Sixteenth basic medical insurance for urban residents, the scope of medication, diagnosis and treatment items, the scope of service facilities and the catalogue of inpatient diseases are temporarily implemented in accordance with the relevant provisions of the basic medical insurance for urban workers, and can be revised in a timely manner according to the actual situation. Appropriately increase the proportion of Chinese medicine treatment paid by insured residents from the overall fund, and appropriately increase drugs, diagnosis and treatment projects and service facilities suitable for children and adolescents. The specific measures shall be formulated separately by the municipal labor and social security administrative department according to the relevant provisions of the state and the province.
Seventeenth basic medical insurance for urban residents shall be managed by designated medical institutions (including designated community health service institutions). If the insured urban residents meet the requirements and need hospitalization, they can choose the designated medical institutions of basic medical insurance for urban workers in Xi for medical treatment. Emergency and rescue patients are not subject to this restriction, but they should go through the examination and approval procedures at the district medical insurance agency within 3 working days.
Eighteenth insured urban residents in the designated medical institutions that meet the conditions of medical insurance settlement and payment (including family beds) medical expenses, according to the proportion of hospital level payment, and control the maximum payment limit.
(a) Qifubiaozhun according to different types of designated medical institutions are divided into: community health service institutions in 250 yuan; 350 yuan, a first-class hospital; 500 yuan, a secondary hospital; 700 yuan, a tertiary hospital.
(2) Annual cumulative maximum payment limit (total expenses of serious illness in hospitalization and outpatient service): 35,000 yuan for urban non-employed residents and 40,000 yuan for children (if the insured urban residents have paid for 10 years continuously, the maximum payment limit can be appropriately increased from next year).
(III) The hospitalization medical expenses that meet the requirements within the range from Qifubiaozhun to the highest payment limit shall be paid in the designated medical institutions at all levels according to the following proportions:
1. Urban non-employed residents
Community health service institutions, the overall fund to pay 70%, individuals bear 30%;
A hospital, the overall fund to pay 60%, individuals bear 40%;
Secondary hospitals, the overall fund pays 50%, and individuals bear 50%;
In tertiary hospitals, 40% is paid by the overall fund and 60% is borne by individuals.
2 children's overall fund payment ratio increased by 5% according to the corresponding standards of urban non-employed residents.
(4) Serious outpatient diseases include: special outpatient diseases (radiotherapy and chemotherapy for malignant tumors, outpatient renal dialysis, taking anti-rejection drugs after organ transplantation) and chronic diseases (hypertension, coronary heart disease, diabetes).
The measures for the administration of outpatient treatment of special diseases and chronic diseases shall be implemented with reference to the relevant provisions of the basic medical insurance for urban workers. Outpatient treatment of special diseases: 50% from the overall fund and 50% from individuals; Outpatient treatment of chronic diseases: In one year, if the medical expenses for outpatient treatment of chronic diseases in designated medical institutions exceed 350 yuan, the excess will be paid by the overall fund according to the standard of 50%, and the maximum payment limit of the overall fund is 2,000 yuan.
(five) the medical expenses above the maximum payment limit of the basic medical insurance for urban residents and beyond the scope of payment are no longer borne by the overall fund, and can be solved by establishing large medical subsidies, commercial health insurance or medical assistance.
(six) the balance rate of the basic medical insurance fund for urban residents shall not exceed 15%, and the risk reserve shall not be less than 15%.
Nineteenth basic medical insurance fund for urban residents shall not pay the following fees:
(1) Medical expenses incurred in non-designated medical institutions without approval;
(2) Suicide or self-mutilation (except mental illness);
(three) fighting, fighting, alcoholism, drug abuse and other injuries caused by crimes or violations of the "Public Security Administration Punishment Law";
(4) Traffic accidents, accidental injuries, medical accidents, etc. ;
(five) because of beauty, plastic surgery, physical defects and other treatment;
(six) belonging to the scope of work-related injury insurance (including occupational diseases) or maternity insurance;
(seven) other expenses that are not paid as stipulated by the national and provincial medical insurance policies.
Twentieth patients need to be transferred or treated in different places due to illness, the referral conditions, referral procedures, referral requirements and reimbursement methods shall be implemented according to the Interim Provisions on Medical Referral of Basic Medical Insurance for Urban Employees in Xi.
Twenty-first medical expenses incurred by insured residents in emergency hospitalization in different places due to family visits, vacations and other reasons shall be included in the payment scope of the basic medical insurance fund. The specific management measures shall be implemented in accordance with the relevant provisions of the basic medical insurance for urban workers.
Twenty-second urban residents' basic medical insurance treatment standard, according to the city's economic development and price level changes, in accordance with the principle of balance of payments, treatment gradually improved, by the municipal labor and social security administrative department to adjust.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.