1. Nanjing Urban and Rural Resident Medical Insurance Benefit Standards
The maximum payment limit of the resident medical insurance fund is linked to the individual payment period. For medical expenses incurred by insured persons within a benefit year, the fund’s maximum cumulative payment limit is 300,000 yuan. For every additional year of continuous payment, the maximum payment limit increases by 10,000 yuan, up to a maximum of 360,000 yuan. If payment is interrupted and insured again, the maximum payment limit of the fund will be recalculated based on the first year (300,000).
1. Outpatient coordinated benefits and outpatient high-cost compensation benefits
(1) Outpatient coordinated benefits
The minimum payment standard is 200 yuan (the portion below 200 yuan is paid by the individual) Burden), for outpatient (emergency) medical expenses incurred within a benefit year, the fund pays 50% for treatment in community medical institutions, and 30% for treatment at non-community medical institutions. The annual fund payment limit is 300 yuan. The fund payment ratio for elderly residents over 80 years old will be increased by 5 percentage points based on the above payment ratio, and the annual fund payment limit will be increased by 10%.
Table 1. Table of outpatient coordinated benefits
(2) Outpatient high-cost compensation benefits
In a treatment year, after enjoying the outpatient coordinated benefits, what continues to happen For outpatient medical expenses, individuals pay more than 2,000 yuan out of pocket. If they are treated in community medical institutions, the fund will pay 50%. If they are treated in non-community medical institutions, the fund will pay 30%. The annual fund payment limit is 2,600 yuan.
Table 2. Compensation table for high outpatient expenses
Outpatient coordination and high outpatient compensation are based on the first-diagnosis and referral system based on designated community health service institutions. Insured residents (except students and children) receive their first diagnosis at designated community health service institutions or medical institutions that refer to community management; specialized hospitals can serve as the first medical institutions for all insured persons. If the insured person needs to be referred, the first medical institution will be responsible for the referral. The outpatient medical expenses incurred if the first consultation or referral is not carried out in accordance with the regulations shall be borne by the individual (except for emergency cases and rescue).
Table 3. List of designated medical institutions for outpatient referral
2. Treatment of residents with “two diseases”
(1) Certification registration
Go through the identification and registration of hypertension and diabetes in a secondary hospital or community health service center (health center) after being confirmed by a physician or specialist. After the medical institution completes the information entry procedures for the insured, you can enjoy outpatient services as required. Coordinate benefits.
(2) Medical benefits
Include the medical expenses for drugs, diagnosis and treatment services and other medical expenses incurred by people with "two diseases" within the scope of medical insurance in designated medical institutions into the scope of outpatient overall payment . The minimum payment standard and fund payment ratio are consistent with the outpatient overall treatment, and the fund payment limit is increased based on the outpatient overall plan.
Outpatient treatment plan for "two diseases" personnel
3. Outpatient treatment for serious illnesses
(1) Outpatient treatment for serious illnesses
Includes Hemodialysis (including peritoneal dialysis) treatment for malignant tumors, severe uremia, anti-rejection treatment after organ transplantation, hemophilia, aplastic anemic disorders, and systemic lupus erythematosus.
(2) Certification and registration
Insured residents suffering from the above serious outpatient diseases can apply for disease recognition to the third-level designated medical institutions with certification qualifications in this city.
(3) Medical treatment
1. Outpatient treatment of malignant tumors
Insured residents with malignant tumors receive outpatient treatment at designated designated medical institutions. Radiation therapy and chemotherapy (referring to intravenous or interventional chemotherapy) medical expenses, the fund payment limit is 120,000 yuan/year; endocrine therapy for breast and prostate cancer, immunotherapy for kidney cancer and melanoma, oral chemotherapy for malignant tumors (including molecules Targeted drug treatment), bladder instillation, anti-bone metastasis or late-stage analgesic treatment and other targeted drug treatment costs, within five years from the date of diagnosis, the fund payment limit is 80,000 yuan/year. If treatment is still required after five years, the fund will After evaluation by prescribed designated medical institutions, the benefit period can be extended; for auxiliary treatment expenses other than radiotherapy, chemotherapy and targeted drug treatment, the fund payment limit is: 10,000 yuan/year for the first to three years, and 10,000 yuan/year for the fourth to fifth years. 5,000 yuan/year, 2,000 yuan/year in the sixth year and thereafter.
Table 4. Malignant tumors, outpatient treatment treatment table
2. Outpatient dialysis treatment for chronic renal failure
Outpatient dialysis treatment for chronic renal failure (including hemodialysis and For insured persons (peritoneal dialysis), the limit of dialysis medical expenses incurred in prescribed designated medical institutions is 63,000 yuan/year, and the fund payment limit for auxiliary examination and medication medical expenses incurred is 8,000 yuan/year.
Table 5. Benefits of outpatient dialysis treatment for chronic renal failure
3. Outpatient anti-rejection treatment after organ transplantation
Occurs in designated designated medical institutions For anti-rejection drug treatment costs, the fund payment limit is: 80,000 yuan in the first year, 75,000 yuan in the second year, 70,000 yuan in the third year, and 65,000 yuan/year in the fourth year and thereafter. For auxiliary treatment expenses incurred, the fund payment limit is: 8,000 yuan in the first year; 6,000 yuan in the second year; 4,000 yuan in the third year; and 2,000 yuan in the fourth year and beyond. The treatment period for outpatient anti-rejection treatment after hematopoietic stem cell (allogeneic) transplantation is the year of surgery and the first year after surgery. The treatment standard shall be based on the corresponding number of years of outpatient anti-rejection treatment after transplantation.
Table 6. Outpatient service after human organ transplantation
Anti-rejection treatment treatment table
Table 7. Outpatient service after hematopoietic stem cell (allogeneic) transplantation
p>
Antibody Rejection Treatment Benefit Table
The fund will pay the medical expenses for outpatient serious illness incurred by the insured person who suffers from the above outpatient serious diseases in the year of diagnosis or surgery in accordance with the first year's treatment standards.
4. Hemophilia treatment
For patients with hemophilia (hereditary coagulation factor VIII and IX deficiency), the corresponding examination and alternative treatment medical expenses incurred in designated designated medical institutions , according to mild, medium and severe hemophilia, the annual fund payment limits are 10,000 yuan, 50,000 yuan and 100,000 yuan respectively. Starting from July 1, 2020, the annual fund payment limit for student and child patients has been increased to 20,000 yuan, 100,000 yuan, and 200,000 yuan respectively.
Table 8.1, Treatment table for hemophilia
Table 8.2, Treatment table for hemophilia
5. Treatment for aplastic anemia and systemic lupus erythematosus< /p>
For medical expenses incurred in specified designated medical institutions, the minimum payment standard is 1,000 yuan, and the annual fund payment limit is 10,000 yuan. Starting from July 1, 2020, the annual fund payment limit for student and child patients has been increased to 20,000 yuan.
Table 9. Aplastic anemia, systemic
Lupus erythematosus treatment table
IV. Outpatient psychiatric treatment
(1) Registration
Suffering from schizophrenia, schizoaffective disorder, paranoid psychosis, bipolar disorder, epileptic psychosis, mental retardation accompanied by mental disorder, depressive episode (moderate or severe), obsessive-compulsive disorder Insured residents with mental illnesses such as mental illness can apply for disease identification at Nanjing Brain Hospital and Zhongda Hospital Affiliated to Southeast University, and review the disease identification at the Medical Insurance Office of designated medical institutions.
(2) Medical benefits
For medical expenses incurred in outpatient services, the fund payment ratio for elderly residents and other residents is 80%, and the fund payment ratio for students, children, and college students is 85%. .
5. Outpatient AIDS treatment
(1) Certification and registration
Insured persons with relevant AIDS species can report their illness to Nanjing Second Hospital Application for disease identification shall be carried out at the hospital’s medical insurance office for review of disease identification.
(2) Medical Treatment
HIV-infected and AIDS patients enjoy free anti-HIV and opportunistic infection treatment and related examinations in outpatient clinics, and are provided by designated medical institutions on a per-person basis. The quarterly quota of 1,000 yuan is standard lump sum.
VI. Hospitalization Treatment
Table 10. Hospitalization Treatment Table
VII. Fertility Medical Treatment
(1) Birth Registration
p>Insured residents who comply with the national family planning policy should bring their marriage certificate, social security card, birth registration service certificate and other materials to a medical institution that has the conditions to create a card to register their birth after pregnancy.
(2) Medical treatment
Including medical expenses for prenatal examination and hospital delivery. For prenatal examination expenses incurred within a benefit year, the fund payment ratio is 40%, and the fund payment limit is 300 yuan; for childbirth hospitalization and delivery expenses, the hospitalization payment policy shall be followed, of which the fund will pay 75% for medical treatment at a tertiary medical institution.
8. Critical illness insurance benefits
Any person who participates in urban and rural residents’ medical insurance and incurs inpatient and outpatient serious illness medical expenses that are within the scope of urban and rural residents’ medical insurance, within one benefit year, Individuals who pay more than 20,000 yuan can enjoy critical illness insurance benefits. "Segment calculation and cumulative payment" are implemented, and there is no maximum payment limit. The details are as follows:
Increase critical illness insurance benefits for needy groups: within a benefit year, individuals who pay more than 10,000 yuan can enjoy critical illness insurance benefits. "Segment calculation and cumulative payment" are implemented, and there is no maximum payment limit. The details are as follows:
Reminder:
1. Insured residents must present their social security card when seeking medical treatment at designated medical institutions. The expenses that should be borne by the individual will be borne directly by the individual. Settlement: The part that should be paid by the overall planning fund shall be settled by the social security agency and designated medical institutions. The medical expenses incurred by insured residents in non-medical insurance designated hospitals or without swiping their cards, as well as medical expenses outside the scope of medical insurance, are borne by the individual.
2. Medical insurance for urban and rural residents does not have set-up retail pharmacies (except for "special drugs"). You cannot pay by credit card when purchasing medicines, and you do not enjoy medical insurance reimbursement benefits.
2. Medical insurance benefits for urban employees in Nanjing
1. Benefit standards
(1) Outpatient chronic diseases
1. Patients suffering from prescribed conditions Medical expenses for outpatient chronic diseases incurred by insured persons with 41 types of chronic diseases in three major categories (see Table 1 for details) when they go to a designated hospital of their choice for outpatient chronic diseases or when they go to a designated pharmacy of their choice with an external prescription to purchase medicines. , if the amount is within the minimum payment standard, the insured person shall pay it out of pocket, and if the amount exceeds the minimum payment standard, subsidies will be provided according to a certain proportion and limit. The individual out-of-pocket portion is settled directly by the patient with the front desk of the hospital or pharmacy, and the portion that should be paid from the overall fund is settled monthly by the medical insurance agency with the designated hospital or pharmacy. See Table 2 for treatment standards.
Table 1 List of Outpatient Chronic Diseases
Table 2 Outpatient Chronic Disease Treatment Standards
2. Chronic hepatitis C patients use interferon during outpatient antiviral treatment The cost of α (including ordinary and long-term) is subject to a limited subsidy. There is no minimum payment standard for the subsidy. The basic medical insurance fund is paid at a rate of 70%. The maximum monthly payment limit is 3,200 yuan. Any excess expenses shall be paid by the patient himself. The monthly limit fee is valid for the current month and does not roll over or accumulate. During the period of interferon alpha treatment, patients can also enjoy the hepatitis C "gate-slow" treatment, and the cost of auxiliary examinations, treatment and medication can be included in the hepatitis C "gate-slow" subsidy limit. Patients do not enjoy this outpatient limit subsidy at the same time during their hospitalization.
The designated medical institutions for hepatitis C outpatient interferon alpha treatment include: Nanjing Second Hospital and the Eighty-first Hospital of the Chinese People's Liberation Army.
3. Hemophilia is classified into mild, moderate and severe types. The fund payment ratio is 85% for in-service and 90% for retirement. The payment limits are 10,000, 50,000 and 100,000 respectively.
(2) Specific Outpatient Items
When a clinician goes to a designated hospital of his or her choice for medical treatment due to a special disease or goes to a designated pharmacy of his or her choice to purchase medicines with an external prescription, The medical expenses incurred for special items that comply with the provisions of basic medical insurance shall be settled directly with the charging front desk of designated hospitals or designated pharmacies; Class B drugs and Class B diagnosis and treatment items shall first be paid by the insured in accordance with the prescribed proportions, and the remaining balance shall be paid by the insured. Pay according to basic medical insurance regulations.
Table 3 Outpatient dialysis treatment treatment table for chronic renal failure
Table 4 Outpatient anti-rejection treatment treatment table after human organ transplantation
Table 5 Hematopoietic stem cells ( Outpatient service after allogeneic transplantation
Anti-rejection treatment treatment table
Table 6 Malignant tumor outpatient treatment treatment table
(3) Outpatient coordination
1. Within a calendar year, for outpatient medical expenses that meet the prescribed requirements for insured persons (excluding outpatient expenses that have been included in the "menman" and "mente" settlements), the expenses below the minimum payment standard shall be borne by the insured person. Individual payment; expenses above the minimum payment standard and below the maximum payment limit shall be shared between the overall fund and the individual.
Table 7 Benefit Standards for Outpatient Coordination
2. Outpatient Coordination implements a first-diagnosis and referral system based on community health service agencies. Insured persons can have their first consultation at designated community health service institutions of the Urban Employee Basic Medical Insurance or medical institutions that refer to community management; specialized hospitals can be used as first consultation medical institutions for all insured persons.
If the insured person needs to be referred, the first medical institution will be responsible for the referral. Emergency treatment and rescue are not subject to this restriction.
Table 8 List of designated medical institutions for outpatient overall referral
The above hospitals must be referred by the first hospital before they can enjoy outpatient overall treatment. First aid and rescue are not restricted.
3. After the outpatient chronic disease subsidy limit is used up, the next payment will be settled directly according to the outpatient overall treatment standard. No referral is required for chronic disease treatment at the original outpatient clinic. After the subsidy limit for specific outpatient items is used up, the referral procedures must be completed in accordance with the regulations of outpatient coordination and general medical records must be used to enjoy outpatient coordination benefits. Buying medicines in pharmacies does not enjoy the outpatient coordination treatment.
(4) Mental illness
1. Mental patients (suffering from schizophrenia, moderate to severe depression, mania, obsessive-compulsive disorder, mental retardation accompanied by mental disorders, epilepsy If you are accompanied by a mental disorder or paranoid psychosis, the same below), when you go to the outpatient clinic of a designated hospital of your choice due to mental illness, you must issue a social security card and register a "medical insurance psychiatric specialist" number. Psychiatric diagnosis and treatment fees (including examination and medication fees) incurred within the payment scope of the basic medical insurance do not need to be paid by the individual, and the Municipal Social Security Center will settle the settlement with the hospital according to the prescribed standards.
2. Mental patients who need to be hospitalized for treatment due to mental illness are exempt from the hospitalization deductible. The medical expenses incurred within the scope of basic medical insurance that are stipulated to be paid out of pocket by the individual will be borne by the serious illness medical insurance company. Relief funds, employers, and individuals each pay one-third. Medical expenses for physical diseases of mental patients shall be governed by basic medical insurance regulations. For long-term personnel stationed abroad, outpatient psychiatric services are provided on a monthly basis at a standard fixed quota of 160 yuan, which is distributed to individuals through their units every year.
(5) Family hospital bed
1. Bed conditions
The insured person is bedridden for a long time and meets one of the following conditions: stroke, paralysis recovery period, Elderly people over the age of 70 who have advanced malignant tumors or require bedridden treatment for fractures and traction and who meet the conditions for hospitalization should apply to the nearest designated medical institution with qualifications for home bed services by themselves or their family members. After examination and diagnosis by a doctor, a home bed can be set up.
2. Benefit standards
There is no minimum payment standard for family hospital beds. Expenses incurred by patients who set up beds and are within the scope of medical insurance are paid by the medical insurance fund payment proportion limit. During the establishment of family hospital beds, the benefits of family care, care, and special benefits are suspended, while outpatient psychiatric, outpatient AIDS, and inpatient benefits are enjoyed normally. See Table 9 for specific standards.
Table 9 Personal burden ratio for family hospital beds
(6) Hospitalization
Hospitalization expenses incurred by insured persons in a calendar year, the basic medical insurance co-ordinating fund The maximum payment is 180,000 yuan. The proportion of the minimum payment standard and Class B drugs, diagnosis and treatment items, service facilities and expenses beyond the scope of basic medical insurance are paid by the individual first, and the remaining expenses are shared between the overall fund and the individual.
Table 10 Hospitalization treatment standard table
(7) Critical illness medical assistance
The critical illness medical assistance fund mainly solves the problem of serious illness, In severe cases, medical expenses incurred exceed the maximum payment limit of the basic medical insurance pooling fund. The payment scope and standards of the critical illness medical assistance fund shall be in accordance with the provisions of basic medical insurance. For medical expenses above the maximum payment limit of the basic medical insurance pooling fund that are within the scope of medical insurance, the payment ratio of the critical illness medical assistance fund is 95%.
(8) Critical illness insurance
Insured persons’ inpatient and outpatient medical expenses for specific items within the scope of payment of basic medical insurance within a calendar year will be covered by basic medical insurance. On the basis of benefits, any part of personal out-of-pocket expenses that exceeds the critical illness insurance threshold will be paid by the critical illness insurance in accordance with regulations.
The minimum payment standard for critical illness insurance is set at about 50% of the city’s annual per capita disposable income of urban residents in the previous year (currently tentatively set at 20,000 yuan). For expenses above the minimum payment standard, "segment calculation and cumulative payment" will be implemented, and there is no maximum payment limit. The specific methods are as follows:
60% is paid for the portion between 20,000 yuan (excluding 20,000 yuan, the same below) and 40,000 yuan (including 40,000 yuan, the same below); For the portion of RMB 10,000, 65% is paid; for the portion from RMB 60,000 to RMB 80,000, 70% is paid; for the portion from RMB 80,000 to RMB 100,000, 75% is paid; for the portion above RMB 100,000, 80% is paid.
Insured persons who meet the conditions for medical assistance will enjoy medical assistance benefits after receiving critical illness insurance benefits. For qualified needy people, the minimum payment standard for critical illness insurance is 10,000 yuan, and the reimbursement rate for each expense segment is increased by 5%.
2. Instructions for medical treatment and drug purchase
(1) Insured persons must present their social security card and swipe the card for outpatient and inpatient treatment. The outpatient service must inform the hospital of the type of treatment (such as outpatient chronic disease outpatient service) , Mente), if the card is not presented or the type of medical treatment is unclear, the medical insurance fund will not pay the medical expenses incurred by the insured person when seeking medical treatment.
(2) When purchasing drugs at designated retail pharmacies, insured persons must present their social security card, inform the type of treatment (such as outpatient chronic disease, special care), and purchase drugs by swiping their card according to relevant policies. Due to special circumstances, When others purchase medicines on their behalf, they must present the ID cards of the insured person and the purchaser, and the medicines must be registered and filed by the pharmacy.
(3) The outpatient department shall implement a first-diagnosis and referral system based on community health service agencies. Insured persons can have their first consultation at community health service institutions designated by the basic medical insurance for employees or medical institutions that refer to community management; specialized hospitals can be used as first consultation medical institutions for all insured persons. If the insured person needs to be referred, the first medical institution will be responsible for the referral. Emergency treatment and rescue are not subject to this restriction. After the outpatient chronic disease subsidy limit is used up, you will enjoy the outpatient overall treatment according to regulations from the next payment onwards. No referral is required for chronic disease treatment at the original outpatient clinic. After the subsidy limit for specific outpatient items is used up, the referral procedures must be completed in accordance with the regulations of outpatient coordination and general medical records must be used to enjoy the benefits of outpatient coordination. Buying medicines in pharmacies does not enjoy the outpatient coordination treatment.