Medicare Guide
I, insurance and contributions
1, the scope of insurance and the object of insurance
Taizhou city urban workers basic medical insurance covers the urban area (including municipal, Jiaojiang, Huangyan, Luqiao three districts) within the scope of the urban all enterprises, state organs, institutions, social organizations, private non-enterprise units and urban employees and flexible employment. The above objects should participate in the basic pension insurance, when participating in the basic medical insurance must first participate in the basic pension insurance.
2, the contribution standard 3, quasi and treatment categories
Medicare each settlement year (July 1 each year to the end of the following year, June) of the contribution standard for the month for the time of collection, the average monthly salary of the province's employees in the previous year for the contribution base, the various types of insurance according to the corresponding proportion of the levy in June each year announced in June, July for adjustment.
Unit nature of the basic medical insurance type of civil service subsidies
Insurance type of major diseases
Insurance type
Unit individual unit personal transfer
Organs
Enterprise
Enterprise 8% 2%/442
Enterprise 5% //442
Individuals/5% //82
Individuals/5%//82
Individuals/5%//82
Insurance type
Insurance type///82///82
Note: 1. Critical illness insurance is operated by commercial insurance, the contribution rate of 0.6%-0.7%, the 2006 settlement year is temporarily set at 10 yuan, the unit and the individual each bear 40%, 20% of the burden of the General Fund; 2. Taizhou College to enjoy the civil service subsidy insurance.
Different contributions correspond to different treatment categories: enterprise basic medical treatment (hospitalization co-ordination payment), career basic medical treatment (outpatient personal account payment, hospitalization co-ordination payment), civil service medical subsidy treatment (outpatient, inpatient civil service subsidy).
3, the new staff how to handle health insurance
(1) not in Taizhou city level and three districts have participated in the basic medical insurance of the new staff, into the school after the submission of two 2-inch white color photo (photo written on the back of the name, the department) and ID card a copy of the School Personnel Office, the School Personnel Office for the insurance procedures.
(2) The new faculty members who belong to the job transfer or introduction will be handled according to the following situations:
①The faculty members who have participated in the basic medical insurance in Taizhou city and the three districts will submit their existing medical insurance cards to the Personnel Office of the school, and then the Personnel Office of the school will unify and reapply for the enrollment procedures.
② original non-Taizhou city in the province and the three districts have participated in the basic medical insurance employees, into the school to submit two 2-inch white color photo (photo written on the back of the name, department) and a copy of the ID card to the school Personnel Office, the school Personnel Office for the insurance procedures, to be paid one month later, the Personnel Office notified their own social security centers in Taizhou City, the issuance of the "cross-coordinated region of the employee's health care relationship Transfer Form", to the original participating medical insurance institutions for the transfer of relations, the city medical insurance center according to this form for the registration of the corresponding personal account and make up contributions, the original contribution years to be recognized. Note: The transfer of relationship should be made within 3 months of the interruption of contributions, and is invalid for more than 3 months, as well as invalid for out-of-province transfer.
(3) How to reduce the number of people's health insurance relationship?
①Transfer of personnel relations and termination: the Personnel Office of the University shall fill in the "Change of Employees of the insured unit, increase or decrease the form" for the transfer, and from the effective date of the business to suspend the enjoyment of the corresponding health insurance benefits, the person should be as soon as possible to handle the corresponding procedures for the convergence of the more than 2 months will be dealt with as an interruption of the participation in the insurance process.
②Retiree health insurance relationship: in the unit retirement documents issued by the University Personnel Office to fill out the "changes in the insured units of the employee increase or decrease table", and for the relevant retirement contribution procedures, the retiree is required to provide their own health insurance card, card.
③Death of the medical insurance relationship: the University Personnel Office is responsible for filling out the "changes in the number of employees of the participating units to increase or decrease the table" for cancellation, and from the effective date of the business to stop enjoying the corresponding medical insurance benefits.
④Time for new personnel to enjoy the medical insurance treatment: enjoy the medical insurance treatment from the next day after the payment of insurance premiums.
Two, health insurance personal account
1, personal account transfer
Personal account transfer funds have three channels: civil service subsidies insurance unit contribution part of the age group into the basic medical insurance unit contribution part of the age group into the basic medical insurance individual contribution part of all into.
Individual account in July each year, a one-time transfer to the health insurance IC card throughout the health insurance settlement year amount, age group division only to July 1 each year as the boundary, the health insurance system by month for the actual transfer, the specific transfer ratio is as follows:
Age with civil service subsidies without civil service subsidies
35 years of age or less (1 + 0.8 + 2)%
* contribution Base*12(0.8+2)%
*Contribution Base*12
36~45 years old(2+1.8+2)%
*Contribution Base*12(1.8+2)%
*Contribution Base*12
46 years old to retirement(3+2.8+2)%
*Contribution Base*12( 2.8+2)%
*contribution base*12
Retired
Persons (4+5)%
*contribution base*125%*contribution base*12
Note: In the above table, 1%, 2%, 3% and 4% are allocated for civil servant's subsidy, 0.8%, 1.8%, 2.8%, 2.8%, and 5% are allocated for the basic health care unit contribution part of the transfer, 2% for the basic medical individual contributions to the transfer. The corresponding individual account amount will be adjusted from the month following the medical insurance procedures when the retirement and the adjustment of the insurance benefits are carried out.
2. Use of personal account
The personal account is divided into two parts: the current year's amount and the balance of the previous years, which are referred to as the current year's account and the previous years' account. The entire balance on the card is transferred to the calendar year balance after the carryover in July each year. The current year's quota is directly used to pay for outpatient and inpatient medical expenses before the civil service subsidy is paid, and the balance of the previous years is used to pay for the self-contained portion of the personal cash payment, i.e., "the balance of the previous years really belongs to oneself".
3, personal account query
Because the city's current health insurance transactions offline, that is, the medical institutions in the IC card settlement with the participants, and then regularly upload the settlement data to the health insurance agency, so the health insurance agency is unable to provide real-time personal account query. Participants are kindly requested to check the latest period's medical insurance settlement bill, which shows the account expenditures and balance.
4, personal account transfer, withdrawal
When a participant with an account is transferred to a different place (out-of-province can not be transferred but only withdrawn), the balance of the personal account can be transferred to the place of transfer (must provide the transfer place of the health insurance organization account bank, account name, account number), and can also be withdrawn (when there is no personal account in the place of transfer); a participant with an account terminates his/her participation in the policy or his/her participation in the policy is lowered, the balance of his/her personal account can be withdrawn; If a participant with an account dies, the balance of the account can be withdrawn by his/her family members. When transferring the above persons, if there is an overdraft in the account (the amount available in the card for one year is credited to the card when the IC card is carried over in July every year, but the amount must be paid until June of the following year before the account is actually credited), the overdraft amount should be paid in cash before transferring the account.
Three, medical insurance card
1, use, carryover
Medicare vouchers by the medical insurance IC card, medical insurance calendar book composed of the insured person to the designated medical institutions to seek medical treatment, the purchase of medicines and to the health care institutions to apply for the relevant procedures to be carried by the medical insurance card certificate. The card is for personal use only and should be kept in a safe place, not bent, twisted, scratched, rubbed, away from high-voltage, strong electromagnetic fields or low-temperature and high-temperature environments, and avoided contact with cell phones and liquid substances.
All insured persons' health insurance IC cards must be carried over to the designated CCB branch in July every year before they can be used:
CBG City Branch Savings Counter: No. 86-2, Workers' Road, Jiaojiang
CBG Savings Counter in Development Zone: No. 238, Donghuan Avenue
Jiaojiang Chengmantou Savings Office: next door to the Real Estate Exchange Center in Jiaojiang
Jiaojiang Cuihua Savings Office: No. 2, Yanyu Road
Jiaojiang Cuihua Savings Office: No. 2, Iwanyu Road, Jiaojiang, China Savings Office: No. 218, Yanyu Road
Jiaojiang Urban Branch Savings Office: No. 44, Jiefang North Road
Fuzian Office, Jiaojiang Zhongshan Sub-branch: No. 451, Shifu Avenue
Huangyan Hengjie Road Savings Office: No. 220, Hengjie Road, Huangyan
Huangyan Tennant Savings Office: No. 460, Hengjie West Road, Huangyan
Huangyan CCB Counter: No.209, Tianchang North Road, Huangyan
Zhenzhong Road Savings Office, Luqiao District: No.117, Yinzuo Street, Luqiao
Chengbei Branch Office, Luqiao District: No.108, Jinshui Road, Luqiao
Linhai CCB No.2 Savings Office: No.65, Chicheng Road, Linhai
2. Receiving
Newly-issued health insurance card certificates will be received by the unit's health insurance agent with the identity card of the participant, and individual The participant will collect the card by himself with his ID card, and if he is entrusted to do so, he should bring the ID card of the commissioner and the ID card of the person acting on his behalf. The new IC cards have been carried over and can be used directly during the year.
3. Lost and Replacement (Consultation Phone: 8556022)
The loss or damage of the IC card should be handled in a timely manner, and the loss of the fund due to the failure to register the lost card in a timely manner will be borne by the individual. Participants can first be lost by phone (must check the ID card number) to prevent unnecessary losses, and then within 3 days to the health insurance agency for written lost card replacement business (with ID card, can be entrusted to another person to do it for you), the lost period of 15 days after the lost period, such as within 15 days to find can be timely call the health insurance center to cancel the lost (must check the ID card number). Lost after the expiration of the period must be accepted by the health insurance agency stamped with the lost list to receive a new card; lost the calendar book with my ID card, the original photo of a new calendar book can be handled on the spot.
Replacement of the calendar book should bring the old calendar book, the old for the new, can only change a book, the old book stamped as invalid, returned to me to save. Replacement of the IC card charge 20 yuan, replacement of the calendar book charge 3 yuan.
Fourth, health insurance-related concepts
Non-basic medical insurance to pay for medical expenses
(1) in the provincial labor security department of the drug list and the provincial and municipal labor security department of the scope of diagnostic and treatment items, medical services and facilities, and the standard of payment of medical expenses;
(2) without the approval of the social security institutions to non-designated medical institutions and non-designated retail pharmacies for medical treatment. Non-designated retail pharmacies;
(3) Transferring to other places for medical treatment without approval;
(4) Carrying out special examinations and treatments without approval;
(5) Medical expenses incurred due to violation of the law, committing a crime, committing suicide, self-inflicted injuries, fights and brawls, drug addiction, alcoholism and so on;
(6) Medical expenses incurred during the period of going abroad or out of the country;
(7) Medical expenses incurred during the period of going out of the country or out of the country;
(8) Medical expenses incurred during the period of going out of the country or out of the country; <
(7) medical expenses incurred in traffic accidents, medical malpractice, extensive food poisoning, and other medical expenses payable under the liability to pay.
Designated medical institutions, designated retail pharmacies
Municipal designated medical institutions: Taizhou Hospital, Taizhou Central Hospital, Taizhou Municipal Hospital, Taizhou Hospital of Traditional Chinese Medicine, the First People's Hospital of Taizhou City, Huangyan Hospital of Traditional Chinese Medicine, Taizhou Hospital Luqiao Hospital, Luqiao Hospital of Traditional Chinese Medicine, and various districts of maternity and child health care centers, and township hospitals.
Provincial designated medical institutions: the First Hospital affiliated to the Medical College of Zhejiang University, the Second Hospital affiliated to the Medical College of Zhejiang University, the Obstetrics and Gynecology Hospital affiliated to the Medical College of Zhejiang University, the Shaw Hospital affiliated to the Medical College of Zhejiang University, the Zhejiang Cancer Hospital, the Zhejiang Provincial People's Hospital, the Zhejiang Provincial Hospital of Traditional Chinese Medicine, the Zhejiang Hospital, the Third People's Hospital of Hangzhou City, the Zhejiang Provincial Tongde Hospital.
Designated retail pharmacies: Longxiang Pharmacy in the Development Zone, Jiaojiang Fuda Pharmacy, Jianchuntang Pharmacy, Huangyan Wuzhou Pharmacy, Tongrentang Pharmacy, Renji Pharmacy, Luqiao Jianmin Pharmacy, Baohuotang Pharmacy, Linhai Fangyiren Pharmacy and so on.
Medicare drug directory, medical insurance medical service item directory
City health insurance fund payment scope unified implementation of the "Zhejiang Province basic medical insurance drug directory, medical service item directory", the two directories are the implementation of access management, the use of the two directories of medicines, medical services and medical materials, health insurance fund will not pay, all of which are personal out-of-pocket expenses. The drugs, medical services and medical materials in the two catalogs are divided into "Category A" and "Category B": the costs incurred for "Category A" items are all paid in accordance with the relevant provisions of the medical insurance; Expenses incurred for "Category B" items will be paid in accordance with the relevant provisions of the medical insurance after a certain percentage of the expenses are taken care of by the insured person himself/herself first. That is, the total cost of medical care for the insured person after deducting the out-of-pocket part, the out-of-pocket part of the cost of entry into the medical insurance fund settlement costs, known as the provisions of the medical expenses.
Fifth, the medical insurance medical treatment and cost settlement
Outpatient individual account and civil service subsidy payment
Enterprise basic medical treatment outpatient by the enterprise or individual self-care;
An account of the participant directly with the medical card card to the designated medical institution outpatient clinic, with the IC card settlement, the individual only need to pay the settlement invoice of the "cash payment". The "cash payment" amount.
The specific settlement methods are as follows:
The prescribed medical expenses incurred in the outpatient clinic of career basic medical treatment can be paid by the current year's personal account, and after the current year's personal account is exhausted, the individual will pay in cash (if there is a calendar year's personal account, the calendar year's personal account will be paid first);
The prescribed medical expenses incurred in the outpatient clinic of the medical subsidy treatment for civil servants can be paid by the current year's personal account, and after the current year's personal account is exhausted, the civil service subsidy fund will be paid in cash by the individual. After exhaustion, the civil service subsidy fund will subsidize the expenses proportionally by age group (75% for those under 45 years old, 85% for those between 46 years old and retirement, and 90% for retirees), and the remaining amount will be paid by the individual in cash (if there is a personal account for the past year, the personal account of the past year will pay for it first);
Purchase of medicines at the pharmacy
Basically the same as the outpatient clinic, the over-the-counter medicines stipulated by the state can be bought by the insured person who chooses the designated retail pharmacy on his own. Prescription drugs can be purchased at designated retail pharmacies only if they are prescribed by a physician of the designated medical institution and signed by the physician and stamped with the seal of the designated medical institution for dispensing prescriptions.
Local hospitalization co-ordination, individual accounts, civil service subsidies to pay
The need for hospitalization due to illness of the insured person with the medical insurance card card, my ID card in the designated medical institutions for hospitalization procedures, hospitalization with the IC card settlement, the individual only need to pay settlement invoices on the amount of "cash payment".
The hospitalization payment for a health insurance year is set up with a starting standard (starting line) and a maximum payment limit, which is announced at the end of June every year: the starting standard is about 10% of the average wage of the provincial employees in the previous year, and the starting standard for the second hospitalization is lowered by 50%, and the starting line cost is borne by the individual; the maximum payment limit is about 4 times of the average wage of the provincial employees in the previous year. (In 2006, the minimum payment standard was temporarily set at RMB 1,200 yuan, and the maximum payment limit was temporarily set at RMB 81,000 yuan)
The specific settlement methods are as follows (segmented calculation and cumulative payment):
The portion of the stipulated medical expenses that is less than two times of the previous year's average salary of the provincial workers above the minimum payment standard (which was tentatively set at RMB 40,500 yuan for the year of 2006) is borne by the employees and 20% by the retirees, and 15% by the individuals. 20%, retirees 15%; more than two times the average wage of the previous year to the maximum payment limit, the active staff 15%, retirees 10%; (the city's third-level and second-level hospitals are in accordance with the above standards, outside the city of the third-level hospitals, the starting standard, the proportion of the individual's responsibility to 20%)
If the participants have an account and the current year's quota has not been exhausted, the above amount of the deductibles If the participant has an account and the quota for the current year has not been used up, the above out-of-pocket amount can be paid by the individual account of the current year;
If the participant is also entitled to the civil servant's medical subsidy treatment, the above out-of-pocket amount (which may include the part of the individual out-of-pocket payment for major illnesses) is paid by the individual account of the current year and the remainder is subsidized by the civil servant's subsidy fund according to the ratio of the age groups; (50% of the participants under 45 years of age, 60% of the participants aged between 46 years of age and retirement, and 70% of the participants in the retired category)
Finally, if If there is a surplus in the individual account of the insured person in the calendar year, the amount of self-contingent in the last individual cash payment may be paid by the individual account in the calendar year first;
After the above payments (including the payment for the major diseases) are completed, the remaining amount will be paid by the individual cash payment.
Outpatient Special Disease Coordination Payment
Employees suffering from diseases within the scope of special diseases (referring to various types of malignant tumors radiotherapy, systemic lupus erythematosus, hemophilia, aplastic anemia, dialysis treatment for chronic renal failure and antirejection treatment after tissue or organ transplantation, uncompensated cirrhosis of the liver, and mental illnesses) will be entitled to the accumulated outpatient medical fees for the outpatient special disease in a medical insurance year, after applying for special diseases' approval procedures. The accumulated outpatient medical expenses for special diseases in one medical insurance year can be treated as one hospitalization and settled with the medical insurance IC card at one designated designated medical institution. The specific settlement method is the same as local hospitalization. This treatment is open to all insured persons, who must provide the "Taizhou District Basic Medical Insurance Special Disease Diagnosis Certificate and Outpatient Treatment Approval Form" issued by designated second-level and above medical institutions, diagnosis, medical records and relevant examinations, laboratory reports, pathology slice reports and other information;
Major Disease Insurance Payment
The part of the hospitalization medical expenses (including outpatient treatment of special diseases) above the maximum payment limit will be paid by the Major Disease Insurance at the coordinated rate of $10,000 per outpatient visit. The portion above the maximum payment limit will be paid by the major disease insurance on a pro rata basis. Critical illness insurance is undertaken by commercial insurance companies, but is collected and paid for by health insurance organizations, and is bundled with basic medical insurance.
The specific settlement methods are as follows:
The part of medical expenses within 100,000 yuan above the coordinated maximum payment limit will be paid 90% by the major disease insurance, and the individual will be responsible for 10%; then the part above that, the proportion of the individual's responsibility for each increase of 10,000 yuan in the prescribed medical expenses will be increased by 1%; and the cumulative total of payments by the major disease insurance will not be more than 200,000 yuan in one medical insurance year.
Transfer for medical treatment
Transfer to other hospitals and overseas due to medical condition (in principle, only to the designated medical institutions in the province, special circumstances require transfer to other provinces, is currently limited to the transfer of Shanghai municipal public tertiary care hospitals), must be filled out by the designated medical institutions with the "Taizhou City District Basic Medical Insurance Transfer Approval Form", and stamped by the hospital and the unit, for the transfer of the approval procedures. (Transferred to the field by the designated third-level medical institutions to fill out)
Transferred to the designated medical institutions in the province or the Shanghai municipal public hospitals within the scope of the medical insurance, medical expenses advanced by myself, personal advances more than 100,000 yuan of the above part of the advance by the school (with 100,000 yuan of medical bills, the need to continue to pay the bill, the school advances to pay the medical expenses by the Finance Division remitted to the hospital account, after discharge) The unused medical fee will be remitted to the school account by the hospital to return the medical fee advanced by the school, and the rest will be returned within one month after I settle the reimbursement at the medical insurance organization). The remainder will be repaid within one month after I settle the reimbursement at the health insurance organization. Then settle the reimbursement at the health insurance organization. Both settlements starting standard, personal deductible proportion are up 20%, and transfer to Shanghai must also be the first out-of-pocket provision of 10% of the total medical costs, the rest of the same as the local hospitalization settlement.
Resettlement
Retirees resettled in other places and employees stationed abroad for work and study (more than 3 months) must present the "Application Form for Resettlement (Stationed) Personnel of Basic Medical Insurance in Taizhou City Area" stamped with the consent of the unit, the grade certificate of the local fixed-point medical institution (2 fixed-point medical institutions in the same coordinating area can be selected), and the calendar of medical insurance card, and then apply for the registration of medical treatment in other places. In order to enjoy the medical treatment of relocation, the medical expenses will be paid by the person himself, and then settled and reimbursed to the medical insurance institution, the specific settlement method is the same as that of local hospitalization (outpatient).
8. Emergency medical treatment outside the home
If a person is hospitalized outside the home due to an emergency while he is out of the home on official business or on leave, he should report to his unit within five working days and his unit should bring the notice of hospitalization or a copy of the notice of hospitalization to the center to go through the registration procedures for the record. The medical expenses will be advanced by the person himself and then settled and reimbursed to the health insurance institution in the same way as local hospitalization (outpatient).
9. Window Settlement and Reimbursement
Window settlement and reimbursement is only for cash reimbursement of medical expenses incurred during the period of approved transfer of medical treatment, relocation to another place, emergency treatment outside the home, computer malfunction of the designated medical institution or loss of the IC card of the medical insurance (which must be proved by the medical insurance office of the designated medical institution or the medical insurance institution by the seal on the corresponding bills), while the rest of the cases will not be reimbursed, and will be handled by the unit or the individual. The rest of the cases will not be reimbursed and will be taken care of by the unit or the individual.
Participants are required to bring their medical insurance calendar, medical insurance IC card, list of medical expenses, receipts for medical expenses, certificates and medical records of medical institutions, discharge summaries of hospitalized patients, copies of medical instructions and other relevant information for reimbursement.
Reimbursement time: 5-15 days of each month, and for outpatient emergencies, within 30 days from the date of discharge from the hospital (outpatient).
10, health insurance settlement invoices
With the health insurance IC card in the designated medical institutions, designated retail pharmacies settlement invoices have health insurance settlement items:
"Cash payment" refers to the amount of participants should be paid in cash;
"Card payment amount" refers to the amount of cash payment;
The "card payment" refers to the amount to be paid by the participant's personal account, including the total amount of payment for the current year's account and all previous years' accounts, which is deducted from the IC card by the medical institution;
"civil service subsidy" refers to the amount to be paid by the civil service subsidy fund, which is booked and advanced by the medical institution. The medical institution will record and advance the payment;
"Co-ordinated payment" refers to the amount of hospitalization medical expenses that are paid by the co-ordinated fund, and the medical institution will record and advance the payment;
"Major disease assistance" refers to the amount of hospitalization expenses that exceed the maximum payment limit of the co-ordinated fund, and the amount of major disease insurance that is paid by the co-ordinated fund after the hospitalization annual expenses exceed the maximum payment limit. The amount paid by the major disease insurance fund after the maximum payment limit of the hospitalization year is recorded and advanced by the medical institution;
"Self-supporting amount" refers to the cumulative self-supporting amount borne by the individual in the current hospitalization, which is equal to the amount of "cash payment", namely If the accumulated out-of-pocket expenses of an individual exceed a certain limit in a health insurance year, the unit should reimburse him/her if he/she is in a position to do so. (The school will subsidize the portion of the individual's "out-of-pocket expenses" in a medical insurance year that exceeds RMB 1,500 for outpatient services and RMB 1,200 for retired students. The school will subsidize the portion of the individual's "out-of-pocket expenses" that exceeds RMB 1,500 for outpatient services and RMB 1,200 for retired students; the school will subsidize the portion of the individual's "out-of-pocket expenses" that exceeds RMB 1,500 for retired students. (Please keep the invoice for the whole year as a voucher at the time of subsidy.)
The "card balance" refers to the remaining available credit on the IC card, which is the sum of the current year's individual account credit and the individual account balance of previous years. Since the city's health insurance system currently takes offline transactions, and the IC card carries forward one year's available credit each year, the balance on the IC card may not match the real account balance in the health insurance system due to factors such as settlement data and payment anomalies. The IC card balance will be automatically checked and adjusted during the annual IC card carry-over, i.e., the real balance of the account will be based on the account balance in the health insurance system (the balance on the invoice of the first transaction of the health insurance year).
Reiterating a few concepts:
Self-care refers to the costs incurred by using drugs or services outside the medical insurance catalog and the 10% part of the costs paid in advance by transferring to other medical institutions, which are not allowed to enter into the stipulated medical costs paid by the medical insurance and the deductible amount reimbursed by the unit; self-care refers to the costs incurred by using drugs or services within the medical insurance catalog but the part of costs that has to be borne by individuals in advance, which are not allowed to enter into the stipulated medical costs paid by the medical insurance. which cannot enter into the prescribed medical expenses paid by the health insurance but can enter into the deductible amount that can be reimbursed back to the unit; self-care refers to the proportionate part of the prescribed medical expenses entered into the scope of payment by the health insurance that is borne by the individual, which can be entered into the deductible amount that can be reimbursed back to the unit; the cash payment includes all the out-of-pocket amount, all or part of the out-of-pocket amount (when there is a personal account of the calendar year), and all or part of the amount (when there is a personal account of the current year and a subsidy for the civil servants) The cash payment includes all out-of-pocket expenses, all or part of the out-of-pocket expenses (in case of current year's accounts and civil service subsidies), and all or part of the deductible amount.
Sixth, individual health insurance audit supervision and penalties
Outpatient clinics with a cumulative total of 15 or more visits per month; a cumulative total of 30 or more outpatient visits in three consecutive months; a cumulative total of more than 3,000 yuan of monthly outpatient medical expenses; a medical insurance year cumulative total of outpatient costs of more than 8,000 yuan of employees and more than 10,000 yuan of retirees; a single dispensing and purchasing costs of more than 200 yuan of medicines in a designated retail pharmacy; and the cost of a single prescription and purchase of more than 200 yuan of medicines. If the cost of a single dispensing or purchasing of medicines at a designated retail pharmacy is more than RMB 200 yuan; if the accumulated hospitalization medical expenses in a medical insurance year reaches RMB 50,000 yuan; and if a participant's outpatient clinic, purchasing of medicines or hospitalization is under one of the above circumstances, the participant will be included in the key auditing and management objects.
Included in the key audit management object of the original IC card with health insurance account settlement method to direct cash settlement, and should bring the relevant information to the health insurance organization for registration procedures, explain the situation, with the audit.
Participants will be their own health insurance card card for others or fraudulent use of other people's health insurance card for medical treatment and purchase of medicines; violation of the provisions of the duplication, overdose dispensing; meet the conditions of discharge is unwilling to be discharged from the hospital; fraud caused by the loss of health insurance funds; health insurance card card lost in a timely manner not to lose the loss of the health insurance fund loss; the health insurance agency will suspend its medical insurance treatment and inform the employer, recover the benefits of the participant. The medical insurance organization will suspend the medical insurance treatment, notify the employer, recover the loss, and may be fined by the administrative department of labor security depending on the circumstances, and if it constitutes a crime, it will be transferred to the judicial organs according to the law.
VII. Maternity Insurance:
The University has participated in the Taizhou Municipal Maternity Insurance. The relevant policy issues are as follows:
(A) Q: What is maternity insurance?
A: Maternity insurance is a social system which, through national legislation, provides working women with timely livelihood protection and material assistance from the state and society when their labor is temporarily interrupted due to the birth of a child. Its purpose is to maintain, restore and improve the health of women who have given birth to children by providing them with maternity benefits, medical services and maternity leave, and to ensure that their babies are well cared for and nurtured.
(2) Q: What are the conditions for entitlement to maternity insurance benefits?
A: 1. The employer must have participated in maternity insurance in accordance with the regulations and fulfilled its obligation to make contributions.
2. Employees who give birth or undergo family planning surgery must meet the conditions stipulated in the Law of the People's Republic of China on Population and Family Planning, i.e., those who give birth to their first child in accordance with the National Family Planning Policy, or those who meet the conditions for giving birth to another child and have been approved by the family planning department, or those who meet the above conditions for giving birth, but who have a miscarriage (induced miscarriage) after pregnancy.
(3) Q: How is the maternity allowance calculated
A: Maternity allowance = contribution base x 600% x the number of months of maternity leave is compensated to the employer. During the maternity leave of a female worker, the employer shall pay the maternity leave wages according to the regulations. If the maternity leave wage is lower than the maternity allowance, it will be paid according to the maternity allowance; if it is higher than the maternity allowance, it will be paid according to the actual calculation, and the difference will be borne by the employing unit.
(4) Q: What expenses are included in the maternity medical expenses?
A: Maternity medical expenses refer to the medical expenses incurred by a female employee due to childbirth, such as prenatal examination fees, delivery fees, bed fees, treatment fees, therapy fees, medication fees, and post-natal visit fees, which are in accordance with the regulations.
(5) Q: How are the standards for maternity medical expenses stipulated?
A: Maternity medical expenses are compensated at a fixed rate; those within the fixed rate of compensation are paid in full according to the facts, while those exceeding the fixed rate are borne by the individual employees.
1, early pregnancy outpatient abortion (including medication abortion) 150 yuan
2, early pregnancy inpatient abortion 900 yuan
3, mid-term pregnancy inpatient induced abortion 1,200 yuan
4, normal vaginal delivery 1,500 yuan
5, vaginal surgical assisted delivery (instrumental assisted delivery, lateral incision assisted delivery) 2,000 yuan
6, cesarean section (including analgesic assisted delivery) 2,000 yuan
6 Q: How are the medical fees for childbirth complications reimbursed?
A: the following complications occurring during childbirth medical costs borne by the employee's personal burden of 10%, paid by the maternity insurance fund: 1, ectopic pregnancy; 2, gestational hypertension syndrome; 3, placenta praevia; 4, early abruption of the placenta; 5, intrauterine foetal death (stillbirth); 6, mother and child blood type incompatibility; 7, pregnancy cholestasis; 8, rupture of the uterus; 9, post-partum haemorrhage; 10, Amniotic fluid embolism; 11, Silhan's syndrome; 12, eclampsia; 13, puerperal infection.
(7) Q: How are medical expenses for family planning surgery reimbursed?
A: Family planning surgeries include: 1) placement of intrauterine device (limited to the use of ordinary device); 2) removal of intrauterine device; 3) removal of residual or embedded devices; 4) subcutaneous implantation; 5) removal of subcutaneous implants; 6) tubal ligation; 7) vasectomy; 8) tubal anastomosis; and 9) vasovaginal anastomosis. The medical expenses incurred by the employee for the above family planning operations in accordance with the regulations shall be paid in full by the Maternity Insurance Fund.
(8) Q: What are the regulations on the scope of medication, diagnostic and treatment programs and standards of service facilities?
A: The scope of medication (except for obstetrics therapeutic medication), diagnostic and treatment items and standards of services and facilities for employees who give birth or undergo family planning surgeries shall refer to the relevant provisions of the basic medical insurance for urban workers in Taizhou.
(ix) Q: What are the treatments for male employees?
A: Male employees who have taken part in maternity insurance and whose spouses are jobless or unemployed in rural or urban areas can be reimbursed 50% of the maternity medical expenses if they meet the conditions stipulated in the Population and Family Planning Law of the People's Republic of China*** and the People's Republic of China.
(J) Q: What are the designated medical institutions for maternity insurance?
A: Medical insurance designated hospitals and family planning technical service organizations at or above the county level in the coordinated area are designated medical institutions for maternity insurance.
(k) Q: What are the procedures for maternity insurance?
A: 1. After an employee becomes pregnant or before she implements family planning, the employer or the employee herself should apply for a Maternity Medical Certificate or Family Planning Surgery Medical Certificate from the Municipal Health Insurance Center and voluntarily determine a designated hospital.
2. With the Maternity Medical Certificate or Family Planning Surgery Medical Certificate, the employee goes to the designated hospital for delivery or surgery.
3. The employer will apply for maternity insurance benefits from the Municipal Medical Insurance Center within 30 days after the expiration of the employee's maternity leave or after the family planning surgery.
(xii) Q: What information is required to apply for the Maternity Medical Certificate or the Medical Certificate for Family Planning Surgery?
A: The original and a copy of the employee's ID card, and the original and a copy of the Reproductive Health Service Certificate.
(xiii) Q: What information is required to apply for maternity insurance benefits?
A: The original and copy of one's ID card; Birth Medical Certificate or Certificate of Maternity Status; original medical records; invoices and lists of hospitalization medical fees; Maternity Medical Certificate or Family Planning Surgery Medical Certificate.
(14) Q: What should I do if I want to give birth to a child or undergo family planning surgery at a medical institution outside the coordinating area?
A: The employee himself/herself submits a written application report to the Municipal Medical Insurance Center for approval.
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