(1) outpatient reimbursement
(1) The reimbursement rate for general outpatient service is 50%, and each person will be reimbursed in 80 yuan every year;
(2) 30 yuan can be reimbursed for outpatient observation every day, with a maximum reimbursement of 1 10,000 yuan per year;
(3) The reimbursement rate for outpatient serious illness is 50%, and patients with cirrhosis, cerebral thrombosis and sequelae of cerebral hemorrhage, rheumatoid arthritis (active stage), femoral head necrosis, hypertension with complications, diabetes, pulmonary heart disease, systemic lupus erythematosus, aplastic anemia, organ or tissue transplantation anti-rejection treatment, leukemia, severe mental illness, congenital adrenal hyperplasia and congenital hypothyroidism are reimbursed 654.38 million yuan per person per year. Patients with malignant tumor, uremia and hemophilia are reimbursed 30,000 yuan per person per year.
(ii) Hospitalization reimbursement
(1) 200 yuan, the deductible line for hospitalization reimbursement at township level (level 1), with the reimbursement ratio of 85%.
(2) 500 yuan, the deductible line for hospitalization reimbursement of county-level (secondary) designated medical institutions, the reimbursement ratio is 70%.
(3) The deductible line for hospitalization reimbursement of municipal (tertiary) designated medical institutions is 700 yuan, and the reimbursement ratio is 55%.
(4) The deductible line for hospitalization reimbursement in provincial (tertiary) designated medical institutions is 1000 yuan, and the reimbursement ratio is 50%.
(5) With the consent of the county-level new rural cooperative medical management institution, the unified reimbursement deductible line is 1 1,000 yuan, the reimbursement ratio is 40%, and the guaranteed reimbursement ratio is 20%.
(6) The reimbursement rate of drugs, Chinese herbal pieces and non-drug and non-surgical therapies such as acupuncture, massage, cupping and scrapping in the list of essential drugs is increased by 10% on the basis of the original reimbursement rate. The deductible lines of Dezhou City, county-level Chinese medicine hospitals and maternal and child health hospitals were reduced by 200 yuan, and the compensation ratio was increased by 5% on the basis of the original reimbursement ratio.
(7) Twenty major diseases such as childhood leukemia, congenital childhood diseases, end-stage renal disease, breast cancer, cervical cancer, severe mental illness, opportunistic infection of AIDS, multidrug-resistant tuberculosis, hemophilia, chronic myeloid leukemia, cleft lip and palate, lung cancer, esophageal cancer, gastric cancer, type I diabetes, hyperthyroidism, acute myocardial infarction, cerebral infarction, colon cancer and rectal cancer are designated in municipal and provincial medical institutions.
(8) Accidental injuries caused by self-reasons, except that the Catalogue of New Rural Cooperative Medical Treatment Projects in Shandong Province will not be reimbursed, the unified threshold for hospitalization reimbursement is 1 1,000 yuan, and the reimbursement ratio is implemented according to the principle of segmentation. If the age of the insured is between 16 years old (including 16 years old) and 60 years old, the reimbursement ratio is 20%; /kloc-those under 0/6 years old and over 60 years old (including 60 years old) will be reimbursed at the rate of 30%.
(9) Compensation for natural delivery and cesarean section of pregnant women in hospital, compensation for 500 yuan for natural delivery and compensation for cesarean section 1 1,000 yuan.
(10) If the insured is hospitalized for many times in the same insurance period and the same medical institution, the deductible will be deducted for the first time, and 50% of the deductible will be deducted for the second hospitalization.
The total amount of reimbursement for outpatient and inpatient services per farmer per year is 200,000 yuan.
How to reimburse the new rural cooperative medical system for hospitalization in different places
Relying on the province's medical insurance network and equipment platform, the information operation platform of the new rural cooperative medical system will be established in each district and city, and the settlement center of medical expenses in different places will be established in the health administrative departments of each district and city, and the hospitalization expenses of participating farmers will be settled by county, so that farmers can be reimbursed immediately for medical treatment. Establish a new rural cooperative medical data backup center and a telemedicine data exchange center in the province.
However, it is worth noting that hospitalization can only be reimbursed, and outpatient service cannot be reported. When you need to go back to your hometown (insured place) for reimbursement, you probably need to go through the following procedures:
1, inpatient medical records
2. Cost list
3. Hospitalization invoice
4. Disease diagnosis
5, discharge summary
6. ID card and household registration book
7, cooperative medical book (or card, card)
8. Transfer procedure or certificate (work certificate or emergency certificate)
Does not belong to the reimbursement scope of the new rural cooperative medical system:
(a) the outpatient medical expenses of designated hospitals in non-co-ordination areas (except for outpatient treatment expenses for special diseases), and the expenses incurred by failing to seek medical treatment according to regulations and purchasing medicines by themselves;
(two) the cost of family planning measures and medical expenses in violation of the family planning policy;
(three) dental implants, orthodontics, optometry glasses, hearing AIDS, artificial organs, beauty therapy, cosmetic surgery, rehabilitation (such as qigong, massage, physical therapy, magnetic therapy, etc.). ), as well as various accompanying expenses, medical transportation expenses, home visits and other miscellaneous expenses during hospitalization;
(4) If there is a third party's liability, the medical expenses incurred due to personal injury, such as traffic accidents, medical accidents and work-related injuries, shall be borne by the third responsible person according to law.
(five) medical expenses caused by illegal acts such as suicide, self-mutilation, taking poison, taking drugs, fighting and other intentional acts of their families;
(six) medical expenses incurred during going abroad or staying in Hong Kong, Macao and Taiwan;
(seven) drugs and articles that are not reimbursed according to the medical insurance system for urban workers;
(eight) other expenses determined by the District Medical Management Committee.
To this end, the National Family Planning Commission issued the "Operational Specification for the Application of Medical Insurance for Urban and Rural Residents (New Rural Cooperative Medical System) for Designated Institutions in Different Provinces (Trial)" to enable farmers to realize direct settlement of hospitalization in different places.
The new rural cooperative medical care system refers to the * * economic system, which is guided by government organizations, participated by farmers voluntarily, and raised by individuals, collectives and the government in many ways, with serious illness as the main consideration. So there are certain reimbursement standards. Generally, if it is a non-designated hospital outside the province, the reimbursement rate is 45%.
Legal basis:
People's Republic of China (PRC) social insurance law
Article 24
The state establishes and improves the new rural cooperative medical system. Measures for the administration of the new rural cooperative medical system shall be formulated by the State Council.
Article 26
The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.