Rural
Edit
Outpatient
Village health centers and village central health centers are reimbursed for 60% of the medical fees, with a limit of 10 yuan for prescription drugs per visit, and 50 yuan for temporary rehydration of prescription drugs by a health center doctor; township health centers are reimbursed for 40% of the medical fees, with a limit of 50 yuan for each checkup and surgery, and 100 yuan for prescription drugs; second-level Hospital visits are reimbursed 30%, with a limit of 50 yuan per visit for each examination and surgery, and a limit of 200 yuan for prescription drugs; tertiary hospital visits are reimbursed 20%, with a limit of 50 yuan per visit for each examination and surgery, and a limit of 200 yuan for prescription drugs; traditional Chinese medicines invoices accompanied by a limit of 1 yuan for each sticker of the prescription; and an annual limit of 5,000 yuan on outpatient reimbursement for township-level cooperative medicine[2].
Hospitalization
Reimbursement scope: medicine: auxiliary examination: EKG, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, CT, nuclear magnetic **** vibration and other various examination fees limit 200 yuan; surgical fees (with reference to the national standard, reimbursement of more than 1,000 yuan according to the amount of 1,000 yuan).The elderly people aged 60 years or older are hospitalized in the health centers, and the daily compensation for treatment and nursing care fees is 10 yuan, with a limit of 200 yuan.
Reimbursement rates: township health centers reimburse 60%; secondary hospitals reimburse 40%; tertiary hospitals reimburse 30%.
Major illnesses
Any hospitalized patient who participates in the cooperative medical care system will be compensated for the one-time or yearly accumulative medical expenses of more than 5,000 yuan, i.e., 65% of the 5,001-10,000 yuan, and 70% of the 10,001-18,000 yuan. The annual limit of compensation for inpatient hospitalization and outpatient blood dialysis for uremia, outpatient radiotherapy and chemotherapy for tumors is 11,000 yuan at the township level cooperative medical treatment.
Exemptions
Medical expenses for self-medical treatment (medical treatment in unappointed hospitals or without referral orders), self-purchased medicines, medicines that cannot be reimbursed under the provisions of the public medical care and medical expenses that are not in line with the family planning; outpatient treatment fees, consultation fees, hospitalization fees, meal fees, companion fees, nutritional fees, blood transfusion fees (except for those who have blood stored in their families, which are reimbursed in accordance with the relevant regulations), heating and cold air fees, ambulance fees, and special other expenses such as nursing fees; medical expenses for car accidents, fights, suicides, alcoholism, work accidents and medical accidents; orthopedic, cosmetic, dental, prosthetic, organ transplantation, named surgery fees, consultation fees, etc.; reimbursement within the scope of reimbursement, but not outside the limit. [2]
Urban
Editorial
Urban residents who are hospitalized for more than two times in a billing year will not be charged the starting standard fee from the second hospitalization. If they are transferred to another hospital or hospitalized more than twice, the difference will be made up in accordance with the stipulated starting payment standard for the hospital to which they are transferred or re-admitted.
Students and children
For medical expenses under 180,000 RMB incurred within a billing year that are eligible for reimbursement, the starting standard for Level III hospitals is 650 RMB, with a reimbursement rate of 50% and a ceiling of 2,000 RMB; the starting standard for Level II hospitals is 300 RMB, with a reimbursement rate of 60%; and Level I hospitals do not have a starting standard, with a reimbursement rate of 65%.
Age 70 and above
In a billing year, for medical expenses of less than 100,000 yuan that are eligible for reimbursement, the starting standard for a tertiary hospital is 650 yuan, with a reimbursement rate of 50% and an upper limit of 2,000 yuan; the starting standard for a second-level hospital is 300 yuan, with a reimbursement rate of 60%; and there is no starting standard for a first-level hospital, with a reimbursement rate of 65%.
Other urban residents
In a billing year, for medical expenses of less than 100,000 RMB incurred that are eligible for reimbursement, the starting standard for third-level hospitals is 659 RMB, with a reimbursement rate of 50% capped at 2,000 RMB; the starting standard for second-level hospitals' inpatient hospitalization is 300 RMB, with a reimbursement rate of 55%; and first-level hospitals do not have a starting standard, with a reimbursement rate of 60%. [3]
Urban and rural residents
Edit
On January 12, 2016, the State Council issued the Opinions on the Integration of the Basic Medical Insurance System for Urban and Rural Residents, which requires the integration of the two systems of basic medical insurance for urban residents (hereinafter referred to as the Urban Residents' Medical Insurance) and the new type of rural cooperative medical care (hereinafter referred to as the New Rural Cooperative Medical Care), and the establishment of a unified basic urban and rural residents' medical insurance (hereinafter referred to as urban-rural residents' medical insurance) system. [4] The following are the reimbursement rates for urban and rural residents in various regions.
Hunan
"Implementation Measures for Basic Medical Insurance for Urban and Rural Residents in Hunan Province"[5]
Article 27: The portion of hospitalization medical fees within the scope of the policy incurred by insured residents at the designated medical institutions for basic medical insurance in the integrated area that is above the starting standard shall be paid for by the urban and rural residents' medical insurance fund according to a ratio: no less than 80% for township health centers and community health service institutions no less than 70% for county-level medical institutions, and no less than 60% for municipal-level medical institutions. Each coordinated area in accordance with the urban and rural residents health insurance fund income and expenditure situation reasonably determine the specific payment ratio.
Article 28 of the insured residents hospitalized in provincial designated medical institutions, the starting standard in accordance with the provincial designated medical institutions in the previous year, about 10% of the average cost of hospitalization, and not less than 1,500 yuan, hospitalization medical expenses within the scope of the policy to pay the proportion of not less than 50% of the specific payment standards by the provincial human resources and social security department in conjunction with the provincial department of finance in accordance with the coordinated areas of the urban and rural residents' medical insurance fund The specific payment standard shall be reasonably determined by the Provincial Human Resources and Social Security Department in cooperation with the Provincial Department of Finance according to the operation of the urban and rural residents' medical insurance fund in each coordinated area and the situation of the insured residents' medical treatment.
Article 30 of the urban and rural residents health insurance fund set the maximum payment limit for hospitalization. Within a settlement year, the cumulative maximum payment limit for urban and rural residents' basic medical insurance (excluding urban and rural residents' major disease insurance) is unified at 150,000 yuan. [6]
Henan
"Measures for the Implementation of Basic Medical Insurance for Urban and Rural Residents in Henan Province (for Trial Implementation)
Article 13 General Outpatient Medical Treatment. A comprehensive outpatient coordination system has been established. Localities can establish outpatient co-ordination funds in accordance with about 50% of the local per capita contribution, mainly for the payment of general outpatient medical expenses incurred by insured residents in primary designated medical institutions (including general consultation and treatment fees, the same below). There is no starting standard for the outpatient coordination, the reimbursement rate is about 60%, and the cumulative reimbursement within a year is limited to about two times the local per capita contribution amount. Where the conditions for the establishment of an outpatient coordinating system are not yet in place, family accounts (individual accounts) may still be used to pay for general outpatient medical expenses. The amount to be credited to the family account (individual account) is determined by reference to the per capita standard for outpatient coordination. Family accounts (individual accounts) should be gradually transitioned to outpatient coordination. Specific measures shall be formulated by the provincial municipalities.
Article 14 outpatient chronic disease medical treatment. Localities should refer to the original basic medical insurance for urban residents and the new rural cooperative medical policy, select part of the need for long-term or lifelong outpatient treatment and higher medical costs of diseases (or treatment programs) into the scope of outpatient chronic disease management. There is no starting standard for outpatient chronic diseases, and the reimbursement rate is no less than 65%, with fixed-point treatment and quota management. Specific measures to be formulated by the provincial municipalities.
Article 16 of the hospitalization medical treatment. Participating residents in the designated medical institutions in the policy scope of hospitalization medical expenses, the starting standard below the individual to pay; starting standard above the hospitalization fund to pay a proportion of the coordinated fund, the amount does not exceed the annual maximum payment limit of the hospitalization fund.
The guidelines for the starting payment standard and reimbursement ratio of hospitalization for insured residents in 2017 are as follows:
Category
Hospital range
Starting payment standard (yuan)
Reimbursement ratio
Township
Township health center
(community medical institution)
200
200-800 yuan 70%
Over 800 yuan 90%
County-level
Second-level or below
(including second-level) hospitals
400
400-1500 yuan 63%
More than 1500 yuan 83%
Municipal
Second level or below
(including second level) hospitals
500
500-3000 yuan 55%
More than 3000 yuan 75%
Tertiary hospitals
900
900-4000 yuan 53%
4000 yuan or more 72%
Provincial
Second level or below
(including second level) hospitals
600
600-4000 yuan 53%
More than 4,000 yuan 72%
Tertiary hospitals
1,500
1,500-7,000 yuan 50%
More than 7,000 yuan 68%
Outside the province
1,500
1500- 7,000 RMB 50%
68% above 7,000 RMB
The starting payment standard is halved for insured residents under 14 years of age (including 14 years of age). For other insured residents, the starting standard will be reduced by half for the second and subsequent hospitalizations in hospitals at or above the county level during the year.
Determining the annual maximum payment limit of the hospitalization fund, which is 150,000 yuan for the 2017 year.
Provincial municipalities may, according to the fund's income and expenditure situation and the level of medical consumption, appropriately adjust the starting payment standard and reimbursement ratio for hospitals below (including) the municipal level. [7]
Employees
Edit
Generally speaking, the economic development of different regions varies, so the reimbursement rate also varies, the following on the situation of the proportion of Beijing employees' medical insurance coverage.
After getting medical insurance, if you are an active employee, you can only be reimbursed for medical expenses above 1,800 yuan after visiting the outpatient or emergency clinic of a hospital, and the reimbursement rate is 50 percent. If you are a retiree under the age of 70, you can be reimbursed for expenses over $1,300, and the reimbursement rate is 70%. If the retiree is over 70 years old, the reimbursement rate is 80 percent for expenses over $1,300.
And regardless of the type of person, the maximum limit for expenses paid for outpatient and emergency major medical expenses is 20,000 yuan. For example, if you are an active employee and spend $2,500 on an outpatient visit, then 50% of the $500 portion can be reimbursed, which is $250. [8]
In the case of hospitalization expenses, the starting amount is $1,300 for the first time you use basic medical insurance to pay in a 2009 year, whether you are an active employee or a retiree. And for the second and subsequent hospitalization medical expenses, the starting amount is determined at 50%, which is 650 yuan. And the maximum payment amount of the basic medical insurance fund (hospitalization expenses) is 70,000 yuan in 1 year.
The standard of hospitalization reimbursement is related to the level of the hospital where the insured person stays, such as staying in a tertiary hospital, from the starting standard to 30,000 yuan, the employee pays 15%, which means 85% reimbursement; from 30,000 yuan to 40,000 yuan, the employee pays 10%, which means 90% reimbursement; for the portion of the expenses exceeding 40,000 yuan and up to the maximum payment limit, 95% of the expenses can be reimbursed, and the employee only has to pay 5%. And while retirees pay 60 percent of what active (that is, the aforementioned) employees pay individually, anything below the starting threshold is paid by the individual.
The diagnostic and therapeutic items that are not paid for by the basic medical insurance for employees are mainly non-clinically necessary and uncertain diagnostic and therapeutic items as well as diagnostic and therapeutic items for special medical services, including services such as registration fees, non-disease treatments such as cosmetic treatments, therapeutic equipment and materials such as hearing aids, therapeutic items such as magnetic therapy, and other categories such as infertility treatments, and so on. In accordance with the "National Basic Medical Insurance Treatment Program Scope", the details are as follows:
(a) Service program category. (1) registration fee, out-of-hospital consultation fee, medical record cost, etc.; (2) visit fee, examination and treatment expediting fee, surcharge for named surgery, quality and premium fee, self-invited special nurses and other special medical services.
(2) Non-disease treatment program category. (1) a variety of beauty, fitness items and non-functional cosmetic, orthopedic surgery; (2) a variety of weight loss, weight gain, height projects; (3) a variety of health checkups; (4) a variety of preventive, health care clinic programs; (5) a variety of medical consultation, medical appraisal.
(C) diagnostic and treatment equipment and medical materials. (1) the application of positron emission tomography (PET), electron beam cT, ophthalmic excimer laser therapy and other large-scale medical equipment for examination and treatment programs; (2) glasses, dentures, eye prostheses, prosthetics, hearing aids and other rehabilitative devices; (3) a variety of health care for their own use, massage, checking and treatment equipment; (4) the provincial pricing departments can not be charged separately for the disposable medical.
(4) treatment program category. (1) all kinds of organ or tissue transplantation of organ source or tissue source; (2) in addition to kidney, heart valve, cornea skin, blood vessels, bone, bone marrow transplantation; (3) myopic eye orthopedics; (4) qigong therapy, music therapy, health care of nutritional therapy, magnetic therapy and other auxiliary treatment projects.
(5) Others. (1) a variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment program; (2) a variety of scientific research, clinical verification of the diagnosis and treatment program.
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