I, medical insurance
Medical insurance
First of all, the difference between medical insurance and non-medical drugs, reimbursement of the starting line according to the level of hospitals are also different
Generally, A class of drugs can enjoy the full report, the C class need to be all the out-of-pocket expenses, while the B class reported 80%, the proportion of the out-of-pocket expenses of 20%.
If a person uses 10,000 yuan in the hospital, if he or she is admitted to a first-class hospital, then 500 yuan will be deducted first; if he or she is admitted to a second-class hospital, then 1,000 yuan will be deducted first; if he or she is admitted to a third-class hospital, then 2,000 yuan will be deducted first, and this is the difference in the starting line.
1, special medical expenses for organ and tissue transplants due to medical conditions, the cost of their purchase of organs and tissues, and the cost of using anti-rejection drugs and immunomodulatory drugs beyond the scope of Zhenjiang City Employees' Medical Insurance Drug Reimbursement Scope;
2, work-related injuries and occupational diseases;
3, childbirth for female workers;
4, hooliganism and brawls;
5, injury caused by alcoholism;
6, traffic accidents;
7, intentional injury to others;
8, medical accidents;
9, cosmetic surgery, health checkups;
10, other expenses not covered by the social medical insurance fund.
1, the insured workers on business trips, visiting relatives in the field of medical expenses, only reimbursement of emergency medical expenses in accordance with the provisions of the medical insurance, non-emergency reasons for hospitalization, all costs will not be reimbursed.
2. If an insured employee resides abroad for more than 6 months, he/she will be reimbursed for the medical expenses according to the nature of the long-term resident.
3. Long-term residents should be certified by their units to identify two designated hospitals (which should be local medical insurance designated medical institutions) and promptly apply for the "Zhenjiang City Long-term Resident Foreign Employee Medical Expense Reimbursement Card"
4. Long-term residents must adhere to the principle of savings in accordance with the provisions of the limited number of prescribed medicines (for each visit to the clinic, the amount of acute medicines in less than 3 days, the amount of medicines for chronic diseases in less than 10 days), tuberculosis, hypertension, chronic diseases, chronic diseases, chronic diseases, chronic diseases, chronic diseases, chronic diseases, chronic diseases, and so on.
5, long-term resident workers referral, need to be signed by the local designated hospital, according to the principle of territorial referral, referral hospitals are the city's employee health insurance to determine the special hospital. Individuals first pay 10% of the total cost, and then reimbursement of costs in accordance with the provisions of health insurance, other hospitals, individuals first pay 20% of the total cost, and then reimbursement of medical costs in accordance with the provisions of health insurance.
Two, rural health insurance reimbursement
1, outpatient reimbursement:
(1) 60% reimbursement for village health clinics and village center health clinics, with a limit of 10 yuan for prescription drug costs per visit, and 50 yuan for temporary rehydration of prescription drug costs by doctors in health centers.
(2) Township health centers will be reimbursed 40% of the cost for each visit, with a limit of 50 yuan for each examination and surgery, and a limit of 100 yuan for prescription drugs.
(3) Secondary hospitals are reimbursed 30% of the cost, with a limit of 50 yuan for each examination and operation and 200 yuan for prescription drugs.
(4) Tertiary hospitals will reimburse 20% of the fees, with a limit of 50 yuan for each examination and operation and 200 yuan for prescription drugs.
(5) Chinese medicine invoices with prescription attached are limited to RMB 1 yuan per sticker.
(6) The annual limit of outpatient compensation for township-level cooperative medical care is 5,000 yuan.
2. Hospitalization Compensation
(1) Reimbursement Scope:
A. Pharmaceutical Fees: Auxiliary Examinations: Limit of 200 RMB for each examination fee such as EKG, X-ray fluoroscopy, radiographs, laboratory tests, physical therapy, acupuncture, CT, MR*** vibration, etc.; Surgical Fees (with reference to the national standard, reimbursement for fees in excess of 1,000 RMB will be made in accordance with the limit of 1,000 RMB).
B. For the elderly over 60 years old who are hospitalized in Xingta Township Health Center, the treatment fee and nursing fee are compensated 10 yuan per day with a limit of 200 yuan.
(2) Reimbursement rate: town health center reimbursement 60%; secondary hospital reimbursement 40%; tertiary hospital reimbursement 30%.
3. Compensation for major illnesses
(1) Compensation from the town risk fund: Any hospitalized patient who participates in the Rural Cooperative Medical Insurance will be compensated for the one-time or yearly cumulative reportable medical expenses of more than 5,000 RMB in segments, i.e., 65% of 5,001-10,000 RMB, and 70% of 10,001-18,000 RMB.
(2) The annual limit of compensation for township-level cooperative medical care inpatient and uremia outpatient hemodialysis, oncology outpatient radiotherapy and chemotherapy is 11,000 yuan.
The following are not covered by the rural cooperative medical insurance reimbursement scope:
1, self-medical treatment (without designated hospitals for medical treatment or without referral orders), self-purchased medicines, medicines not reimbursable by the public medical care regulations, and medical expenses not in accordance with the family planning;
2, outpatient treatment expenses, consultation fees, hospitalization fees, meals, accompanying guests, nutritional costs, blood transfusion costs (with the exception of those with family blood storage, except for those who are reimbursed in accordance with the relevant regulations), heating and cooling costs, ambulance fees, special care fees and other costs;
3, car accidents, fights, suicides, alcoholism, workplace accidents and medical malpractice medical expenses;
4, orthopedics, cosmetic surgery, dental implants, prosthetics, organ transplants, naming the surgical fees, consultation fees and so on;
5, reimbursement of the scope of reimbursement, the portion of the limit outside the scope of reimbursement.
Many farmers have purchased some commercial medical insurance after purchasing the New Rural Cooperative Medical Insurance (NRCMI). If you purchase commercial medical insurance, you will have to reimburse the NRCMI expenses first, and then seek reimbursement from the insurance company for the rest of the expenses.
Leaving hospitalization information and related invoices, because incomplete information can cause a lot of insurance claims problems, WiseChoices.com also received a lot of insurance complaints because of claims information problems, you leave the relevant information can reduce a lot of unnecessary trouble.
Three, urban health insurance reimbursement
The scope of urban health insurance reimbursement refers to all urban employers, as follows:
1. including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises, etc.);
2. organs, institutions, public organizations, social organizations, non-enterprise units and their employees, are required to participate in the basic
3. Some cities and towns have stipulated that township and village enterprises and their employees, as well as owners of self-employed economic organizations in cities and towns and their employees, should gradually be included in the scope of the basic medical insurance (the last of which varies from place to place depending on the local policy), so that they can enjoy medical reimbursement.
The urban medical reimbursement mainly refers to is in the hospital to see a doctor, medicine, hospitalization, surgery, etc., can be through the medical insurance card in accordance with the relevant provisions of the medical cost reimbursement, urban medical insurance is more specialized, the project size and coverage is larger, but it is in the major illnesses or accidents in the limited payout, this time the author suggests that the participants can be separately purchased commercial catastrophic medical supplement insurance and social security The combination of the way to reduce their financial losses.
Four, employee health insurance reimbursement
Medicare reimbursement, basic insurance does not pay the cost of the scope of the treatment program
(a) the service category
1, registration fees, out-of-hospital consultation fees, medical records, such as the cost of books;
2, consultation fees, examination and treatment of expedited fees (except for the emergency), the surcharge on the operation of a named, high quality and premium fee, the self-initiated special nurse fee and other special medical services.
(2) Non-disease treatment program category
1, a variety of cosmetic (cosmetic life, medical aesthetics) fitness program and messy non-functional cosmetic surgery, orthopedic surgery, etc.;
2, a variety of weight loss, weight gain, height projects;
3, a variety of health checkups;
4, a variety of preventive, health care clinic programs;
Medical insurance reimbursement of registration fee, out-of-hospital consultation fee, medical record cost, etc.;
2, consultation fee, examination and treatment expediting fee (except for emergency), surcharge for named surgery, quality and premium fee, self-invited special nurse fee, and other special medical services.
(2) non-disease treatment program category
1, a variety of cosmetic (cosmetic life, medical cosmetic) fitness program and messy non-functional cosmetic surgery, orthopedic surgery, etc.;
2, a variety of weight loss, gain weight, increase in height project;
3, a variety of health checkups;
4, a variety of preventive, health care clinic program; 5, dental orthopedics, Dental porcelain;
6, a variety of medical consultation (excluding psychiatric consultation), medical appraisal.
(C) diagnostic and therapeutic equipment and medical materials
1, the application of positron emission tomography device, electron beam CT, ophthalmic excimer laser therapy instrument and other large-scale medical equipment for the examination and treatment of the project;
2, eyeglasses, dental prostheses, prosthetic eyes, prosthetic limbs, hearing aids, and other rehabilitation appliances;
3, all kinds of health care for their own use, massage, rehabilitation and checking therapeutic instruments.
(4) therapeutic items category
1, all kinds of organ transplantation or tissue transplantation of organ source or tissue source;
2, in addition to kidney, heart valves, cornea, skin, blood vessels, bone, bone marrow transplantation other organs or tissue transplantation;
3, myopic eye orthopaedics;
4, qigong therapy, music therapy, health care of nutrition therapy, magnetic therapy and other complementary treatment therapy, magnetic therapy and other complementary treatment programs.
(5) Other
1, various infertility (pregnancy), sexual dysfunction diagnosis and treatment programs;
2, various scientific research, clinical verification of diagnosis and treatment programs;
2, basic medical insurance to pay part of the cost of the diagnosis and treatment program range
(1) Diagnostic and treatment equipment and medical materials
1, the application of X-ray computed tomography devices, and the use of medical materials. -ray computed tomography (CT), stereotactic radiography (γ-knife, χ-knife), cardiac and angiography X-ray machine (including digital subtraction equipment), magnetic **** vibration imaging device (MEI), single-photon emission computerized scanning device (SPECT), Color Doppler, medical linear gas pedal and other large medical equipment for examination, treatment projects;
2, extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy;
3, pacemakers, artificial joints, artificial crystals, vascular scaffolds in vivo replacement of artificial organs, in vivo replacement of materials;
4, the provincial price department can be charged separately for the disposable medical materials. .
(B) treatment project category
1, hemodialysis, peritoneal dialysis;
2, kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow transplantation;
3, cardiac laser perforation, anti-tumor cellular immunotherapy and fast neutron therapy projects. [1]
Hearing aids and other rehabilitation appliances;
3. A variety of self-use health care, massage, checkup rehabilitation and treatment equipment.
(3) therapeutic items category
1, all kinds of organ transplants or tissue transplants of organ sources or tissue sources;
2, in addition to kidney, heart valves, cornea, skin, blood vessels, bone, bone marrow transplants other organs or tissue transplants;
3, orthopedic surgery for nearsightedness;
4, qigong therapy, music therapy, health care nutritional therapy, magnetic therapy and other complementary treatment programs.
(D) other
1, a variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment programs;
2, a variety of scientific research, clinical validation of diagnosis and treatment programs;
(A) diagnostic and therapeutic equipment and medical materials
1, the application of X-ray computed tomography (CT), stereoscopic directional radiography (γ), and other medical materials. Directional radiography device (γ-knife, χ-knife), cardiac and angiography X-ray machine (including digital subtraction equipment), magnetic *** vibration imaging device (MEI), single-photon emission computerized scanning device (SPECT), color Doppler, medical linear gas pedal, and other large-scale medical equipment for the examination and treatment of the project;
2, extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy;
3, pacemakers, artificial joints, artificial crystals, vascular stents in vivo replacement of artificial organs, in vivo placement of materials;
4, the provincial pricing department of the provisions of the disposable medical materials that can be charged separately.
(B) treatment project category
1, hemodialysis, peritoneal dialysis;
2, kidney, heart valves, cornea, skin, blood vessels, bone, bone marrow transplants;
3, cardiac laser perforation, anti-tumor cellular immunotherapy and fast neutron therapy projects.