 46,336 yuan. The reimbursable expenses calculated by Liu through the formula have exceeded the upper limit.
Therefore, the actual expenses he can reimburse this time are 46,336 yuan, and the expenses that he needs to bear are as follows:
60000-46336 = 13664 yuan
B, outpatient reimbursement
Social security agencies have established individual accounts for basic medical insurance for each insured person. The amount in the personal account can be swiped at the pharmacy to buy medicine, and the outpatient medical expenses and hospitalization expenses can also be paid according to the regulations. When I go out to the clinic, if there is no balance in my personal account, I will pay in cash; Those who have savings are owned by themselves and can be inherited according to law.
Below, we will explain the incumbents, retirees and freelancers respectively.
In-service employee
First of all, all the personal contributions (that is, 2% of my monthly salary) are transferred to my personal account, and then the unit contributions are also transferred to my personal account. Therefore, the formula for calculating the monthly increase of personal account is:
Employees under 50 years old: (my monthly salary ×2%)+ (my monthly salary ×0.02%× my age)
Employees aged 50 and above: (my monthly salary ×2%)+ (my monthly salary ×0.035%× my age)
for instance
Wang is 30 years old, with a monthly salary of 1000 yuan. The total amount transferred to Wang's personal account every month should be: (1 0,000× 2%)+(10,000× 0.02 %× 30) = 26 yuan.
Jiang is 52 years old, with a monthly salary of 1200 yuan. The total amount transferred to Jiang's personal account every month should be: (1, 200×2%)+( 1, 200× 0.035 %× 52) = 24+21.84 = 45.84 yuan.
retiree
The calculation formula for the monthly increase of personal account is:
Last year, the average monthly salary of employees in this city was ×2%+ last year, the average monthly salary of employees in this city was ×0.035%× my age.
If the monthly basic pension of retirees is higher than the average monthly salary of employees in the previous year, it will be included in the calculation based on my monthly basic pension.
for instance
Zhang is 6 1 year old this year, and his monthly basic pension is 1000 yuan (higher than the average monthly salary of employees in Chengdu last year of 965 yuan). The amount that should be credited to a personal account every month is:
(1000× 2%)+(1000× 0.035 %× 61) = 41.35 yuan.
Huang is 62 years old, and his monthly basic pension is 800 yuan (lower than the average monthly salary of employees in Chengdu last year of 965 yuan). The amount that should be transferred to Huang's personal account every month is:
(965× 2%)+(965× 0.035 %× 62) = 40.3 yuan.
freelance journalist
The calculation formula for the monthly increase of personal account is:
Under 50 years old: the average salary of this city last year ×2%+ the average salary of this city last year ×0.02%× my age.
50 years old and above: the average salary of this city last year ×2%+ the average salary of this city last year ×0.035%× my age. (The average monthly salary in Chengdu last year was 965 yuan)
for instance
Zhu is 40 years old and is a freelancer. The total amount transferred to Zhu's personal account every month shall be:
(965× 2%)+(965× 0.02 %× 40) =19.3+7.72 = 27.02 yuan.
Guide to employee medical insurance
1. What designated medical institutions are there?
Local designated medical institutions: local designated medical institutions selected and announced by the social insurance management office of our bureau among the designated medical institutions determined by the local labor and social security administrative department.
2. How to see a doctor in a clinic?
Designated medical institutions:
The online designated pharmacies announced by the social security department can directly swipe their cards to seek medical treatment and purchase medicines, and the expenses directly offset the funds in personal accounts.
Local designated medical institutions: social security designated medical institutions announced by the local labor and social security departments can purchase medicines for medical treatment, and the expenses are paid in advance by themselves, and then reimbursed to the railway hospitals in their respective jurisdictions to offset the funds in personal accounts.
Medical process:
Medical institutions: medical certificate, IC card, medical record → registration → consultation room → holding inspection application form and prescription → pricing at the toll collection office → recording expenses into the microcomputer → canceling personal IC card account → inspection, disposal and taking medicine.
Local designated medical institutions: with medical records → registration → consultation room → holding examination application forms and prescriptions → pricing at the toll collection office → cash payment → taking medicines for disposal → holding valid vouchers → reducing personal accounts in railway hospitals under the jurisdiction of the unit.
Expense reimbursement:
Medical institutions can directly swipe their cards to offset the funds in personal accounts. The expenses of local designated medical institutions are paid by individuals first, and then the funds in personal accounts are offset by relevant bills in the designated institutions in the overall planning area. If the personal account is short of funds, you should take care of yourself.
3. What should I pay attention to in critical and severe rescue?
Principles of treatment:
In line with the principle of timely treatment, emergency treatment can be carried out in designated and non-designated hospitals nearby.
Due to emergency rescue in a nearby non-designated hospital, after temporary disposal, it should be transferred back to the designated medical institution in time. If it cannot be transferred back in time, the family members or units shall hold the emergency rescue certificate and illness summary, and go to the Social Insurance Management Office (Guiyang and Chongqing Medical Insurance Management Department) for approval and filing within 3 days (holidays postponed).
Expense reimbursement:
Calculate the reimbursement of hospitalization medical expenses. If the patient is hospitalized after emergency rescue, the expenses shall be included in the calculation of reimbursement of hospitalization medical expenses.
4. What are the rules for outpatient special diseases?
First, what is the outpatient special disease?
What is outpatient special disease?
Refers to the insured's illness, which requires long-term outpatient treatment under the condition of stable condition, and the medical expenses are high.
Second, the types of outpatient special diseases
Each master planning area has different regulations, among which:
Units in Sichuan are divided into two categories: the first category: diseases that can be treated with drugs in outpatient department after definite diagnosis: ① diabetes; ② stage Ⅱ and Ⅲ hypertension; ③ Aplastic anemia; ④ Hyperthyroidism; ⑤ Sequela of cerebrovascular accident; ⑥ Mental illness (stable period); ⑦ Cirrhosis; (8) Hepatitis A, B, C, D and E; Pet-name ruby pulmonary heart disease; Go to school in Parkinson's disease. The second category: diseases that can be treated in outpatient clinic after the condition is stable: ① radiotherapy, chemotherapy and postoperative outpatient support treatment for malignant tumors; ② Chronic leukemia; ③ Systemic lupus erythematosus; ④ Dialysis treatment of chronic renal failure; ⑤ Anti-immune rejection drugs after kidney (liver) transplantation.
Guizhou Setting: Dialysis treatment of various malignant tumors, aplastic anemia, hemophilia, systemic lupus erythematosus, chronic renal failure and anti-rejection treatment after organ transplantation.
Chongqing Setting: 1, Chemotherapy and analgesia for malignant tumor; 2. Dialysis treatment for patients with renal failure; 3. Anti-rejection therapy after kidney, heart valve and hematopoietic stem cell transplantation; 4. Diabetes 1 type and type 2; 5. Systemic lupus erythematosus; 6, hypertension, 1 high risk and extremely high risk, grade 2 hypertension, grade 3 hypertension; 7. coronary heart disease; 8. Rheumatic heart disease; 9, cerebrovascular accident sequelae, cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage sequelae; 10, bronchial asthma, chronic bronchitis with obstructive emphysema, chronic pulmonary heart disease; 1 1, liver cirrhosis, decompensated stage; 12, aplastic anemia; 13, schizophrenia, mood disorder, depression and mania, paranoid mental disorder; 14, tuberculosis.
Three, outpatient special disease management principles
The principles are as follows: define diseases, medical institutions, treatment items, drug scope, cost control standards, subsidy time limit, etc. ? 6? nine
Fourth,
1, in the hospital where the unit is located, you need to carry the confirmed information (examination and laboratory test sheet, etc.). ) I went to the medical insurance office of the hospital to fill out the Application Form for Special Diseases in Chengdu * * * Basic Medical Insurance Outpatient Service in Sichuan, and clearly declare the diseases (in Chongqing, I received the application form in my unit).
2, the hospital for preliminary examination, relevant review when necessary, a clear diagnosis, put forward the treatment plan, drug name and treatment time limit.
3. The hospital will summarize and submit the information of the declaration form to the social insurance management office on a monthly basis, mark the personal information after passing the examination and inform the hospital, and the hospital will inform the individual who receives the declaration form to keep the special prescription for outpatient special diseases, and then he can begin to enjoy the treatment of outpatient special diseases.
Retirees living in different places can go to the local designated hospital for medical treatment, but they need to get the declaration form from the social security office first, fill it out, stamp it in the hospital, and submit the relevant materials to the social security office for approval.
5. How to reimburse outpatient special disease expenses?
Former railway hospital: direct credit card, personal account funds are partially offset by personal payment, the insufficient part is paid in cash, and some are automatically reimbursed through the network.
Local hospital staff relocation expenses: submitted to the social security department for reimbursement every quarter.
Six, expense reimbursement standards
, the basic medical insurance fund reimbursement:
(1) Sichuan unit: The accumulated expenses of outpatient special diseases according to the natural year.
Payment from the overall fund: the accumulated insurance coverage of Class I diseases exceeds that of 400 yuan in a natural year, and it shall be paid by the overall fund according to the proportion of 40% in-service and 60% in retirement. In a natural year, the accumulated payment from the overall fund shall not exceed 1 000 yuan for in-service and 1 for retirement, 500 yuan. In a natural year, the accumulated insurance coverage of Class II diseases exceeds that of 970 yuan, which shall be paid by the overall fund according to the proportion of 80%;
(2) Guizhou: In each natural year, the outpatient medical expenses for special diseases below 700 yuan (including 700 yuan) shall be borne by individuals, and those above 5,000 yuan (including 5,000 yuan, the same below) in 700 yuan shall be borne by individuals; 5000 yuan to 10000 yuan, personal burden15%; 10000 yuan to 15000 yuan, personal burden10%; Personal commitment15,000 yuan or more, 5% of the part below the capping line.
Retirees bear 70% of the above items.
(3) In Chongqing, Qifubiaozhun is the same as hospitalization, which is calculated once a year and paid by individuals. If the outpatient medical expenses for special diseases are above the deductible line and below the capping line, the proportion of the overall fund payment is: chemotherapy, radiotherapy and analgesia for patients with advanced cancer, dialysis treatment for patients with renal failure, and anti-rejection drug treatment after organ transplantation is paid at 90%; Other special diseases are paid at 80%. The same patient in more than two designated medical institutions, according to the high-level medical institutions to determine the Qifubiaozhun charges.
2, supplementary medical insurance reimbursement:
After the above reimbursement, the rest of the supplementary medical care will be reimbursed according to the proportion of 70% retirement and 90% retirement. Funds above the maximum payment limit shall be reimbursed by 90%.
3. Cap line: In a natural year, the total amount of outpatient special diseases and hospitalization medical expenses paid by the overall fund and supplementary medical insurance fund to individuals shall not exceed the fund cap line stipulated by the basic medical insurance and supplementary medical insurance.
5. What are the rules for hospitalization reimbursement?
First, how to go through the hospitalization and discharge procedures?
1. hospital: with medical guarantee, IC card and admission ticket → go through hospitalization procedures (pay hospitalization advance payment) → go through hospitalization treatment → go through discharge procedures → settle accounts → only pay medical expenses paid by individuals.
2. Local designated hospitals announced by the social security department: with medical guarantee, unit certificate, ID card and admission ticket → go through hospitalization procedures (pay hospitalization advance payment) → go through hospitalization procedures → copy and prepare relevant reimbursement materials → settle accounts → pay medical expenses in full.
When leaving the hospital, you need to prepare reimbursement materials: the first copy of the unified medical receipt (original) stipulated by local provinces and cities, the list of expenses, the discharge certificate (original), the copy of objective medical records, the emergency medical records (emergency rescue), and the unit certificate. When you submit the reimbursement, you should attach the medical certificate and card.
3. The former railway hospital in the non-integrated area under the local administration: the medical treatment process is the same as that of the local designated hospital, but it still enjoys relevant treatment when reimbursing.
2. What is the reimbursement method?
Coordinating hospitals in the jurisdiction: no reimbursement is required, and it has been reimbursed through the network when leaving the hospital. Administration of local designated hospitals and other former railway hospitals: submit relevant reimbursement materials to the Social Security Department (Chongqing and Guiyang Medical Insurance Department) for review and reimbursement as required. The reimbursement amount will be wired to the unit, and the unit will inform me to collect the cash.
Illustrate the calculation method of hospitalization reimbursement with examples:
(1) Unit stationed in Sichuan:
Case 1. Fang, a retired employee, was born in August 1934 (has purchased supplementary medical insurance) and is hospitalized in Sichuan Provincial People's Hospital. When he was discharged from the hospital, he incurred medical expenses of 290,000 yuan. Among them, the self-funded expenses are 2,500 yuan, the expenses of Class B drugs and the items that pay part of the expenses are * * * 30,000 yuan, the expenses of imported implant materials are * * * 30,000 yuan, and the blood expenses are 5,000 yuan.
Where: compliance cost = 290,000 -2500-? 1? 730000×20% -? 1? 730000×36% -? 1? 75,000× 60% = 267,700 yuan
1, reimbursement expenses for basic medical insurance:
Reimbursement ratio = (75+70× 0.2 )× 100% = 89%
The total payment amount is (267700-970)×89% = 237389.70 yuan.
Because the ceiling line of 237389.70 > overall payment is 35000, the actual overall payment amount is 35000 yuan.
2, supplementary medical insurance reimbursement costs:
Subsidies above the threshold fee but below the capping line:
(35,000/89%-35,000) × 90% = 3,893.26 yuan
Subsidies above the top line of basic medical insurance:
Total cost = 267700-970-? 1? 735000/89% = 227404.438+06 yuan
Subsidy amount = 227,404.16× 90% = 204,663.74 yuan.
Because of 204663.74 > 150000, the payment cost of large supplementary medical insurance is150000-the supplementary medical insurance has paid 3893.26 =146106.74 yuan.
Total reimbursement for supplementary insurance: 3893.26+146106.74 =150,000 yuan.
3, basic medical insurance+supplementary medical insurance reimbursement:
35000+150000 =185000 yuan
Individuals need to pay: 290000-185000 =105000 yuan.
If you don't participate in supplementary medical insurance, you need to pay 255000 yuan.
(2) Guizhou unit
Example 2: An on-the-job employee was hospitalized for the first time in a local third-class first-class hospital this year due to illness, and the hospitalization medical expenses were 30,000 yuan, including: the cost of using the second-class drug list 1.2 million yuan; The operating cost of large medical devices is 1200 yuan, and the calculation method is as follows:
1, basic medical insurance reimbursement:
(1) Calculate the total personal burden in the early stage: 2640 yuan. These include:
Personal burden of Class B drugs:1.20,000× 20% = 2,400 yuan, personal burden of special examination and treatment expenses:1.20,000× 20% = 240 yuan. After excluding the first burden, the medical expenses to be shared by stages are 27360 yuan.
(2) Market segment share:
The personal burden totals 3588 yuan. These include:
Deductible line: 900 yuan (tertiary hospital)
The first paragraph:? 1? 75,000 -900× 20% = 820 yuan
The second paragraph:? 1? 710000-5000×15% = 750 yuan.
The third paragraph:? 1? 715000-10000×10% = 500 yuan.
The fourth paragraph:? 1? 727360-15000× 5% = 618 yuan.
The total payment from the overall fund is 23,772 yuan, of which:
The first paragraph:? 1? 75,000-900× 80% = 3,280 yuan
The second paragraph:? 1? 7 10000-5000× 85% = 4250 yuan
The third paragraph:? 1? 715000-10000× 90% = 4500 yuan
The fourth paragraph:? 1? 727360-15000× 95% =11742 yuan
Total of the above items: the personal burden is 6228 yuan, accounting for 20.76% of the total expenditure? 1? 7. Overall fund reimbursement: 23,772 yuan, accounting for 79.24% of the total expenditure.
2, supplementary medical insurance reimbursement:
Reimbursement amount = (27360-900-23772) × 70% =1881.6 yuan.
3. Basic+supplementary total reimbursement:
23772+1881.6 = 25653.6 yuan.
Individual needs to pay: 30000-25653.6 = 4346.4 yuan.
(If individuals who have not participated in supplementary medical insurance pay 6228 yuan)
(3) In Chongqing:
Example 3: Li (who has participated in supplementary medical insurance), a 53-year-old employee, was hospitalized in the former Neijiang Railway Hospital and incurred medical expenses *** 1680 yuan. The entrance fee for this hospital is 560 yuan (the entrance fee for local hospitals at the same level is 640 yuan), the fees for using self-funded drugs and self-funded medical treatment items are 1 10 yuan, and the fees for using Class B drugs and paying part of the expenses are 420 yuan.
Medical expenses that meet the requirements of basic medical insurance:
1680-110-420× 20% =1486 yuan
1, basic medical insurance reimbursement:
(1486-560) × 75% = 694.50 yuan.
2, supplementary medical insurance reimbursement: divided into two parts:
(1) threshold fee reimbursement: 560× 30% = 168 yuan.
(2) Reimbursement above the minimum expenses but below the maximum limit:
(1486-560-694.50) × 70% =162.50 yuan.
(3) Total: 330.05 yuan
3. Basic+supplementary total reimbursement:
694.5+330.05 = 1024.55 yuan
Personal payment is as follows:
1680-694.50-330.05 = 655.45 yuan
(If the specific provisions are inconsistent with the relevant policies of the overall planning area, the provisions of the overall planning area shall prevail. )
3. What are the provisions for reimbursement of basic medical insurance?
1. General principle: The basic medical insurance and supplementary medical insurance will not reimburse the self-funded part, 20% of the project expenses of Class B drugs and other project expenses beyond the limited reimbursement ratio.
2, the basic medical insurance Qifubiaozhun standard fee (more than the standard fee shall be reimbursed):
(1) In Sichuan, the first-level hospital is 400 yuan, the second-level hospital is 650 yuan, and the third-level hospital is 970 yuan. Qifubiaozhun is calculated by time. In a natural year, if you are hospitalized in a secondary or tertiary hospital for more than two times (including two times), the Qifubiaozhun will be gradually reduced to 80 yuan. Fees below the minimum amount should be paid through personal account or cash.
(2) Guizhou Units: 900 yuan, a tertiary hospital and its corresponding medical institution, 700 yuan, a secondary hospital and its corresponding medical institution, and 500 yuan, other medical institutions. In a natural year, the number of hospitalizations will be reduced in turn according to the above criteria. The minimum threshold fee is 300 yuan, a tertiary hospital; 200 yuan, a secondary hospital; Other medical institutions 100 yuan.
The threshold fee for retirees shall be reduced to 200 yuan according to the above standards, but it shall not be lower than the minimum threshold fee.
(3) Chongqing regional units: 400 yuan, a first-class hospital, 640 yuan, a second-class hospital, and 880 yuan, a third-class hospital.
Within one year, if you are hospitalized in Chongqing Railway Hospital, the threshold fee will be reduced by 1 percentage point on the basis of the above standards.
3, the basic medical insurance fund cap line (the highest reimbursement within one year, including outpatient special disease expenses):
(1) The current implementation standard in Sichuan is 35,000 yuan/year.
(2) In Guizhou: the current implementation standard is 39,000 yuan/year.
(3) Units in Chongqing: The current implementation standard is 32,000 yuan/year.
4. What is the reimbursement standard for hospitalization medical expenses?
1, basic medical insurance reimbursement:
Only the part that is higher than Qifubiaozhun and lower than the maximum limit of the total fund can be reimbursed.
(1) Sichuan:
Reimbursement amount = (total cost-threshold fee-out-of-pocket item cost and out-of-pocket part cost of Class B drugs ×20%)×(75%+ age× 0.2%).
(2) In Guizhou:
The threshold fee is more than 5,000 yuan (including 5,000 yuan, the same below), and the personal burden is 20%; 5000 yuan to 10000 yuan, personal burden15%; 10000 yuan to 15000 yuan, personal burden10%; 15000 to the top line, personal burden 5%. The rest is paid by the overall fund.
(3) In Chongqing:
Is it necessary to charge less than 5000 yuan for medical expenses above the threshold? 1? 7 5000 yuan, 70% for employees under 45 years old, 75% for employees over 45 years old (including 45 years old) and 85% for retirees; Pay for the rest.
5000 yuan to 10000 yuan (including 10000 yuan) for medical expenses, 75% for employees under 45 years old, 80% for employees over 45 years old (including 45 years old) and 90% for retirees; Pay for the rest.
10000 yuan to medical expenses above the top line, 80% of employees under 45 years old, 85% of employees over 45 years old (including 45 years old) and 95% of retirees pay; Pay for the rest.
Payment amount of the overall fund = (total hospitalization expenses-Qifubiaozhun-self-funded part-expenses of Class B drugs and diagnosis and treatment items that pay part of the expenses × 20% )× corresponding percentage coefficient.
2, supplementary medical insurance reimbursement:
(1) threshold fee for basic medical insurance pooling fund
The threshold fee for hospitalization in the former railway hospital: 30% for registered employees and 60% for retirees.
(2) Above the deductible line of the basic medical insurance and below the ceiling line of the overall fund: the balance after the overall fund is paid, and 70% of registered employees and 90% of retirees supplement insurance subsidies.
(3) The top line of the above-mentioned overall funds: 90% of registered employees and retirees receive supplementary insurance subsidies.
(4) Top line of supplementary medical insurance fund (maximum reimbursement within one year): the maximum reimbursement of supplementary insurance within a natural year is 1.5 million yuan.
The reimbursement scope of new rural medical security in Chengdu High-tech Zone
1, reimbursement scope
Where farmers go to the designated social security medical institutions in High-tech Zone (see Annex II) for medical treatment, the medical treatment items and drugs used are within the scope of "Chengdu Medical Service Price" and "Sichuan Basic Medical Insurance Drug Catalogue", which belongs to the reimbursement scope of the new rural insurance fund.
The medical expenses such as work-related injuries and disabilities of farmers are solved by the employer, which is not within the scope of reimbursement of the new agricultural insurance fund.
2. reimbursement standard
(1) outpatient medical expenses
Where outpatient treatment is conducted in the street community health service center (station) where the household registration is located, and the cost of diagnosis and treatment exceeds 10 yuan, the fixed subsidy per person per year is 10 yuan; If it does not exceed 10 yuan, it will be subsidized according to the actual amount.
(2) Hospitalization expenses
Where in the area of community health service institutions in hospital, medical qifubiaozhun for 100 yuan, more than 45% reimbursement; Hospitalization in the second-level and second-level hospitals designated by social security in this district, with the medical qifubiaozhun of 300 yuan, and the excess part will be reimbursed by 35% with the hospitalization referral certificate of community health service institutions in this district; The medical qifubiaozhun for hospitalization in the designated tertiary hospitals of social security in this district is 700 yuan, and the excess will be reimbursed by 25% based on the referral certificate of hospitalization in community health service institutions in this district.
The hospitalization expenses incurred by farmers in social security designated medical institutions in different places (outside Chengdu) during their migrant work shall be reimbursed by 25% except for the self-funded part.
The medical expenses of individual hospitalization for many times throughout the year are paid in installments. The annual personal reimbursement amount shall not exceed 12000 yuan.
Farmers who enjoy the new rural insurance in high-tech zones can voluntarily participate in rural medical insurance at the same time, but they can only choose one of them when reimbursing, and cannot be reimbursed repeatedly.
3, reimbursement procedures
The settlement of medical expenses reimbursement adheres to the principle of simplicity, locality and quickness, and two-level settlement is implemented with reference to social security medical reimbursement procedures. That is, community health service institutions (or social security designated medical institutions) and farmers timely settlement; The Social Security Bureau and the community health service institutions shall settle monthly 1 time, and the free medical examination fees provided by the community health service center shall be settled at the end of the year.
(1) outpatient expenses
Patients with my ID card (residence booklet) in the street community health service center (station) for household registration, timely settlement.
(2) Hospitalization expenses
Patients who are hospitalized in community health service institutions in the region and approved to be hospitalized in designated hospitals at or above the first level shall be paid in advance by individual farmers. After discharge from the hospital, the community health service center in the street where the household registration is located will review it and reimburse it on its behalf.
The expenses incurred by migrant farmers in hospitalization in social security designated medical institutions in different places (outside Chengdu) shall be audited by the community health service center of the neighborhood where they live on the basis of the identity certificate issued by the neighborhood office where they are registered after discharge, and reimbursed on their behalf.