Beijing Medical Insurance Specific Reimbursement Conditions and Procedures
I. Outpatient Expenses
(1) Reimbursement Scope: The insured person shall be reimbursed for the general outpatient and emergency expenses incurred in the designated hospitals of the individual's choice for medical insurance or in the specialized hospitals, Chinese medicine hospitals, and hospitals of category A (Youyi, Xuanwu, Guang'anmen Hospital of Traditional Chinese Medicine, Tongren, Xiehe, Peking Third Hospital, Peking University People's Hospital, Peking University First Hospital, Jishuitan, Chaoyang, Jengong, and Liangxiang). General outpatient and emergency medical expenses incurred.
(2) Reimbursement rate: for general outpatient and emergency expenses incurred in a natural year, if the total amount of such expenses incurred by an employee exceeds 2,000 yuan, the part of the large medical mutual fund above 2,000 yuan shall be paid 50%, and the individual shall pay 50% out of his/her own pocket. For retirees, the total amount exceeds RMB 1,300 yuan, and the part of RMB 1,300 yuan or more is paid 70% by the large medical mutual fund for those who are 70 years old and 30% by the individual, while the large medical mutual fund for those who are 70 years old or more is paid 80% by the large medical mutual fund, and the individual pays 20% out of his own pocket. The maximum payment limit of 20,000 yuan in a natural year.
(3) Medical management: general outpatient, emergency expenses personal cash payment, incurred medical expenses to comply with the scope of the three major directories of medical insurance library, purchasing drugs should be in the designated hospitals to issue a special prescription and stamped with the special seal of medical insurance purchasing, and then go to the designated pharmacy to buy drugs.
(4) Reimbursement process: if the accumulated amount exceeds the starting standard in a natural year, the insured person will submit the documents to the unit or social security office, which will enter the documents into the enterprise version and declare the electronic information and documents to the medical insurance center. The medical insurance center will complete the audit, settlement and payment within 15 working days.
(5) Reporting materials: receipts for general outpatient and emergency treatment, medical insurance prescriptions (prescriptions with double scratch), and details of the costs of examination and treatment.
(F) Declaration date: 1-20 days a month, the current month's expenses next month, the current year's expenses need to be declared before January 20 of the next year.
II. Hospitalization Expenses
(I) Scope of Reimbursement: Hospitalization expenses incurred by the insured in the designated hospitals or specialized hospitals of medical insurance of personal choice, Chinese medicine hospitals and Class A hospitals.
(2) Reimbursement rate: the starting standard for the first hospitalization in a natural year is 1,300 yuan, and 650 yuan for each subsequent hospitalization. The payment rate is divided into three grades. Taking the tertiary hospitals as an example, the starting standard is: 30,000 yuan, 85% for in-service and 91% for retired, 30,000-40,000 90% for in-service and 94% for retired, and more than 40,000 yuan, 95% for in-service and 97% for retired. General hospitalization 90 days as a billing cycle. 360 days for psychiatric hospitalization is a billing cycle, and the starting and ending standards are halved. Maximum payment of 70,000 yuan from the integrated fund in one natural year. The maximum payment for hospitalized large amount is 100,000 yuan, and the payment ratio for hospitalized large amount is always 70%.
(3) Management of medical treatment: Please use the Beijing Medical Insurance Handbook when seeking medical treatment. If the unit pays in full, the individual only needs to pay part of the hospitalization advance payment to go through the hospitalization procedure. The medical expenses incurred should be in line with the scope of the three major catalog pools of medical insurance.
(4) Reimbursement process: when discharged from the hospital, the hospital and the individual settle the amount of out-of-pocket expenses and self-payment, and the amount of reimbursement from the integrated fund is settled between the hospital and the district health insurance center.
Three, outpatient special diseases
(a) the scope of reimbursement: malignant tumors radiotherapy, renal dialysis, kidney transplantation after taking anti-rejection drugs of the insured, in the approval procedures for special diseases, the outpatient medical expenses incurred within the scope of the outpatient special disease medication.
(2) Reimbursement rate: The reimbursement rate is the same as hospitalization. The settlement cycle for outpatient special diseases is 360 days.
(3) Management of medical treatment: Participants can only choose one hospital as the designated hospital for special diseases, and please use the Beijing Medical Insurance Handbook when seeking medical treatment. If the unit pays the fee in full, the individual only needs to pay the individual out-of-pocket expenses and the amount of the self-payment, and the amount of reimbursement from the integrated fund will be settled between the hospital and the district medical insurance center.
(4) Reimbursement process: the insured person will submit the documents to the unit or social security office, and the unit will declare the documents to the medical insurance center. The medical insurance center will complete the audit, settlement and payment work on the same day
Four, Beijing medical insurance reimbursement scope
(a) Western medicines and proprietary Chinese medicines, in accordance with the Municipal Bureau of Health, "on the issuance of < Beijing public medical care, labor insurance medical reimbursement scope of medicines > notice" (Beijing Health Public Character [1997] No. 15) and the "dry implementation of the < Beijing public medical care, labor insurance medical reimbursement scope of medicines> and" the "Beijing public medical care, labor insurance medical reimbursement scope of medicines>. The additional opinions on the scope of reimbursement for medication" (Beijing Health Public Character [1998] No. 2) are carried out.
The cost of medicines that are indicated to be "partially borne by individuals" shall be borne by individuals first by 10%, and the rest of the cost shall be included in the scope of payment by the basic medical insurance fund.
(2) hospital preparations; according to the Municipal Bureau of Health "on the implementation of & lt; Beijing public medical care, labor insurance medical hospital reimbursement range of preparations & gt; notice" (Beijing health public word [1999] No. 2) document implementation.
(C) the scope of payment and use of traditional Chinese medicine tablets
1. Traditional Chinese medicine tablets to be borne by individuals, in accordance with the Municipal Bureau of Health, "on the review of the issuance of & lt; Beijing enjoy the public medical care, labor insurance medical personnel at their own expense the scope of the provisions of the drug & gt; notice" (Beijing Health Finance [77] No. 267) document, the implementation of the first article.
2. Single-flavored use and because of the need for reasonable use in the compound prescription (not exceeding the normal dosage) of traditional Chinese medicine, according to the Municipal Bureau of Health, "on the review of the issuance of & lt; Beijing City to enjoy the public health care, labor insurance medical personnel to enjoy the scope of self-financed medicines, notice & gt;" (Beijing Health Finance [77] No. 267) the second article of the document is carried out.
3. The costs of traditional Chinese medicine tablets in paragraphs 1 and 2 above, which are reasonably used during the period of resuscitation of critically ill patients, are included in the scope of payment by the basic medical insurance fund.
(4) Scope of payment for medicines used in outpatient radiotherapy and chemotherapy for malignant tumors
When participants undergo radiotherapy and chemotherapy for malignant tumors on an outpatient basis, the following medicines can be included in the scope of payment of the Basic Medical Insurance Coordination Fund:
1. Tumor medicines
"Reimbursement Scope of Medicines Used for Beijing Municipal Public Medical Care and Labor Insurance Medical Care" in respect of both Western and Chinese medicines In the "eleventh category of tumor drugs", other than the removal of A Zebranin tablets, immune ribonucleic acid injection, thymus peptide injection three kinds of drugs, the other 59 kinds of oncology drugs.
2. Promote leukopoiesis
Granulocyte colony-stimulating factor [special] injection (imported), Lixisheng tablets, shark liver alcohol tablets, inosine tablets injection four drugs.
3. Anti-infective drugs
Beijing public medical care, labor insurance medical reimbursement scope of "the first class of anti-infective drugs" in the "antibiotics" (45 kinds) and "antifungal drugs Antibiotics" (45 types) and "Antifungals" (5 types) in "Class I Anti-infective Drugs" in the "Reimbursement Scope". ***50 medicines.
(E) The scope of anti-rejection drugs for kidney transplantation outpatient clinic
Cyclosporine, prednisone, dexamethasone, methylprednisolone, azathioprine***5 kinds of drugs.
Two, the scope and standard of basic medical insurance services and facilities
(a) ordinary bed fees
Ordinary bed fees are included in the scope of payment of the Basic Medical Insurance Co-ordination Fund. It is RMB 16 yuan per bed day for wards that have not been remodeled as a whole; RMB 24 yuan per bed day for wards that have been remodeled as a whole; if the actual charge is lower than the above standard, it will be paid according to the actual charge.
(2) The bed charges of the emergency observation room, rescue ward and blood ward are included in the scope of payment, and the charges approved by the Municipal Price Bureau are implemented.
(3) The cost of bone marrow transplantation and hematological chemotherapy for hospitalization in laminar flow wards due to medical conditions is included in the scope of payment.
(4) Enhanced ward, according to the Municipal Health Bureau "enhanced ward (ICU) admission standards" (Beijing Health Public [1996] No. 8) document implementation.
(e) The bed building and bed checking fees for therapeutic family hospital beds established by community health service centers (stations) are included in the scope of payment.
(vi) Heating expenses during hospitalization; the participant's unit will pay according to the relevant regulations.
Third, the basic medical insurance diagnosis and treatment items
(a) Artificial organs installed in the body, the maximum cost standard included in the scope of payment is as follows:
1. Pacemakers: single-chambered each set of 14,000 yuan, dual-chambered each set of 18,000 yuan, temporary each set of 6,000 yuan;
2. Heart valves: biological membranes each set of 7000 yuan, mechanical membranes each set of 8000 yuan Artificial joints: artificial hip joints: RMB 4500 per set, artificial knee joints: RMB 5000 per set, artificial femoral head: RMB 3300 per set;
5. The maximum payment for the installation of other artificial organs in the body is RMB 18,000;
The above If the actual charges are lower than the above standard, the payment will be made according to the actual charges.
(2) Organ transplants and tissue transplants are included in the scope of payment and cost standards as follows:
1. The scope of payment shall be in accordance with the third article in the Municipal Bureau of Labor and Social Security's "Circular on Issues Relating to Further Deepening the Reform of Publicly-funded Medical Care" (Beijing Laosha Medical Care Development [2000] No. 86);
2. For the inpatient medical expenses of organ transplants and tissue transplants, the individual has to bear 2% and the rest of the expenses are then incorporated into the medical expenses of organ transplants and tissue transplants. bear 2%, and the rest of the expenses will then be included in the scope of payment.
(C) large medical equipment and medical materials
Large medical equipment reimbursement scope and use, according to the Municipal Bureau of Health "on large medical equipment, valuable medical materials, public medical reimbursement of the scope of the Interim Provisions" (Beijing Health [1998] No. 14) document, articles 1 to 6 implementation.
Because of the condition, the use of the above document article 2 (included in the "large-scale medical equipment reimbursement scope") of the equipment for examination, treatment costs (including approved for reimbursement of the scope of a single examination, treatment costs more than 200 yuan of the project), the individual must first bear the cost of the first 8% of the rest of the cost of the basic medical insurance fund into the scope of payment. The rest of the cost will be included in the scope of payment of the basic medical insurance fund.
(D) community health service centers (stations)
Community health service centers (stations), the scope of payment of medical expenses and standards, according to the Municipal Bureau of Labor and Social Security "on the public medical care, major medical insurance community health services management issues related to the notice" (Beijing Laoshaifa [2000] No. 106) document implementation.
(E) Other
1. X-ray computed tomography and magnetic **** vibration imaging, according to the Municipal Bureau of Health "X-ray computed tomography technology and magnetic **** vibration imaging specifications" (Beijing Health Public Character [1996] No. 9) document implementation;
2. Hyperbaric oxygen therapy, according to the Municipal Bureau of Health "Hyperbaric Oxygen Therapy Reimbursement of Publicly-funded Health Care" (Beijing Health Public Character [ 1996] No. 7) document implementation. 1996]7);
3. Post-polio corrective surgery fees are included in the scope of payment of the basic medical insurance fund.
(F) not included in the basic medical insurance fund to pay the relevant costs:
basic medical insurance fund does not pay for the items, according to the Municipal Bureau of Health "on the issuance of & lt; Beijing City, the management of publicly-funded medical care & gt; notice" ([90] Beijing Health Public Character No. 100) annex "Beijing City, publicly-funded medical care management approach" of the fourth and the Municipal Bureau of Labor and Employment Security "on the strengthening of public medical care, major medical expenses, and the management of the public medical expenses of the city. Notice on Strengthening the Management of Publicly-funded Medical Treatment and Medical Insurance for Major Diseases (Beijing Labor and Social Security Medical Development [2000] No. 90), Article 2 is implemented.
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