2, the social health insurance reimbursement method has some differences around.
In order to standardize the city's urban workers social health insurance cash reimbursement management, according to the "Shenzhen Urban Workers Social Health Insurance Measures" (Municipal Government Decree No. 125), we formulated the "Shenzhen Urban Workers Social Health Insurance Cash Reimbursement Management Measures", which is hereby issued, please comply with the implementation.
Shenzhen Urban Workers Social Medical Insurance Cash Reimbursement Management Measures
Article 1 In order to standardize the management of cash reimbursement of social medical insurance for urban workers in our city, we have formulated these Measures in accordance with Shenzhen Urban Workers Social Medical Insurance Measures (Municipal Government Decree No. 125).
Article 2 The city workers' social medical insurance participants (hereinafter referred to as the participants) medical expenses incurred in accordance with the provisions of the basic medical insurance, local supplemental medical insurance or maternity medical insurance by the participants and their relatives to pay in cash in the first place, need to be reimbursed, the application of these measures.
Article 3 If a participant pays cash in advance for medical treatment under one of the following circumstances, he or she can go to the municipal social insurance management organization (hereinafter referred to as the municipal social insurance organization) for reimbursement within the scope of Article 2 of these Measures on the basis of the relevant documents and information:
(1) The designated medical institution where the medical treatment is conducted suffers from a computer malfunction or the account cannot be kept because of the damage of the employee's social insurance card;
(2) The medical expenses incurred due to emergency, local supplemental medical insurance or maternity medical insurance are not covered by these Measures. p> (ii) Treatment at a non-scheduled medical institution in the city for an emergency or critical illness;
(iii) Referral to an out-of-town medical institution with the consent of the scheduled medical institution in the city or the social insurance institution in the city;
(iv) Attendance at an out-of-town medical institution due to an emergency illness during business trips, family visits, vacations, or studies outside of the city (including births by insured persons outside of the city);
(v) (e) When the insured person is sent to work outside the city for a long period of time or settles outside the city after retirement, the insured person shall seek medical treatment there.
Article 4 If the insured person has one of the situations stipulated in Article 3 of these Measures, he should provide the following information to the municipal social insurance institution when he pays the medical expenses in cash:
(1) the original fee receipt;
(2) the detailed list of expenses;
(3) a copy of the outpatient medical record or inpatient medical record (stamped with the official seal of the healthcare institution);
(D) Diagnostic certificate of disease;
(E) Social insurance card of the employee.
Being permanently stationed outside the city to work or retired outside the city to settle in the medical expenses incurred in the local clinic, for reimbursement, in addition to submitting the information in the preceding paragraph, should also be submitted to the municipal social insurance agency for registration of the work (settlement) in a different place in advance.
Article 5: When a participant is referred to a designated medical institution in the city or a social insurance institution in the city for reimbursement of medical expenses incurred for medical treatment outside the city, in addition to providing the information stipulated in Article 4 to the social insurance institution in the city, the participant shall also submit the "Application Form for Audit of Out-of-City Referral of Shenzhen Social Medical Insurance" with an approved opinion, and reimbursement shall be approved in accordance with the following procedures:
(a) When a referral is approved by the social insurance institution in the city, the applicant shall submit the application form for audit of the out-of-city referral. (a) If the referral is approved by the municipal social insurance institution, the above information shall be sent directly to the municipal social insurance institution for approval of reimbursement;
(b) If the referral is made by the municipal tertiary hospital or municipal specialized hospital, the above information shall be sent to the medical institution from which the referral is made, and the approved reimbursement plan shall be reported to the municipal social insurance institution for review, and the reimbursement after review shall be subject to the reimbursement cost after review.
Anyone who is not approved in accordance with the regulations, but is referred to a hospital outside the city, or finds a hospital, purchases medicines, or goes to a for-profit medical institution (except for emergency treatment), will not be reimbursed for the expenses incurred.
Article 6 If a participant pays medical expenses in cash (except for those stipulated in Article 9 of these Measures) and needs to be reimbursed, he should submit the relevant information to the municipal social insurance institution for reimbursement within 6 months from the date of incurring the expenses (the date of hospitalization and the date of discharge, hereinafter the same), and the reimbursement will not be made after that date.
Article 7: The basic medical expenses (excluding baby expenses) for outpatient prenatal checkups, delivery hospitalization, postnatal visits and family planning surgeries outside of the city of the insured person enrolled in maternity medical insurance shall be paid by the Maternity Medical Insurance Fund. In addition to the documents stipulated in Article 4(1) of these Measures, marriage certificate, unit certificate and birth certificate (for the second child), the reimbursement of hospitalization expenses for delivery is also based on the birth certificate; the reimbursement of expenses for family planning surgeries is also based on the birth control surgery certificate, which will be approved for reimbursement by the Municipal Social Insurance Institution in accordance with the regulations.
Prenatal checkups include the following basic items:
First checkup: (before 13 weeks) establishment of the Shenzhen Maternal and Child Health Handbook; urine HCG, gynecological examination, blood routine (3 classifications), urine routine (10 classifications), electrocardiogram, ultrasound;
Second checkup: (16-18 weeks) obstetrical examination (all with Fetal heart Doppler), blood type (ABO, Rh), blood routine, urine routine, renal function (3 items), liver function (5 items), hepatitis B two-half pairs, hepatitis C virus antibody, syphilis serum antibody, blood glucose;
The third checkup: (20-24 weeks) obstetric examination, urine routine, color ultrasound;
The fourth checkup: (24-28 weeks) obstetric examination, urinalysis, color ultrasound;
The fourth checkup: (24-28 weeks) obstetric examination, urinalysis, color ultrasound. -28 weeks) obstetric examination, routine urine;
Fifth examination: (28-30 weeks) obstetric examination, routine urine;
Sixth examination: (30-32 weeks) obstetric examination, routine blood, routine urine, ultrasound;
Seventh examination: (32-34 weeks) obstetric examination, routine urine;
Eighth examination: (34-36 weeks) obstetric examination, fetal monitoring, routine urine;
Ninth examination: (37 weeks) obstetric examination, routine urine;
Tenth examination: (38 weeks) obstetric examination, fetal monitoring
11th visit: (39 weeks) obstetrics, urine, ultrasound;
12th visit: (40 weeks) obstetrics, fetal monitoring, urine.
Surgical items for family planning include:
(a) placing (removing) intrauterine devices;
(b) artificial termination of pregnancy (abortion), including artificial abortion (negative pressure suction, forceps scraping), induced abortion in midterm pregnancy, and termination of pregnancy by medication;
(c) placing and removing subcutaneous implantation of contraceptives;
(d) Tubal sterilization and vasectomy;
(v) Tubal reversal and vasectomy.
Article 8: Emergency hospitalization expenses incurred during the period of going abroad, going to Hong Kong, Macao and Taiwan on official business or visiting relatives shall be reimbursed according to the reimbursement standard of municipal hospitals in the city, while outpatient and medicine purchase expenses shall not be reimbursed. When applying for reimbursement, in addition to the need to provide the information stipulated in Article 4, paragraph 1 of these Measures, it is also necessary to provide proof of the unit, the passport to go abroad or Hong Kong, Macao and Taiwan special passes.
Article 9: The basic outpatient medical expenses of comprehensive medical insurance participants and the outpatient expenses for drugs and diagnostic and therapeutic items listed in the local supplemental medical insurance drug list shall be paid by the individual account.
If the individual account is not enough to pay, the excess outpatient basic medical expenses during the social medical insurance year, which is more than 10% of the average annual salary of urban workers in the previous year, shall be paid by the basic medical insurance fund at 70%, and the individual shall pay 30% out-of-pocket.
The insured person should go to the municipal social insurance organization for examination and reimbursement within the next medical insurance year with the information stipulated in the first paragraph of Article 4 of these Measures.
Article 10: The local supplementary medical insurance participant shall pay 85% of the basic medical expenses exceeding the maximum limit of payment by the basic medical insurance fund, and the expenses for the use of medicines and diagnostic and therapeutic items of the local supplementary medical insurance drug list during the period of hospitalization, subject to the approval of the local supplementary medical insurance fund, and the individual shall pay 15% out of his own pocket.
Article 11 The cost of blood transfusion (whole blood, component blood) required by the condition of the patient shall be paid in cash by the individual, and with the information stipulated in paragraph 1 of Article 4 of these Measures and the certificate of blood used for rescue, the reimbursement shall be approved by the municipal social insurance organization, and 90% shall be paid by the basic medical insurance fund, and the individual shall pay 10% out-of-pocket.
Article 12 approved by the municipal social insurance institutions, the use of disposable medical materials with a unit price of more than 1,000 yuan in the basic medical insurance program, the basic medical insurance co-ordination fund will pay 90% of the price of domestic universal (including domestic disposable medical materials), and there is no comparable price of domestic universal, according to the price of imported universal 50%.
Article 13 The basic medical expenses for organ transplantation treatment are approved for reimbursement in accordance with the regulations. The cost of purchasing organs or tissue sources at their own expense.
The scope of organ transplantation includes: kidney, heart valve, cornea, skin, blood vessels, bone and bone marrow transplantation.
Article 14 The cost of placing and replacing artificial organs shall be reimbursed to the municipal social insurance agency with the information stipulated in Article 4, paragraph 1 of these Measures and approved in accordance with the regulations.
Artificial organs include artificial pacemakers, artificial heart valves, artificial crystals and artificial joints. The cost of artificial organs is reimbursed at 90% of the price of the domestically produced universal model; if there is no comparable price for the domestically produced universal model, it is reimbursed at 50% of the price of the imported universal model. The maximum reimbursement is 15,000 yuan for a pacemaker, 8,000 yuan for an artificial heart valve, 5,000 yuan for an artificial joint, and 1,500 yuan for an artificial crystal.
Article 15 special medical materials, including intracardiovascular catheters, intracardiovascular stents and intravascular balloons. Special medical materials fees are reimbursed at 90% of the domestic universal price; without domestic universal comparable price, reimbursement is made at 50% of the imported universal price. The maximum reimbursement limit is 1,200 yuan for intracardiovascular catheters, 11,500 yuan for intracardiovascular stents, and 6,500 yuan for intracardiac vascular balloons.
Article 16 The outpatient dialysis (hemodialysis, peritoneal dialysis) for chronic renal failure, outpatient anti-rejection therapy medication after organ transplantation, and outpatient chemotherapy, interventional therapy, radiotherapy or nuclide therapy for malignant tumors shall be reimbursed by the patients in cash advance, and then with the information stipulated in the first paragraph of Article 4 of the present Measures, the reimbursement will be approved by the municipal social insurance institution, and the expenses shall be paid by the basic medical insurance fund. 90% of the expenses shall be paid by the Basic Medical Insurance Coordination Fund and 10% shall be paid by the individual.
Article 17 The present measures shall be implemented from the date of issuance.
July 16, 2003