The portion of the medical fee above the threshold fee up to and including 5,000 yuan?1?7 including 5,000 yuan shall be paid at 70% by active employees under 45 years of age, 75% by active employees over 45 years of age (including 45 years of age), and 85% by retired persons; the rest shall be paid out of pocket.
The portion of medical expenses above 5,000 yuan and up to and including 10,000 yuan shall be paid at 75% for active employees below 45 years of age, 80% for active employees above 45 years of age and including 45 years of age, and 90% for retirees; the rest shall be paid out of pocket.
The portion of medical expenses above 10,000 yuan up to the ceiling line is paid at 80% for active employees below 45 years old, 85% for active employees above 45 years old (including 45 years old), and 95% for retirees; the rest is paid out of pocket.
The amount to be paid by the fund = (total hospitalization cost - threshold fee - out-of-pocket expenses - cost of Class B drugs and diagnostic and therapeutic items for which part of the cost is to be paid x 20%) x the corresponding percentage coefficient.
2. Supplementary medical insurance reimbursement:
(1) Threshold fee of the basic medical insurance fund
The threshold fee of the former Railway Hospital's hospitalization〃 is 30% for registered employees and 60% for retired employees.
(2) Above the threshold fee of the basic medical insurance and below the ceiling of the general fund: the balance of the payment from the general fund is subsidized by the supplementary insurance to 70% of the registered employees and 90% of the retirees.
(3) The portion above the ceiling line of the Coordinated Fund: 90% of the supplemental insurance benefits for both registered employees and retirees.
(4) Supplementary medical insurance fund ceiling line (maximum reimbursement in one year): the maximum reimbursement for supplementary insurance is 150,000 yuan in one natural year.
Chengdu High-tech Zone new rural medical insurance reimbursement
1, the scope of reimbursement
Where farmers go to the high-tech zone social security fixed-point medical institutions (see Annex II) to seek medical treatment for medical expenses incurred, the diagnostic and treatment items and the use of medicines in the "price of medical services in Chengdu City" and the "Sichuan Province, basic medical care drug catalog" within the scope of the new rural health care insurance fund The scope of reimbursement is subsidized by the new rural medical insurance funds.
Farmers who are injured or disabled at work will have their medical expenses settled by the employer, and will not be reimbursed by the new rural medical insurance funds.
2. Reimbursement Standards
(1) Outpatient Medical Expenses
Anyone who undergoes outpatient treatment at a community health service center (station) on the street where his or her household is registered and the cost of the treatment exceeds RMB 10 yuan will be subsidized with a fixed amount of RMB 10 yuan per person per year; those who do not exceed RMB 10 yuan will be subsidized according to the actual amount incurred.
(2) Inpatient Medical Expenses
Where a person is hospitalized in a community health service institution in the district, the starting fee for medical treatment is RMB 100, and the excess is reimbursed by 45%; where a person is hospitalized in a second-class hospital or hospitals below the second-class level designated by the social security authorities in the district, the starting fee for medical treatment is RMB 300, and the excess is reimbursed by 35% with the certificate of referral to a hospital in a community health service institution in the district; and where a person is hospitalized in a tertiary hospital designated by the social security authorities in the district The starting fee for medical treatment is 700 yuan, and 25% of the excess amount will be reimbursed on the basis of the certificate of referral for hospitalization from the community health service institution under the jurisdiction.
Farmers are reimbursed 25% of the hospitalization fees incurred at social security designated medical institutions in other places (outside Chengdu) during the period when they go out to work, except for the part of the hospitalization fees that they pay out of their own pockets.
Individuals who have been hospitalized several times throughout the year will have their medical fees settled in installments. The amount of individual reimbursement shall not exceed 12,000 yuan for the whole year.
Farmers in Hi-tech Zone who enjoy the new rural medical insurance can voluntarily participate in rural medical insurance at the same time, but they can only choose one of them when reimbursement is made, and cannot be reimbursed repeatedly.
3. Reimbursement Procedures
The reimbursement and settlement of medical expenses adheres to the principles of simplicity, localization and speed, with reference to the social security medical reporting procedures, and the implementation of two-tier settlement. That is, the community health service organizations (or social security designated medical institutions) and the farmers timely settlement; Social Welfare Bureau and the community health service organizations once a month, the end of the year on the community health service centers to provide free medical examination costs settlement.
(I) outpatient costs
Patients with their ID cards (hukou) at the community health service centers (stations) on the streets where they are registered to settle in a timely manner.
(2) Hospitalization Expenses
Patients who are hospitalized in community health service institutions in the region and those who have been approved and agreed to be hospitalized in designated hospitals above the first level will be advanced by the individual farmers, and after being discharged from the hospital, they will present proof of their identity from the street office where their household registration is located, and will be examined by the community health service center of their respective streets and settle the reimbursement on behalf of the farmers.
Farmers going out to work, hospitalization costs incurred in social security designated medical institutions in other places (outside of Chengdu), after discharge from the hospital with a certificate of identity issued by the street office where the household registration is located, by the community health service center of the street to conduct an audit and settle the reimbursement on behalf of the.
Another:
Hospitalization "threshold fee" many health insurance patients mind "muddled account"
The reporter then interviewed the Chengdu Municipal Social Security Bureau of Health Insurance Director Tang Tao. Tang Tao said, "threshold fee" is an inaccurate statement, the accurate title is "integrated fund starting standard" or "starting line", it is not the social security bureau or hospitals to charge a fee to the hospitalized patients. It is not an additional fee charged by the Social Security Administration or hospitals to hospitalized patients, but a bottom line set by the government for the reimbursement of medical expenses by insured persons. That is to say, the social security bureau will only reimburse the expenses between the "starting line" and the "ceiling line" according to the regulations, and the patients will be responsible for the expenses below the "starting line". Setting a "starting line" is aimed at establishing a reasonable sharing mechanism for employees' medical expenses. It is reported that, according to the "Chengdu urban workers basic medical insurance interim measures" provisions, "hospitalization during the medical costs, should be paid by the integrated fund part of the settlement by the hospital and the health insurance agency, should be borne by the individual part of the settlement by the hospital and the individual". Chengdu City, so far, the implementation of the starting standard for the first-class hospitals 404.2 yuan, 646.72 yuan second-class hospitals, third-class hospitals 970.8 yuan; a natural year, more than one hospital or third-class hospitals, each time to reduce the 1%. 2001, Chengdu Municipal Bureau of Labor and stipulated that the starting standard is reduced, shall not be lower than the starting standard of the first-class hospitals.