I. Students and children. In a billing year, incurred in line with the scope of reimbursement of medical expenses of less than 180,000 yuan, the starting standard for third-level hospitals 500 yuan, reimbursement rate of 55%; second-level hospitals starting standard for 300 yuan, reimbursement rate of 60%; first-level hospitals do not set the starting standard, reimbursement rate of 65%.
II. Elderly people over 70 years old. In a settlement year, the medical expenses of less than 100,000 yuan that meet the scope of reimbursement, the starting standard for third-level hospitals is 500 yuan, and the reimbursement rate is 50%; the starting standard for second-level hospitals is 300 yuan, and the reimbursement rate is 60%; and first-level hospitals don't have a starting standard, and the reimbursement rate is 65%.
Third, other urban residents. In a settlement year, incurred in line with the scope of reimbursement of medical expenses of less than 100,000 yuan, the starting standard for third-level hospitals is 500 yuan, reimbursement rate of 50%; second-level hospitals hospitalization starting standard is 300 yuan, reimbursement rate of 55%; first-level hospitals do not set the starting standard, reimbursement rate of 60%. If an urban resident is hospitalized for more than two times in one billing year, from the second hospitalization, the starting standard will no longer be charged. If they are transferred to another hospital or hospitalized for more than two times, the difference will be made up in accordance with the starting standard of the hospital to which they are transferred or to which they are re-admitted.
Hubei Rural Medical Insurance Reimbursement Ratio
I. Outpatient Reimbursement Ratio
Accumulated general outpatient emergency expenses incurred in one natural year for active employees exceeds 1,800 yuan, and the portion of 1,800 yuan or more is paid by 50% of the large amount of the Medical Mutual Aid Fund, while the individual pays 50% out-of-pocket. Retirees accumulated more than 1300 yuan, more than 1300 yuan part of less than 70 years of age of the large medical mutual fund to pay 70% of individual out-of-pocket payment of 30%, more than 70 years of age of the large medical mutual fund to pay 80%, individual out-of-pocket payment of 20%. The maximum payment limit is 20,000 yuan in a natural year.
Second, hospitalization reimbursement rate
The starting standard for the first hospitalization in a natural year is 1,300 yuan, and 650 yuan for each subsequent hospitalization. The payment ratio is divided into three grades, taking the third-level hospitals as an example, the starting standard: 30,000 yuan, 85% in service, 91% retired, 30,000-40,000 90% in service, 94% retired, more than 40,000, 95% in service, 97% retired. General hospitalization 90 days as a billing cycle. 360 days for psychiatric hospitalization is a billing cycle, and the starting and ending standards are halved. Maximum payment of 100,000 RMB from the integrated fund in one natural year. The maximum payment for hospitalized large amount is 200,000 yuan, and the payment ratio for hospitalized large amount is always 85%.
Hubei rural insurance is not reimbursable range
A, service category
① registration fee, outpatient consultation fee, inter-hospital consultation fee, medical records cost;
② out of the clinic fee, inspection and diagnosis of expedited fee, name surgery surcharge, quality premium fee, self-requested special nurses fee, and other special medical service fee;
③ referral transportation fee, ambulance fee;
4) Meal fee, air-conditioning cooling fee, heating fee, TV fee, telephone fee, food insulation and heating fee, compensation for damage to public property;
5) escorting fee, nursing fee, cleaning fee, decoction fee, and other living services and services and facilities type of fees.
Two, non-disease treatment projects
①All kinds of beauty, fitness projects and non-functional cosmetic and orthopedic surgery projects, such as: treatment of freckles, age spots, pigmentation, filling the nose, mole removal, warts, blepharoplasty, cosmetic massage, hair loss, armpit odor, teeth cleaning, dental, orthodontics, pigmented teeth, orthodontics, breast augmentation, etc.;
②All kinds of weight loss, weight gain, height enhancement projects, and so on. weight loss, fat gain, height increase program;
③ all kinds of health checkup;
④ all kinds of prevention, health care, family planning treatment program;
⑤ all kinds of medical consultation, medical appraisal;
⑥ all kinds of sanatorium convalescence costs.
Three, diagnostic and therapeutic equipment and medical materials
① application of positron emission computed tomography device (PET), ophthalmic excimer laser therapy and other large-scale medical equipment for the examination and treatment of the project;
② eyeglasses, dental prostheses, eye prostheses, prosthetic limbs, hearing aids, and other rehabilitation appliances;
③ all kinds of health care for their own use, massage, check and treatment Instruments, such as: massagers, massage cushions, wheelchairs for the disabled, infusion thermostat, a variety of self-use testing and treatment equipment, a variety of magnetic therapy equipment, a variety of traction belts, crutches, leather and steel back armour, waist circumference, steel head and neck, gastric support, kidney support, uterus, hernia belts, knee belts, testicular band, brain fitness device, pillows, pads, Shen Gong Yuanqi belt, hot packs, etc.;
④ Provincial and municipal pricing departments can not be separately charged for disposable medical materials. Provincial and municipal pricing departments stipulate that the disposable medical materials cannot be charged separately.
Four, the treatment program category
① vision and strabismus orthopedics;
② qigong therapy, music therapy, health care nutrition therapy, magnetic therapy and other complementary treatment programs.
V. Other:
①Organ or tissue transplantation of various organ or tissue source;
②Blood and various plasma products costs;
③various infertility (pregnancy), sexual dysfunction diagnosis and treatment;
④transgender surgery and other diagnostic and treatment projects;
⑤various scientific research, clinical validation of diagnostic and treatment projects;
6.
6 All additional insurance items during hospitalization (including premiums for artificial organ transplants such as installation of ** pacemakers);
7 Medical malpractice or medical expenses that have been identified as a medical malpractice dispute that has not yet been identified.
8 should enjoy the national and provincial special subsidy policy of the disease treatment costs.
Legal basis
"Chinese People's **** and the State Social Insurance Law"
Article 30
The following medical expenses are not included in the scope of payment of the basic medical insurance fund:
(a) should be paid from the workers' compensation insurance fund;
(b) should be borne by the third party;
(c) should be paid by the third party. person;
(iii) should be borne by the public ****health;
(iv) medical treatment outside the country.
Medical expenses shall be borne by a third party in accordance with the law, and if the third party fails to pay or if the third party cannot be identified, the basic medical insurance fund shall pay in advance. The basic medical insurance fund shall have the right to recover the costs from the third party after the first payment.