The reimbursement policies for outpatient medical insurance in Shanghai are as follows:

(1) The reimbursement ratio for outpatient and emergency departments:

The medical expenses incurred by the insured in outpatient and emergency departments (including family sickbeds) are set as the minimum payment standard, specifically:

1. 3 yuan is for people aged 6 and above, severely disabled people, primary and secondary school students and infants;

2. People over 18 years old and under 6 years old are 5 yuan.

3. The part that exceeds the minimum threshold shall be paid by the urban and rural residents' medical insurance fund according to the following proportions: 7% for outpatient emergency treatment in community health service centers (or first-class medical institutions); 6% in the outpatient emergency of secondary medical institutions; In the third-level medical institutions outpatient emergency, pay 5%.

4. The medical expenses incurred by the insured in the clinic of the village clinic are not included in the Qifubiaozhun, and 8% will be paid by the urban and rural residents' medical insurance fund.

(II) Proportion of reimbursement for hospitalization:

The threshold for hospitalization (including observation in emergency observation room) is:

1. 5 yuan, a first-level medical institution, 1 yuan, a second-level medical institution and 3 yuan, a third-level medical institution.

2. The medical expenses incurred by insured residents in each hospitalization, which exceed the minimum threshold, shall be paid by the urban and rural residents' medical insurance fund according to the following proportions: 9% for people aged 6 or above and severely disabled people who are hospitalized in community health service centers (or first-class medical institutions), 8% for those hospitalized in second-class medical institutions and 7% for those hospitalized in third-class medical institutions;

3. For people under 6 years old, 8% of them are hospitalized in community health service centers (or first-class medical institutions), 75% in second-class medical institutions and 6% in third-class medical institutions.

(III) Reimbursement process:

1. Settlement procedures for hospitalization and outpatient treatment of special diseases:

Before the 1th day of each month, the designated medical institutions will report the expense statement, hospitalization statement and related materials of patients discharged from the hospital last month to the medical insurance agency, which will use them as the basis for monthly pre-allocation and year-end final accounts after review;

the medical insurance agency shall allocate the overall expenses for hospitalization and outpatient treatment of special diseases last month every month;

Insured persons who are identified as suffering from special diseases should go to a designated medical institution designated by the labor and social security department for medical treatment and purchase medicines, and the medical expenses incurred shall be directly accounted for and settled immediately.

2. Emergency settlement procedure:

The medical expenses incurred by the insured for emergency rescue to non-designated medical institutions in the city and medical institutions in different places shall be paid in advance by the individual or unit first. After the emergency rescue, the medical insurance agency shall go through the reimbursement procedures according to the regulations with the hospital emergency medical records, inspection, laboratory report, invoices and detailed medical charge list.

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