2. The maximum payment limit for chronic diseases cannot be exceeded in one medical year.
(1) Outpatient reimbursement rate
After getting basic medical insurance for urban workers, if you are an active employee, you can only be reimbursed for medical expenses over 2,000 yuan after visiting the outpatient or emergency clinic of a hospital, and the reimbursement rate is 50%. If you are a retiree under 70 years old, you can be reimbursed for expenses over 1,300 yuan, and the reimbursement rate is 70%. If the retiree is over 70 years old, expenses over $1,300 can be reimbursed the reimbursement rate is 80%. And no matter which category of people, the maximum amount of 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, the $500 portion is reimbursed at 50 percent, or $250.
(2) Hospitalization reimbursement rate
The current starting amount is 1,300 yuan for the first time in a year when you use the basic medical insurance to pay, whether you are an active employee or a retiree. For the second and subsequent hospitalizations, the starting amount is set at 50%, which is RMB 650. And the maximum payment from the Basic Medical Insurance Co-ordination Fund (for hospitalization expenses) in a year is currently 70,000 yuan.
(C), hospitalization starting standard
Tertiary including tertiary hospitals: 700 yuan within a year for multiple hospitalizations starting payment in order of 500 yuan, 400 yuan, 300 yuan employee health insurance reimbursement rate of 2016.
Second level including second level of specialized hospitals: 600 yuan within a year for multiple hospitalizations starting payment in order of 400 yuan, 300 yuan, 200 yuan.
The first level including the following hospitals: 500 yuan within a year multiple hospitalization starting payment in order of 300 yuan, 200 yuan, 100 yuan.
Below the maximum payment limit above the starting line, Category A and general diagnosis and treatment fees for active employees pay 85%
Retirees pay: 90%. Class B drugs pay 75% high precision pay 70%.
Employee health insurance for chronic and special diseases, major diseases, the annual starting standard is 700 yuan. Category A and general diagnosis and treatment pays 80%, Category B is 75% highly refined 70%.
(D), the scope of reimbursement
Outpatient and emergency medical expenses;
The cost of medicines purchased at designated retail pharmacies;
Emergency rescue and hospitalization and income inpatient treatment, the medical costs of their hospitalization before staying within 7 days;
Malignant tumors radiation therapy and chemotherapy, renal dialysis, kidney transplantation, taking antirejection drugs for outpatient medical expenses. The cost of the following.
The following items are excluded from the reimbursement of urban workers' medical insurance:
(1) Service item category.
(1) registration fee, out-of-hospital consultation fee, and cost of medical records;
(2) special medical services such as consultation fee, expedited fee for examination and treatment, surcharge for named surgery, quality and premium fee, and self-invited special nurse, etc.
The following items are not covered by the urban workers' medical insurance:
(1) outpatient medical expenses.
(2) The category of non-disease treatment programs.
(1) all kinds of beauty, fitness and non-functional cosmetic and orthopedic surgery;
(2) all kinds of weight loss, weight gain, height increase program.
(3) Health checkups;
(4) Preventive and health care programs;
(5) Medical consultations and appraisals.
(3) Diagnostic and therapeutic equipment and medical materials
Employee production, outpatient and inpatient medical reimbursement rates are different, and they both have a starting standard, over which medical expenses can be reimbursed. Not all medical items are eligible for reimbursement, and health insurance will not reimburse expenses for items such as cosmetic items, physical examinations and medical appraisals.
Legal basis
The Social Insurance Law of the People's Republic of China
Article 26 The standards of treatment for basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.
Article 27 Individuals who have participated in basic medical insurance for employees and whose accumulated contributions have reached the number of years prescribed by the State by the time they reach the legal retirement age shall not pay any more basic medical insurance premiums after their retirement and shall enjoy basic medical insurance benefits in accordance with the State's stipulations; and those who have not yet reached the number of years prescribed by the State may pay contributions up to the number of years prescribed by the State.
Article 28 Medical expenses that conform to the basic medical insurance drug list, diagnostic and treatment items, standards of medical service facilities, as well as those for emergency treatment and rescue, shall be paid out of the basic medical insurance fund in accordance with the state regulations.
Article 29 The portion of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be settled directly by the social insurance administrative organization with the medical institutions and drug business units.
The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.