Tianjin medical insurance outpatient special disease reimbursement standard
What is the threshold of outpatient special diseases, and what is the reimbursement ratio?
Outpatient threshold 1.300 yuan. Hospitalization or two or more outpatients occur at the same time, and they are combined according to the principle of "high priority". See the table below for details:
The current outpatient special disease treatment payment table in this Municipality
kind
Qifubiaozhun
Reimbursement ratio
Qifubiaozhun is 55,000 yuan.
55,000 yuan to 6.5438+0.5 million yuan
Outpatient special diseases
1300 yuan
In-service 85%
Retire 90%
According to the principle of high priority, what is the combined deductible?
Combined deductible means that in a natural year, outpatient medical expenses for special diseases and hospitalization medical expenses are subject to the same deductible standard according to the principle of higher deductible. The way to combine Qifubiaozhun is that the Qifubiaozhun for special diseases is only combined with the Qifubiaozhun for the first hospitalization in a year. Hospitalization is divided into one, two and three hospitals and family beds. First-class hospital deductible line 800 yuan, second-class hospital 1 100 yuan, third-class hospital 1700 yuan, family bed 660 yuan.
For example, under normal circumstances, the insured patients have paid the medical expenses of 1.300 yuan before hospitalization. If they choose a tertiary hospital for hospitalization, they still need to pay the Qifubiaozhun of 400 yuan; Choose a secondary hospital, a hospital or family beds, no longer charge Qifubiaozhun.
Under normal circumstances, if a patient is hospitalized in a tertiary hospital first, the threshold of 1300 will not be charged for the second visit. If you are hospitalized in a secondary hospital first, you have already paid the minimum payment standard of 1 100 yuan, and you need to pay the minimum payment standard of 200 yuan for the second treatment of the disease; If you are hospitalized in a first-class and first-class hospital and have paid the 800 yuan Qifubiaozhun, you need to pay the 500 yuan Qifubiaozhun for the treatment of portal diseases; 660 yuan Qifubiaozhun has been paid for family sickbed treatment first, and 640 yuan Qifubiaozhun has been paid for treatment of special disease.
What is the minimum payment standard, reimbursement ratio and maximum payment limit for outpatient special diseases?
The threshold fee for medical insurance for urban and rural residents is also 500 yuan. Hospitalization and treatment of portal vein diseases within one year, or two or more portal vein diseases, are combined into a one-time minimum payment, and the maximum payment limit is 6.5438+0.8 million yuan. The reimbursement rate of students is different from that of adult residents. Students and children are reimbursed according to the proportion of 65% in first-class hospitals, 60% in second-class hospitals and 55% in third-class hospitals. Adult residents also pay according to different levels and hospital levels, with 65%, 60% and 55% for first-class hospitals, 60%, 55% and 50% for second-class hospitals and 55%, 50% and 45% for third-class hospitals.
Tianjin outpatient special disease payment standard:
Type I: renal dialysis treatment and anti-rejection treatment after renal transplantation; Radiotherapy, chemotherapy and analgesia for cancer.
The qifubiaozhun of the overall fund is 65438+ 00% of the average annual salary of employees in this city in the previous year; For expenses above Qifubiaozhun and below the maximum payment limit, 85% of standard employees, 90% of retirees and 95% of old workers who participated in revolutionary work before the founding of the People's Republic of China will be paid by the overall fund.
Class II: diabetes; Pulmonary heart disease; Lupus erythematosus; Hemiplegia; Mental illness.
The Qifubiaozhun of the overall fund is 20% of the average annual salary of employees in this city in the previous year; For expenses above Qifubiaozhun and below the maximum payment limit, 85% of standard employees, 90% of retirees and 95% of old workers who participated in revolutionary work before the founding of the People's Republic of China will be paid by the overall fund.
Special diseases of Class I outpatient service shall be settled on a monthly basis, and special diseases of Class II outpatient service shall be settled on a quarterly basis.
The following items are paid by the overall fund:
(A) renal dialysis treatment
Hemodialysis, peritoneal dialysis and colon dialysis for acute and chronic renal failure; Electrolyte, hepatitis B virus markers, liver (kidney) function, blood (urine) routine examination; Antihypertensive drugs, erythropoietin drugs.
(2) Anti-rejection therapy after renal transplantation
Immunosuppressants, antihypertensive drugs, gastric mucosal protective agents, leukopenia drugs used for leukopenia caused by immunosuppressants; Renal puncture, cyclosporine concentration determination, B-ultrasound, color ultrasound, liver (kidney) function, blood (urine) routine examination.
(3) outpatient radiotherapy for cancer patients
Cancer radiotherapy, necessary supportive treatment during radiotherapy and symptomatic treatment of systemic or local reactions; X-ray examination, liver (kidney) function and routine blood (urine) examination.
Radioactive sources for radiotherapy include: radioisotopes; X-ray therapy machine, afterloading therapy, various accelerators.
Radiotherapy irradiation includes external irradiation, short-distance irradiation and isotope internal irradiation.
(4) Cancer outpatient chemotherapy.
Cancer chemotherapy (systemic and local), necessary supportive treatment during chemotherapy, and symptomatic treatment of local or systemic reactions after chemotherapy; X-ray examination, liver (kidney) function and routine blood (urine) examination.
Outpatient chemotherapy for cancer must be carried out in hospitals above the second level.
(5) analgesic treatment of cancer patients
Analgesics (oral and injection), analgesic pump (PCA), various nerve block analgesic methods (such as spinal nerve block and lumbar plexus block), traditional Chinese medicine and acupuncture.
(6) Pulmonary heart disease
Antibiotics, bronchodilators, expectorants, respiratory stimulants, diuretics, cardiotonic agents, vasodilators, drugs for reducing the right ventricular load and improving left ventricular function, adrenocortical hormones, drugs for reducing blood viscosity and preventing and treating complications, antitussive drugs, antiasthmatic drugs and traditional Chinese medicines; Blood gas analysis, electrolyte, electrocardiogram and chest X-ray examination; Continuous low concentration oxygen supply, tracheal intubation, mechanical respirator.
(7) Diabetes
Insulin, oral hypoglycemic drugs, traditional Chinese medicine; Routine examination of blood sugar, urine sugar and blood (urine).
(8) Lupus erythematosus (discoid lupus erythematosus, systemic lupus erythematosus)
Corticosteroid hormone (for internal and external use), immunosuppressant, immunopotentiator, traditional Chinese medicine, plasma exchange therapy, dialysis therapy.
(9) Hemiplegia
Treatment of lowering intracranial pressure and controlling hypertension; Brain metabolism activator, thrombolytic agent, anticoagulant, vasodilator, calcium antagonist, sedative, analgesic, antipyretic, acupuncture, traditional Chinese medicine.
(10) Mental illness
Antipsychotics, antimanic drugs, antidepressants, anti-anxiety drugs, traditional Chinese medicine, acupuncture.