I. Basic medical insurance treatment
(A) the source of funds for the individual account
1, the basic medical insurance premiums paid by the individual employee's own 2% of his or her total wages are all transferred to the individual account.
2. 8% (6% in 2002) of the total wages paid by the employer for basic medical insurance premiums are partially transferred to the individual account in accordance with the regulations, with the specific method of transferring 0.5% of the total wages for the age of 45 and below; 1% of the total wages for the age of 46 to 59; and 1.5% of the total wages for the age of 60 and above.
(2) Sources of the Coordinated Fund
The basic medical insurance premiums paid by employers, except for the prescribed portion to be transferred to individual accounts, the rest goes into the Basic Medical Insurance Coordinated Fund.
(3) Scope of Payment of Individual Accounts
Individual accounts are mainly used to pay for outpatient medical expenses in accordance with the basic medical insurance drug list and diagnostic and therapeutic items; to pay for inpatient medical expenses that should be paid by the individual; and to pay for the costs of special examinations and special treatments as well as some outpatient medical expenses of chronically ill outpatients.
(4) The scope of payment of the coordinated fund
1. Payment of hospitalization medical expenses: medical expenses incurred during hospitalization in accordance with the basic medical insurance regulations: above the starting standard and below the maximum payment limit shall be paid by the coordinated fund in accordance with the cumulative method of payment by segments, and the individual shall pay a certain percentage out of his/her own pocket:
Payment ratio of the coordinated fund % Individuals' out-of-pocket payments Proportion%
Hospitalization medical expenses In-service Retired In-service Retired
Above the threshold to 5,000 yuan 70 75 20 15
5,000-10,000 yuan 75 80 15 10
10,000 yuan to the maximum limit of 80 85 10 5
2. The maximum payment limit of the coordinated fund is four times the annual salary of the employee in a year. Participants pay in cash, and through commercial medical insurance and other means.
The Interim Provisions on Medical Subsidies for State Civil Servants
(1) Scope of Subsidies
1. Medical expenses and drug lists in accordance with the standards for diagnostic and therapeutic items and medical services and facilities of the basic medical insurance.
2. Part of the medical expenses exceeding the maximum payment limit of the basic medical insurance fund.
3. Medical expenses within the scope of payment of basic medical insurance for which the individual's out-of-pocket payment exceeds a certain amount.
4. Medical expenses incurred by medical care personnel who are entitled to medical care according to regulations.
5. Work-related (public) injuries that are eligible for medical benefits for state civil servants. Maternity medical expenses.
(B) outpatient medical assistance
In line with the provisions of the basic medical insurance, incurred once the medical expenses:
Active personnel subsidies 55% (total outpatient medical expenses within a year more than 1600 yuan or more) no longer subsidized.
Retirees are subsidized at 65% (outpatient medical expenses totaling more than 1,800 yuan in one year).
Medical caregivers are subsidized 90% (total outpatient medical expenses exceeding $2,000 in one year).
(C) hospitalization subsidies
1, hospitalization bed fee subsidies: for the part of the bed fee that exceeds 15 yuan of the basic medical insurance, the daily subsidy is: 10 yuan for the active staff, 15 yuan for the retirees, and 25 yuan for the medical care personnel.
2. For the medical expenses incurred in hospitalization within one year, the subsidies for the part of the expenses borne by individuals above the starting standard and below the maximum payment limit of the Basic Medical Insurance Co-ordination Fund, such as the part of Class B medicines, Class B materials, Class B diagnostic and therapeutic items, and the part of the expenses accumulated by segments and out-of-pocket expenses of individuals, are as follows: 85% for the incumbent employees, 90% for the retired persons, 95% for the medical care personnel, and 100% for the health care recipients. 100%.
3. The subsidies for the use of medicines other than those listed in the Basic Medical Insurance Drug List in critical condition are: 50% for the active staff, 60% for the retired staff, and 90% for the medical care staff. The subsidy method is to fill in the application form by the doctor, report to the medical insurance center for approval and then settle the bill in cash, holding the hospital invoice and the application form to the medical insurance center for reimbursement according to the regulations.
Three, part of the outpatient chronic patient medical treatment
1, included in the outpatient chronic disease are: coronary heart disease, diabetes mellitus, various malignant tumors, chronic obstructive pulmonary emphysema, hypertension, Parkinson's syndrome, cirrhosis of the liver in a period of loss of compensation, uremia stage, chronic heart failure, organ transplantation, anti-rejection of the immune system to regulate the treatment.
2. Each insured person can declare a maximum of 3 diseases.
3, outpatient chronic diseases in accordance with the regulations can only enjoy the scope of the chronic disease prescribed by the medical insurance drug list drugs.
4. Before entering the chronic disease subsidy, the individual pays for the drugs below the starting standard, i.e., 8% of the employee's annual average gross salary, and the rest of the drug costs are paid proportionally into the integrated fund.
Fourth, the proportion of payment for special examination and treatment programs
1, according to the provisions of part of the special examination and treatment by the individual to pay 40% of the cost, the remaining costs of basic medical insurance in accordance with the prescribed proportion of the individual part of the subsidy according to the proportion of the civil service subsidies and limits for the subsidy.
2, the use of imported materials by the individual first 50% of the proportion of cash payments, the remaining costs of subsidies in accordance with the provisions of Article 1 approach.
Fifth, in the region directly in the Yong organs and institutions employees (public) injury medical treatment
According to the spirit of the Guilao social medical insurance (2002) No. 9 document:
1, in the region directly in the Yong organs and institutions eligible to enjoy the national civil service medical subsidies for the employees, incurred in line with the provisions of the work (public) injury medical expenses, in the national civil service medical subsidies for the funds reimbursement.
2, in the region directly in the Yong organs and institutions of the occurrence of work (public) injury accidents must be reported within 48 hours by telephone to the District Labor Office of the Medical Insurance Department, and within 15 days to fill out (in the region directly in the Yong unit employees work (public) injury accident report form in triplicate, by the autonomous region of the Department of Labor and Social Security Administration recognized as a work-related injuries of the employees, in accordance with the provisions of the medical treatment of work (public) injuries.
3. The employer and the injured worker shall provide the following proofs
Report form of work-related (public) injury, diagnosis certificate of the designated hospital or certificate of diagnosis of occupational disease, relevant interrogation notes and circumstantial materials; in the case of traffic accidents, materials such as the certificate of responsibility of the traffic police department for dealing with the accidents.
4, in the regional institutions in Yong organs and institutions after the occurrence of industrial (public) injury accidents, the current fixed-point hospital is set as the First Affiliated Hospital of Guangxi Medical University (including the Second Affiliated Hospital, that is, the West Hospital). Guangxi District People's Hospital, Guangxi Workers' Hospital, Nanning Second People's Hospital. Critically injured can be the nearest hospital rescue, to be stabilized and then transferred to the designated hospital to continue treatment.
5, work (public) injured workers during the implementation of the Guangxi Zhuang Autonomous Region urban workers basic medical insurance treatment items, medical services and facilities range and payment standards, Guangxi District basic medical insurance drug catalog. The use of drugs required during the rescue period can be appropriately relaxed, but must be declared to the Autonomous Region Social Security Bureau for approval.
6. The hospitalization medical expenses during the treatment of work-related injuries in accordance with the relevant provisions of the basic medical insurance shall be reimbursed in full in the medical subsidies for state civil servants.
7. Expenses incurred during outpatient treatment and hospitalization by employees recognized as having suffered work-related injuries are first advanced in cash by the unit, and then reimbursed by the autonomous region's Social Security Bureau on the basis of the approval form for the work-related injuries, the medical insurance certificate, the hospital certificate, and the list of medical expenses, and so on.
Sixth, the management of individual medical insurance IC card
1, individual medical insurance IC card records the medical insurance file information, personal account funds and the use of the status of the use of the individual, by the individual to keep and use.
2. The principal and interest of the individual account are owned by the individual, and in principle, no cash can be withdrawn.
3, lost or damaged IC card, with a personal ID card to the district health insurance center lost, a moment failed to handle the lost, can be notified by phone in advance of the district health insurance center lost, so as to avoid unnecessary losses, lost telephone 2853836.
Municipal health insurance
A, outpatient specific items of medical treatment
1, the scope of the specific item Yes: radiotherapy for malignant tumors, dialysis treatment for uremia, anti-rejection treatment after organ transplantation.
2. The insured persons who are eligible for the specific items will be required to submit a written application by the doctor at each visit, and the expenses incurred after going through the approval procedures will be borne by 15% for the active employees; 8% for the retirees, and the rest of the expenses will be paid into the integrated fund.
3, 50 years of age or older insured persons suffering from serious chronic diseases in outpatient clinics within 30 days of the cumulative cost of medicines more than 500 yuan, with outpatient drug invoices, medical records to the Municipal Health Insurance Center to fill in the drug reimbursement form and reimbursement in accordance with the provisions.
The management and payment of special examinations and treatments
1. For the special examinations and treatments that are approved by the application, the active staff shall pay 30% of the fees and the retired staff shall pay 15% of the fees.
2, hospitalized patients due to the needs of the condition of the approved use of imported artificial organs, the cost of materials placed in the body by the individual cash advance, and then reimbursement of other relevant information to the Municipal Health Insurance Center in accordance with the provisions.
Three, the medical mutual aid payment treatment
1, participate in the medical mutual aid employees, such as the occurrence of more than the integrated fund payment reaches the maximum limit, the exceeding medical expenses in cash, with a ticket to the municipal health insurance center in accordance with the provisions of the reimbursement from the medical mutual aid.
2. The maximum limit of payment from the integrated fund is four times the average gross salary of employees in the previous year.
3, hospitalization expenses incurred in the first half of the coordinated area of the average salary of employees less than 9 times (including 9 times) medical mutual fund to pay 70%, the individual to pay 30%; more than 9 times the average salary of less than 13 times (including 13 times) medical mutual fund to pay 80%, the individual to pay 20%; more than 13 times the average salary of up to 15 times medical mutual fund to pay 90%, the individual to pay 10%.
Basic medical insurance does not pay for the scope of treatment programs are divided into the following categories
I. Service items
1. Registration fee, out-of-hospital consultation fee, consultation fee, expedited examination and treatment fee, surcharge for named surgery, and self-employed nurses for special medical services.
2. All kinds of cosmetic, fitness and non-functional cosmetic and orthopedic surgeries.
3. All kinds of weight loss, fat gain and height gain programs.
4. All kinds of health checkups, medical appraisal costs.
II. Diagnostic and therapeutic equipment and medical materials
1. Applied electron emission tomography device (PET), ophthalmic excimer laser treatment.
2. Eyeglasses, dentures, prosthetic eyes, hearing aids.
3. A variety of self-use health care, massage, examination and treatment of equipment.
3. Therapeutic items category
1. Various types of organ or tissue transplantation of organ source or tissue source.
2. Transplantation of organs or tissues other than kidney, cardiac pleura, cornea, skin, blood vessel, bone and bone marrow transplantation.
3. Orthopedic surgery for myopia.
4. Qigong, music therapy, spectrum therapy, laser therapy, light quantum therapy.
5. Various infertility (pregnancy), sexual dysfunction diagnostic and treatment programs, venereal disease examination and treatment costs.
4. Life service items category
1. Consultation and referral transportation fees, emergency vehicle fees.
2. Hospitalization air-conditioning fee, escort fee, escort fee.
3. Expensive special services.
V. Others
1. Medical expenses incurred by not consulting and treating in the designated medical institutions (except for rescue).
2. Expenses incurred for medical treatment outside the country without the approval of the relevant departments.
3. Medical expenses incurred abroad, in Hong Kong, Macao and Taiwan.
4. Medical expenses incurred by female workers for childbirth (separately reimbursed in accordance with the relevant policies on childbirth).
5. Expenses incurred as a result of work-related accidents (reimbursement shall be made in accordance with the relevant regulations on work-related injuries).
6. Medical expenses incurred as a result of traffic accidents, medical accidents, suicides, self-inflicted injuries, alcoholism, and fights and brawls.
7. Dental cleaning, dentures, prosthetic eyes and limbs.
8. Expenses for medicines other than those listed in the Guangxi Zhuang Autonomous Region's basic medical insurance drug catalog.
9. Self-made medicines, self-defined items, and new inspection and treatment items that are not approved for use by the health, drug supervision and management, price authorities and the district social security bureau of the hospital.