First, the employee medical insurance benefits hospitalization Qifubiaozhun:
The third level includes hospitals above the third level: hospitalization in 700 yuan for many times within one year, and the deductible line is 500 yuan, 400 yuan and 300 yuan in turn.
Secondary hospitals include secondary specialized hospitals: 600 yuan was hospitalized several times in one year, followed by 400 yuan, 300 yuan and 200 yuan.
The first level includes the following hospitals: hospitalization in 500 yuan for many times within one year, and minimum compensation for 300 yuan and 200 yuan, 100 yuan.
Two, employee medical insurance payment ratio:
Above the deductible and below the maximum payment limit, 85% of class A and general medical expenses are paid by employees and 90% by retirees. Class B drugs pay 75% and cutting-edge drugs pay 70%.
Three, employee medical insurance Qifubiaozhun:
Medical insurance for employees with chronic diseases, special diseases and major diseases, the annual Qifubiaozhun is 700 yuan. Class A and general diagnosis and treatment 80%, class B 75%, high accuracy 70%. Maximum payment limit: 50,000 yuan (including hospitalization+outpatient chronic diseases+special diseases+major diseases)
Four, the basic insurance will not pay the cost of the scope of the diagnosis and treatment project.
(1) service items
1, registration fee, out-of-hospital consultation fee, medical record fee, etc.
2. Special medical services such as visiting fees, urgent fees for examination and treatment (except for emergency), surcharge for roll call operation, high quality and good price, and special care by oneself.
(2) Non-disease treatment projects
1, various beauty (life beauty, medical beauty) bodybuilding projects and disorderly non-functional plastic surgery, orthopedic surgery, etc. ;
2, a variety of weight loss, weight gain, increase the project.
3. Various health checks.
4, all kinds of prevention and health care projects.
5, tooth deformity, tooth porcelain.
6, all kinds of medical consultation (excluding psychiatric consultation), medical appraisal.
(3) Diagnostic equipment and medical materials.
1, a project for examination and treatment with large medical equipment such as positron emission tomography, electron beam CT and ophthalmic excimer laser therapeutic apparatus.
2, glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation equipment.
3, all kinds of self-use health care, massage, rehabilitation and treatment equipment.
(4) Treatment items
1, the organ source or tissue source of various organ transplants or tissue transplants;
2, in addition to the kidney, flap, cornea, skin, blood vessels, bones, other organs or tissues transplantation.
3. Orthopedic surgery for myopia
4, Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.
The proportion of hospitalization reimbursement for urban medical insurance is as follows:
1, level 1 hospital, reimbursement rate is 65%;
2, secondary hospitals, in the county (city) secondary hospitals, the reimbursement rate of medical expenses below 6000 is 65%, and the reimbursement rate above 6000 is 80%;
3, tertiary hospitals, in the county tertiary hospitals, the reimbursement rate of medical expenses above 600 is 65%, and the reimbursement rate of medical expenses above 6000 yuan is 80%; When seeking medical treatment in a municipal tertiary hospital, the reimbursement rate of medical expenses is below 12000, below 12000, 55%, and above 12000, 75%.
Medical insurance reimbursement conditions are as follows:
1, the insured person must go to the designated medical institution of basic medical insurance or the designated retail pharmacy determined by the social insurance institution with the medical prescription issued by the doctor in the designated hospital;
2. The medical expenses incurred by the insured in the process of medical treatment must conform to the scope and payment standards of the basic medical insurance drug list, medical treatment items and medical service facilities standards, and can be paid by the basic medical insurance fund according to regulations;
3. The medical expenses incurred by the insured that meet the payment scope of basic medical insurance shall be paid by the social medical pooling fund in a unified proportion, with the expenses above the Qifubiaozhun and below the maximum payment limit.
legal ground
People's Republic of China (PRC) social insurance law
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations. Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.