Medical insurance is divided into new rural cooperative medical care, urban residents medical insurance and employee medical insurance. The three audiences are: rural people, urban people and employees.
The three reimbursement ratios are also different:
Rural Cooperative Medical Care:
A. Outpatient
Village health clinics and village center health clinics are reimbursed 60% of the cost of each visit, with a limit of 10 yuan for prescription drugs, and a limit of 50 yuan for temporary rehydration of the doctor's prescription drug costs in the health center; the township health clinics are reimbursed 40%, with a limit of 50 yuan for each visit for each examination fee and surgery, and a limit of 100 yuan for the cost of prescription drugs. RMB 100 for prescription drugs; 30% for reimbursement for secondary hospitals, RMB 50 for each examination and operation and RMB 200 for prescription drugs; 20% for reimbursement for tertiary hospitals, RMB 50 for each examination and operation and RMB 200 for prescription drugs; RMB 1 per sticker of prescription attached to the traditional Chinese medicine invoice; and RMB 5,000 for outpatient reimbursement for township-level cooperative medical care. The annual limit for town-level cooperative medical outpatient compensation is 5,000 yuan.
B. Hospitalization
Reimbursement scope: medicine: auxiliary examination: EKG, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, CT, MR*** vibration and other examination fees are limited to 200 yuan; surgical fees (with reference to the national standard, reimbursement for more than 1,000 yuan will be made in accordance with the amount of 1,000 yuan.) For elderly people aged 60 or above hospitalized in a health center, the compensation of the treatment fee and nursing care is 10 yuan per day, with a limit of 200 yuan. 10 yuan, with a limit of 200 yuan.
Reimbursement rates: township health centers reimburse 60%; secondary hospitals reimburse 40%; tertiary hospitals reimburse 30%.
C. Major Diseases
All hospitalized patients who participate in cooperative medical care will be compensated for their one-time or yearly accumulative reportable medical expenses exceeding 5,000 RMB in sections, i.e., 65% for 5,001-10,000 RMB and 70% for 10,001-18,000 RMB. The annual limit of compensation for township-level cooperative medical care inpatient and outpatient blood dialysis for uremia, and outpatient radiotherapy and chemotherapy for tumors is 11,000 yuan.
D. Exemptions
Medical expenses for self-medical treatment (medical treatment in unappointed hospitals or without referral orders), self-purchased medicines, medicines that cannot be reimbursed under public medical care regulations, and medical expenses that are not in line with family planning; medical expenses for outpatient treatment, office visit, hospitalization, meals, accompanying guests, nutritional expenses, blood transfusion (except for those who have blood stored in their families, which are reimbursed according to the relevant regulations), heating and cold air conditioning, ambulance service, and special other expenses such as nursing care; medical expenses for car accidents, fights, suicides, alcoholism, work accidents and medical accidents; orthopedics, plastic surgery, dentures, prosthetics, organ transplants, named surgery fees, consultation fees, etc.; reimbursement of expenses within the scope of reimbursement, but not outside the limit.
2. Urban Medical Insurance
Urban residents who are hospitalized more than twice in a billing year will not be charged the starting standard fee from the second hospitalization. If they are transferred to another hospital or hospitalized for more than two times, the difference shall be made up in accordance with the starting standard of the hospital to which they are transferred or re-admitted.
A. For students and children
In a billing year, for medical expenses up to 180,000 RMB incurred that are eligible for reimbursement, the starting standard for tertiary hospitals is 650 RMB, with a reimbursement rate of 50% and an upper limit of 2,000 RMB; for secondary hospitals, the starting standard is 300 RMB, with a reimbursement rate of 60%; and for first-class hospitals, there is no starting standard, with a reimbursement rate of 65%.
B. For medical expenses of less than 100,000 RMB incurred within one billing year that are eligible for reimbursement when the person is 70 years of age or older
The starting standard for Level III hospitals is 650 RMB, with a reimbursement rate of 50% and an upper limit of 2,000 RMB; the starting standard for Level II hospitals is 300 RMB, with a reimbursement rate of 60%; and Level I hospitals do not have any starting standard, with a reimbursement rate of 65%.
C. For other urban residents
In a billing year, for medical expenses of less than 100,000 RMB incurred that meet the scope of reimbursement, the starting standard for third-level hospitals is 659 RMB, with a reimbursement rate of 50% and an upper limit of 2,000 RMB; for hospitalization in second-level hospitals, the starting standard is 300 RMB, with a reimbursement rate of 55%; and in first-level hospitals, there is no starting standard, with a reimbursement rate of 60%.
3. Employee medical insurance
Generally speaking, the economic development of different regions is different, so the reimbursement rate is also different, the following on the situation of Beijing's employee medical insurance coverage.
After getting medical insurance, if you are an active employee, you can only be reimbursed for medical expenses of more than 1800 RMB after visiting the outpatient or emergency clinic of a hospital, and the reimbursement rate is 50%. If you are a retiree under the age of 70, you can be reimbursed for expenses over $1,300, and the reimbursement rate is 70%. If the retiree is over 70 years old, the reimbursement rate is 80 percent for expenses over $1,300.
And regardless of the type of person, the maximum limit for expenses paid for outpatient and emergency major medical expenses is 20,000 yuan. For example, if you are an active employee and you spend $2,500 on an outpatient visit, you can be reimbursed 50 percent of the $500 portion, which is $250.
In the case of hospitalization expenses, the starting amount is $1,300 for the first time you use basic medical insurance to pay in a 2009 year, whether you are an active employee or a retiree. And for the second and subsequent hospitalization medical expenses, the starting amount is determined at 50%, which is 650 yuan. And the maximum amount of payment from the basic medical insurance fund (hospitalization expenses) is 70,000 yuan in 1 year.
The standard of hospitalization reimbursement is related to the level of the hospital where the insured person stays, such as staying in a tertiary hospital, from the starting standard to 30,000 yuan, the employee pays 15%, which means 85% reimbursement; from 30,000 yuan to 40,000 yuan, the employee pays 10%, which means 90% reimbursement; for the portion of the expenses exceeding 40,000 yuan and up to the maximum payment limit, 95% of the expenses can be reimbursed, and the employee only has to pay 5%. And retirees pay 60 percent of what active (that is, the aforementioned) employees pay individually, but anything below the starting level is paid by the individual.
The diagnostic and therapeutic items that are not paid for by the basic medical insurance for employees are mainly non-clinically necessary and uncertain diagnostic and therapeutic items as well as diagnostic and therapeutic items for special medical services, including services such as registration fees, non-disease treatments such as cosmetic treatments, therapeutic equipment and materials such as hearing aids, therapeutic items such as magnetic therapy, and other categories such as infertility treatments, and so on. In accordance with the "national basic medical insurance treatment program scope", as follows:
(a) service category. (1) registration fee, out-of-hospital consultation fee, medical record cost, etc.; (2) visit fee, examination and treatment expediting fee, surcharge for named surgery, quality and premium fee, self-invited special nurse and other special medical services.
(2) Non-disease treatment program category. (1) a variety of cosmetic, bodybuilding and non-functional cosmetic, orthopedic surgery; (2) a variety of weight loss, weight gain, height increase program. (3) a variety of health checkups; (4) a variety of preventive, health care treatment programs; (5) a variety of medical consultation, medical appraisal.
(C) diagnostic equipment and medical materials. (1) the application of positron emission tomography device (PET), electron beam cT, ophthalmic excimer laser therapy and other large medical equipment for examination and treatment programs; (2) glasses, dentures, eye prostheses, prosthetics, hearing aids and other rehabilitative devices; (3) a variety of health care for their own use, massage, inspection and treatment equipment; (4) the provincial price departments can not be charged separately for disposable medical.
(D) treatment program category. (1) all kinds of organ or tissue transplantation of organ source or tissue source; (2) in addition to kidney, heart valves, cornea skin, blood vessels, bone, bone marrow transplantation of other organs or tissue transplantation; (3) myopic eye orthopedics; (4) qigong therapy, music therapy, health care of nutritional therapy, magnetic therapy and other complementary therapeutic projects.
(v) Others. (1) a variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment program; (2) a variety of scientific research, clinical verification of the diagnosis and treatment program.
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