The starting line is set according to the level of hospitals, which is 100 yuan for hospitals below the city level, 200 yuan for hospitals at the second level, and 300 yuan for hospitals at the third level. If a participant is referred to a different hospital for inpatient treatment, the starting line will be calculated separately. The reimbursement ratio of outpatient and inpatient medical insurance in Shenzhen:
The individual account of a participant of the first class of basic medical insurance is used to pay for the basic outpatient medical expenses of the participant, the local supplemental medical expenses, and the expenses of purchasing the medicines within the scope of the medical insurance catalog in the designated retail pharmacies with the prescription issued by the doctors of the designated medical institutions in the city, and the part of the individual account that is not sufficient to pay for the expenses is to be paid by the participant himself/herself.
One, the basic medical insurance first class participants have been continuously insured for one year, in the same - medical insurance year, the individual out-of-pocket basic outpatient medical expenses and local supplementary medical expenses exceeded the average salary of employees in the previous year in the city. Last year, the average salary of on-the-job workers of 5%, the part of the excess by the basic medical insurance fund or local supplementary medical insurance fund to pay 70%, 80% of the participant aged 70 years or older.
2. If the accumulated amount of the individual account of a participant in the first grade of basic medical insurance exceeds 5% of the average salary of the on-the-job workers in the previous year in the city, the exceeding portion can be used to pay for the following expenses:
1. The expenses of non-prescription drugs within the scope of the drug catalog of basic medical insurance and local supplementary medical insurance purchased by the participant at the designated retail pharmacy;
2. The expenses for the spouse and immediate family members of the participant and the spouse of the participant participating in the basic medical insurance of the city. Spouses and immediate family members who are covered by the city's basic medical insurance will have to pay for the basic medical expenses and local supplementary medical expenses when they visit the designated medical institutions;
3. Health check-ups and preventive vaccinations for the spouses and immediate family members who are covered by the city's basic medical insurance will have to be paid for by me and my spouses and immediate family members who have been covered by the city's basic medical insurance;
4. Other medical expenses stipulated by the State, Guangdong Province and the city will have to be paid for by me and my spouses who have been covered by the city's basic medical insurance.
3. 70% of the basic medical expenses and local supplementary medical expenses incurred by the participants of the first class of basic medical insurance in the designated community health centers of the city shall be paid by their individual accounts, and 30% shall be paid by the Basic Medical Insurance Fund for Major Diseases and the Local Supplementary Medical Insurance Fund in accordance with the provisions of the Basic Medical Insurance Fund, with the exception of the expenses of the following items:
1. Stomatology treatment expenses;
2, Rehabilitation and physical therapy costs;
3. Large-scale medical equipment inspection and treatment costs;
4. Other items prescribed by the municipal government.
Maximum amount of reimbursement
In Shenzhen, in a medical insurance year, the cumulative interruption of more than three months of service, is called a break in the continuous payment of contributions, that is, "years of zero", which will affect the maximum reimbursement and reimbursement rate.
The maximum amount of reimbursement for Shenzhen medical insurance is the limit of payment from the basic medical insurance fund and the limit of payment from the local supplementary medical insurance fund, which are linked to the number of years of contribution.
For example, if you have paid your social security contributions for less than 6 months, then, when you go to the hospital, the payment limit of the basic medical insurance co-ordination fund = ( 6753 yuan x 12 months) x 1=81,036 yuan ( 6753 is the 2015 social wage) , so the maximum amount you can be reimbursed is 91,036 yuan.
Legal basis:
1.The Social Insurance Law of the People's Republic of China
Article 28: Medical expenses that are in line with the basic medical insurance drug catalog, diagnostic and therapeutic items, and medical service facility standards, as well as those for emergencies and salvages, shall be paid from the basic medical insurance fund in accordance with state regulations.
2. The Social Insurance Law of the People's Republic of China
Article 30: The following medical expenses shall not be included in the scope of payment by the basic medical insurance fund:
(1) those that should be paid from the Workers' Compensation Insurance Fund;
(2) those that should be borne by a third person;
(3) those that should be borne by the public ****health;
(iv) for medical treatment outside the country. Medical expenses shall be borne by a third party in accordance with the law, and if the third party does not pay or the third party cannot be identified, the basic medical insurance fund shall pay first. After the basic medical insurance fund pays first, it has the right to recover from the third party.