According to the basic requirements for the payment of basic medical insurance benefits in China, participants who go to medical insurance institutions to reimburse themselves for the medical expenses incurred in seeing a doctor generally have to meet the following conditions:
1. Participants must go to the designated medical institutions of the basic medical insurance to purchase medicines, or go to the designated retail pharmacies determined by the social insurance agency with the prescription issued by the doctor in the designated hospitals. Purchase of medicines.
2. Medical expenses incurred by insured persons in the course of seeking medical treatment must be in accordance with the scope and payment standards of the basic medical insurance drug list, diagnostic and therapeutic items, and standards of medical service facilities, in order to be paid by the basic medical insurance fund in accordance with the regulations.
3. The part of the medical expenses of the insured persons that meet the scope of payment of the basic medical insurance and are above the starting standard and below the maximum payment limit of the social medical insurance fund shall be paid by the social medical insurance fund in a uniform proportion.
Private hospitals are not eligible for reimbursement.
2, hospital reimbursement rate
1, the reimbursement rate of medical expenses during the hospitalization of active employees
"Basic medical insurance" patients: calculated according to a medical insurance year (January 1 - December 31). The reimbursement standard is as follows:
① The part of the starting line - 30,000 yuan is paid 85% by the integrated fund and 15% by the individual;
② The part of 30,000 yuan - 40,000 yuan is paid 90% by the integrated fund and 10% by the individual;
③ The part of 40,000 yuan - 70,000 yuan is paid by the integrated fund and 10% by the individual;
③ The part of 40,000 yuan - 70,000 yuan is paid by the integrated fund. 70,000 yuan, 95% paid by the coordinated fund and 5% paid by the individual;
④70,000 yuan-170,000 yuan, 70% paid by the large mutual fund and 30% paid by the individual;
⑤100% paid by the individual for the portion of more than 170,000 yuan.
2. Reimbursement rate of medical expenses during hospitalization for retirees
Basic medical insurance patients: calculated on the basis of one medical insurance year (January 1-December 31). The reimbursement rate is as follows:
① The part of the starting line-30,000 RMB is 91% paid by the integrated fund, 4.5% paid by the individual, and 4.5% paid by the supplement;
② The part of 30,000 RMB-40,000 RMB is 94% paid by the integrated fund, 3% paid by the individual, and 3% paid by the supplement;
③ The part of 40,000 RMB-70,000 RMB is 94% paid by the integrated fund, and 3% paid by the individual, and 3% paid by the supplement;
3 For the portion of 40,000 yuan-70,000 yuan, 97% is paid by the integrated fund, 1.5% by individuals and 1.5% by supplemental payment;
④ For the portion of 70,000 yuan-170,000 yuan, 70% is paid by the large mutual fund and 30% by individuals;
⑤ For the portion of more than 170,000 yuan, individuals pay 100%.
3. Reimbursement ratio of medical expenses during hospitalization for "Elderly People's Health Insurance for Major Diseases"
"Elderly People's Health Insurance for Major Diseases" patients: calculated on the basis of one medical insurance year (January 1 - December 31) The reimbursement rates are as follows The reimbursement standard is:
① the starting line - 70,000 yuan of the part of the medical insurance fund to pay 60% of the individual to pay 40%;
② 70,000 yuan (including outpatient special disease costs) above the part of the individual to pay 100%.