About the scope and standard of reimbursement of medical insurance for urban workers and urban and rural residents
The scope and standard of reimbursement of medical insurance for urban workers and urban and rural residents in 20xx:
First, the scope of reimbursement of medicines: Reimbursement of medicines is made according to the "Drug Catalog of Sichuan Province for Basic Medical Insurance, Work Injury and Maternity Insurance" (2010 version). (2010 edition) (including Western medicines, proprietary Chinese medicines, ethnic medicines***2373 kinds, of which: 1817 kinds of Class B medicines) standard reimbursement, divided into Class A and Class B, and adjusted periodically. Category A all included in the scope of reimbursement, Category B first out-of-pocket a certain percentage of the scope of reimbursement (10% out-of-pocket Category B drugs, Category B drugs in the smallest package unit price of more than 100 yuan in accordance with the special use of drugs out-of-pocket 15%).
The scope of reimbursement for diagnostic and treatment items: Reimbursement of diagnostic and treatment items according to the standard of basic medical insurance for permitted to pay expenses, permitted to pay part of the expenses and non-payment of expenses determined by the "Catalogue of Diagnostic and Treatment Items of Sichuan Provincial Urban Workers' and Urban Employees' Basic Medical Insurance". Attachment to the Sichuan Province basic medical insurance diagnosis and treatment items catalog:
Basic medical insurance does not pay the cost of diagnosis and treatment items
(a) service items: 1. Registration fees, consultation fees, consultation fees, outpatient consultation fees, remote diagnosis and treatment fees, medical guide service fees and so on.
2. Expedited examination and treatment fees, naming (appointment) medical service fees, room inspection fees, special nurse fees, door-to-door service fees, discharge follow-up fees, mother and child system of the whole service and other special medical service fees.
3. Labor cost of medical records, microcomputer query and management fees, and labor cost of various bills.
(B) non-disease treatment projects: 1. Various cosmetic such as freckles, pimples, black spots, warts, acne, blemishes, pigmentation and hair loss (including baldness), white hair, mole removal, ear piercing, saddle nose, breast augmentation, single eyelid to double eyelid, massage and other cosmetic projects.
2. A variety of cosmetic, orthopedic (except for the sequelae of polio) and physiological defects in the treatment of such cuts as fox-smell, make up for the hare lip, stuttering, orthopedic strabismus, cut more than one finger (toes), circumcision, "O" shaped legs, "X" shaped legs, refractive error, The surgery program of vision correction, etc..
3. Diabetes decision support system, sleep and respiration monitoring system, trace element testing, bone densitometry, body information diagnosis, computerized selection of the optimal period of gestation, fetal gender and fetal development checkups and other diagnostic and therapeutic programs.
4. A variety of weight loss, fat, height, bodybuilding, smoking cessation treatment programs.
5. All kinds of health checkups. 6. All kinds of preventive health care treatment programs.
7. A variety of medical consultations (including psychological forecasting, health forecasting, dietary advice, disease counseling), a variety of predictions (including stroke prediction, health prediction, disease prediction,) a variety of appraisal (forensic appraisal, industrial injury appraisal, labor appraisal, medical appraisal, paternity appraisal), health guidance and other projects.
(C) therapeutic equipment and medical materials: 1. Cell knife, positron emission segmentation device PET, electron beam CT, ophthalmic excimer laser treatment instrument and other large medical equipment for the inspection and treatment program.
2. Eyeglasses, prosthetic eyes, prosthetic teeth, prosthetic limbs, hearing aids, brain apparatus, leather (steel) undershirts, steel girth, steel head and neck, stomach, kidney, scrotum, uterus, crutches, wheelchairs, deformed insoles, pill pillows, pill pads, hot packs, pressure pulse belt, infusion net, testicular belt, hernia belt, knee belt, artificial anal bags and other appliances.
3. A variety of home inspection detector (device), treatment instrument (device) physiotherapy instrument (device), massagers and magnetic therapy supplies and other therapeutic appliances.
4. The use of medical instruments, equipment and medical materials do not meet the national or provincial supervision of the management of medical instruments, equipment and medical materials for diagnostic and treatment programs.
5. Provincial price departments can not be charged separately for disposable medical materials.
(D) therapeutic project category: 1. Various types of organ or tissue transplantation ` organ source or tissue source and access to organ source, tissue source of the relevant surgery.
2. Transplantation of organs or tissues other than kidney, heart valve flap, cornea, skin, blood vessel, bone and bone marrow transplantation.
3. Prostate hyperplasia microwave (radiofrequency) treatment, helium-neon laser intravascular irradiation (hemotherapy), anesthesia and post-operative analgesia new technology (pain beds), endoscopic retrograde appendicography and other diagnostic and therapeutic projects.
4. Dentures, dental implants, teeth, teeth, teeth, yellow and black teeth, dental defects, stained teeth, grilled magnetic teeth and other diagnostic and treatment programs.
5. Qigong therapy, music therapy, hypnotherapy, magnetic therapy, water bar therapy, oxygen bar therapy, positional therapy, psychotherapy and suggestive therapy (except for psychiatric patients), food therapy, nutritional therapy and other auxiliary treatment programs.
6. A variety of infertility (pregnancy), sexual dysfunction and family planning programs.
7. A variety of scientific research, teaching, clinical verification of the treatment program.
Basic medical insurance to pay part of the cost of diagnostic and treatment projects
(a) diagnostic and treatment equipment and medical materials: 1. The application of r-knife, x-knife, x-ray computed tomography (CT), cardiac and angiographic x-ray machine (including digital subtraction equipment), magnetic **** vibration imaging device (MRI), single-photon emission computerized scanning device ( SPECT), color Doppler, medical linear gas pedal and other large medical equipment for examination and treatment projects.
2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy program.
3. All kinds of clinical monitoring (except intraoperative and postoperative monitoring).
4. Provincial price departments can be charged separately for disposable medical materials.
(B) treatment program category: 1. Hemodialysis, peritoneal dialysis treatment program.
2. Kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow transplantation project.
3. Pacemakers, artificial valves, artificial joints, artificial crystals, a variety of stents, a variety of anastomoses, a variety of catheters, implanted drug delivery devices and other internal replacement of artificial organs, materials and installation or placement of the body surgery program.
4. Heart bypass, cardiac catheterization balloon dilatation, cardiac radiofrequency ablation and other surgical projects.
5. Coronary angiography, laparoscopic and thoracoscopic surgery, cardiac laser perforation, tumor biotherapy T lymphocyte infusion method, prostate electrocautery, oncological thermotherapy and other diagnostic and therapeutic projects.
6. A variety of microwave, spectrum, far infrared, light quantum (liquid therapy) and other auxiliary treatment programs.
Third, the scope of reimbursement of medical services and facilities: reimbursement according to the "Interim Measures of Sichuan Provincial Urban Workers' Basic Medical Insurance Medical Services and Facilities" standard. The scope of medical service facility items with basic medical insurance
The scope of medical service facility items paid according to the basic medical insurance regulations
(a) Scope of payment:
(i) Payment scope:
(i) Ordinary ward beds 2. outpatient (emergency) clinic beds 3. isolation ward beds 4. critical rescue ward beds (CCU, ICU)
(ii) Payment standards:
1. ...General ward beds are paid at the price of general ward beds for three or more persons as stipulated in the price policy. Specialty and grade hospitals can be paid in accordance with the price policy specified by the percentage of upward mobility.
2. Outpatient (emergency) hospitalization beds are paid according to the price of the price policy. However, the maximum price also does not exceed the general ward bed fee payment standard.
3. The need for isolation and critical rescue ward bed fee payment standards are appropriately relaxed, and by the co-ordination area according to the actual determination.
The scope of basic medical insurance does not pay the cost of medical services and facilities
1. Consultation (referral) transportation fees, emergency vehicle fees.
2. Air-conditioning, heating, television, telephone, electric stove, refrigerator, baby warmer, food warmer and compensation for damage to public property, as well as water, electricity, gas and other fees.
3. Accompanying fee, accompanying bed fee, nursing fee, cleaning fee, bathing fee, medicinal bath fee, disinfection fee, hairdressing fee, washing fee, etc. 4. Outpatient decoction fee, traditional Chinese medicine processing fee.
5. Recreational activities, newspapers and magazines, fitness activities. 6. Meals.
7. Flowers and flower arrangement fees. 8. Sanitary tableware, washbasin, mouth cups, toilet paper, bed sheets, pillowcases, sweeping bed towels, diapers and other disposable items.
9. The cost of soap and water, decontamination, garbage bags, mosquito killer and other household items.
10. Cost of other living services.
Fourth, special medical materials, one-time medical materials and hospital bed reimbursement standards: according to the "Ganzi State Health Insurance Payment Standards for Hospital Bed Fees, Special Medical Materials and One-time Medical Materials" (Gan Medical Insurance Center [2006] No. 29) and "Comments on Adjustment of the Payment Standards for Medical Insurance Hospital Bed Fees and Medical Materials" (Gan Medical Insurance Center [2006] No. 29) and "Comments on Adjustment of the Payment Standards for Medical Insurance Hospital Bed Fees and Medical Materials" (Gan Medical Insurance Center [2006] No. 29). Approval of the Opinions on Adjusting the Payment of Medical Insurance Hospitalization Bed Charges and Medical Material Charges" (Gansha Insurance [2014] No. 28) are implemented.
(a) hospitalization bed fee payment standards
1, hospitalization bed fee basic medical insurance fund payment standards are unified, the specific payment standards are as follows: tertiary hospitals: 35 yuan / bed day; second-level hospitals: 25 yuan / bed day; the first level and unclassified hospitals: 15 yuan / per bed day; critical rescue ward beds (ICU, CCU): 60 yuan / bed day. The hospitalization bed fee of the insured person is lower than the payment standard, calculated according to the actual bed fee, higher than the payment standard is calculated according to the payment standard.
2, the enjoyment of civil service medical subsidies for county-level cadres in excess of the standard hospitalization bed costs are included in the official medical subsidies alone to give the price limit to make up for the difference (deputy director level or above to enjoy the subsidies for cadres at the district level alone). Specific subsidies limit standard is as follows: three hospitals not more than 30 yuan / bed day; two A hospitals not more than 20 yuan / bed day; two B hospitals not more than 15 yuan / bed day: two B following hospitals not more than 10 yuan / bed day; critical rescue ward beds (ICU, CCU) not more than 20 yuan / bed day.
(B) special medical materials fee payment standards
1, implantation of human materials and artificial organs and other special medical materials, according to the following standards into the basic medical insurance fund to pay for the scope of payment:
(1) unit price of less than 100 yuan (including 100 yuan) is included in the 100%;
(2) unit price of more than 100 yuan to 10,000 yuan (including 10,000 yuan) by 80% inclusion, 20% out-of-pocket;
(3) unit price of more than 10,000 yuan to 50,000 yuan (including 50,000 yuan) by 70% inclusion, 30% out-of-pocket;
(4) unit price of more than 50,000 yuan by 60% inclusion, 40% out-of-pocket.
2. The implanted human body materials and artificial organs and other special medical materials currently included in the scope of payment of the basic medical insurance fund are clarified, and the implanted human body materials and artificial organs and other special medical materials that have not been clarified are not included in the scope of payment of the basic medical insurance for the time being. Attachment Ganzi basic medical insurance payment scope of implanted human materials and artificial organs and other special medical materials table
Cardiovascular: 1. vascular stent 2. coronary stent 3. thrombolytic catheter 4. interventional catheter 5. balloon catheter 6. finger-guided position 7. radiofrequency ablation catheter 8. guiding catheter 9. ultrasonic thrombolytic catheter 10. intravascular ultrasound catheter 11. laser catheter 12. endoscopic catheters Catheter 13.Cardiac pacemaker 14.Temporary pacemaker 15.Central venous catheter 16.Deep venous catheter (single lumen) 17.Deep venous catheter (double lumen) 18.Deep venous catheter (triple lumen) 19.PIU catheter 20.Floating catheter 2l.Radiofrequency catheter 22.Temporary pacemaker electrodes 23.Defibrillator 24.Prosthetic cardiac valve 25.Artificial blood vessel 26.Embolization tube 27.Disposable Anastomosis 28.Heart valve 29.Biological valve 30.Mechanical valve 31.Hemoperfusion device 32.Vascular pump 33.Balloon dilatation tube 34.Filter 35.Valve cutter 36.Bovine pericardium slice
Digestive system category: 1.Biliary stent 2.Esophageal stent 3.Membranous esophageal frame 4.Staple silo 5.Intestinal stent 6.Interviewer 7.Cigar gas patch 8.Composite patch 9.Anastomotic device 10.Chin Clip
Respiratory category: memory alloy respiratory stent
Ophthalmic materials: 1. IOL (folding) 2. IOL 3. viscoelastic agent 4. glaucoma valve 5. emulsification special knife 6. silicone oil 7. artificial iris septum 8. heavy water 9. amniotic membrane 10. silicone tube
Urological category: 1. balloon catheter 2. prostate stent
Orthopedics Material category: 1.T-plate 2.Pressurized plate 3.Y-plate 4.V-plate 5.Restriction plate 6.H-plate 7.Intramedullary nails 8.Power front plate 9.Power medullary plate system (4 holes) 10.Chin system cloverleaf plate 11.Goose head nails 12.Hollow nails (stainless steel) 13.Thoracic and lumbar de-rooter nails 14.Femoral step on nails 15.Bone cement 16.Chin alloy hollow threaded nails 17. Bone nail (screw) nail 18.Chin nail (for extracerebral use) 19.Baiyou resorbable nail 20.Artificial bone 21.Allograft bone 22.Allograft bone (powder) 23.Long white clay spade guide wire 24.Thoracolumbar anterior Chin nail plate 25.Bone cement embolization (sterile) 26.Bone cement 27.Artificial hemipelvis 28.Artificial ask disc 29.Artificial femoral head (unilateral) 30.Artificial femoral head (bilateral) 31. Semi-pseudoprosthetic joint 32.Total medullary joint 33.Artificial elbow joint 34.Artificial joint 35.Anatomical porous surface knee 36.Surface stranded chain knee 37.Grouped knee (unilateral) 38.Grouped knee (bilateral) 39.Shoulder joint 40.Surface elbow 41.Knuckle joint 42.Treadle joint 43.Head of femur (unilateral) 44.Head of femur (bilateral) 45.Artificial vertebral body
Other: 1. p>
Others: 1. buried chemotherapy pumps 2. closed indwelling needles 3. closed safety indwelling needles
(C) disposable medical materials fee payment standards
hospitalized medical materials in the treatment of the use of disposable medical material costs at a unit price of less than 10 yuan 100% into the scope of payment of the basic medical insurance fund, the unit price of more than 10 yuan (including 10 yuan) For non-therapeutic use of disposable medical materials costs are not included in the basic medical insurance fund.
V. According to the "Notice on the inclusion of new diagnostic and treatment program costs in the basic medical insurance reimbursement" (Ganlao social insurance [2010] No. 38) provides that: the new diagnostic and treatment program costs of clinically proven treatment conditions (including diagnostic and treatment surgery and the corresponding diagnostic and treatment material costs), in accordance with the relevant provisions of the current medical insurance policy into the basic medical insurance reimbursement scope of special projects.
;