Outpatient expenses are basically not reimbursed, while hospitalization expenses are partially reimbursed
Basic medical insurance medicines are divided into Class A and Class B medicines. The drugs in Category A are fully reimbursed, the drugs in Category B are partially reimbursed on a pro rata basis, and some diagnostic treatments and services are partially reimbursed, so you should make sure to ask for clarification when you go to the doctor!
1. What are Class A drugs?
1, what is a Class A catalog drug and how do I pay for it?
The "Category A List" drugs are those that are necessary for clinical treatment, widely used, effective, and low-priced in the same category. Costs incurred for the use of Class A drugs are paid by the integrated fund in accordance with the provisions of the basic medical insurance.
2. What are Class B drugs? How to pay?
"Class B list" drugs are drugs that can be used for clinical treatment with good efficacy and are slightly more expensive than Class A drugs in the same category. The costs incurred for the use of Class B list drugs will be paid by the insured person at a certain percentage, and the rest will be paid by the integrated fund in accordance with the regulations.
3. How are the costs of traditional Chinese medicine and hospital preparations paid?
(1) The expenses incurred for the use of Chinese medicine tablets are paid according to the provisions of the basic medical insurance, except for the part of tablets which are not paid according to the provisions of "Shandong Province Basic Medical Insurance Drug Catalog".
(2) If the hospital preparations have been approved by the municipal labor security department to be included in the scope of basic medical insurance medicines, the costs that should be partially borne by individuals shall first be borne by the insured in proportion to their own expenses.
(3) Drugs with prescribed limited use shall be paid for according to the prescribed limited use.
4. What are the medicines that the insured person pays for at his/her own expense?
(1) Drugs that mainly play the role of nutrition and tonic.
(2) Part of the animal and animal organs, dried (water) fruits that can be used as medicine.
(3) Various types of alcohol preparations made from Chinese herbal medicines and Chinese medicinal tablets.
(4) All kinds of fruit preparations in medicines, oral effervescent.
(5) Blood products, protein products (except for special indications and first aid and rescue).
(6) The Ministry of Labor and Social Security as well as the province stipulates that the basic medical insurance fund will not pay for other drugs.
5, the basic medical insurance fund to pay part of the cost of diagnosis and treatment of how the proportion of self-payment?
(1) Diagnostic and therapeutic equipment and medical materials
A, the application of x-ray computed tomography (CT), cardiac and angiography x-ray machine (including digital subtraction equipment), magnetic **** vibration imaging device (MRI), single-photon emission computerized scanning (CPECT), color Doppler, medical linear gas pedal for examination, treatment Items are 10% of the individual's responsibility.
B. Stereotactic radiation device (γ-knife, x-knife) (limited to the treatment of diseases of the central nervous system), the individual pays 40%.
C, extracorporeal vibratory wave lithotripsy with hyperbaric oxygen therapy, individual co-payment of 15%.
D, pacemaker, human joints, artificial crystals, artificial larynx, vascular stents (installation of the above imported artificial organs will be billed at the highest price of similar types of artificial organs made in China), individuals will pay 10% out-of-pocket.
E. Individuals shall pay 15% for disposable medical materials that can be charged individually for more than 100 yuan as stipulated by the provincial price department.
(2) Treatment Programs
A. Hemodialysis and peritoneal dialysis, individuals pay 5%.
B, Kidney, heart valve, cornea, skin, blood vessel, bone and bone marrow transplantation, individuals pay 10% out-of-pocket.
C, cardiac laser perforation, microwave knife therapy, fast neutron therapy program, individuals pay 15% out-of-pocket.
D, Anti-tumor cellular immunotherapy, individuals pay 40% out-of-pocket.
(3) Under the condition of meeting the diagnostic and treatment conditions, the cost of using the network remote consultation, the individual will pay 50% out-of-pocket.
6, the basic medical insurance fund to pay part of the cost of medical services and facilities of the project out-of-pocket ratio is how to stipulate?
First, the scope of medical service facility items for which the basic medical insurance fund pays for the expenses
(1) basic bed charges
(2) simple bed charges for outpatient (emergency) clinics
Second, the out-of-pocket payment ratio for medical service facility items for which the basic medical insurance fund pays for part of the expenses
(1) guardianship ward charges (CCU, ICU), individual out-of-pocket payment of 10%. ), individual out-of-pocket payment of 10%.
(2) Laminar flow ward bed fee, 10% of the individual out-of-pocket.
Third, the scope of medical service facility items for which the basic medical insurance fund will not pay the fees
(1) transportation fee for consultation (referral), emergency vehicle fee;
(2) air-conditioning fee, TV fee, heating fee, telephone fee, food humidor fee, maternity hygiene fee, electric stove fee, microwave oven fee, refrigerator, and compensation for damage to public property;
(3) Accompanying fee, nursing fee, cleaning fee, outpatient decoction fee, medicine guide fee, herbal medicine processing fee, corpse storage fee;
(4) Meal fee, nutrition fee;
(5) Books, newspapers, recreational activities and other special needs living services.
If you still don't understand the above instructions, let me give you an example:
Example 1: Wang, an in-service employee of a certain organization, participated in the city's basic medical insurance, and was admitted to a Grade 2A hospital due to an illness, with a medical cost of 9,760 yuan. Among the three major catalog outside the cost of 200 yuan, the cost of Class B drugs 2000 yuan (out-of-pocket ratio of 15%), asked Wang personal burden of medical expenses and the overall payment of each for how much?
Analysis:
1. Deducting the personal out-of-pocket expenses before the co-ordination fund pays:
Out-of-catalog expenses: 200 yuan
Personal out-of-pocket expenses for Class B drugs: 2000 × 15% = 300 (yuan)
Total deducted expenses: 200+300=500 (yuan)
2. Entering into the scope of co-ordination payment The expenses within the scope of payment are: 9760-500=9260 (yuan)
3. Individual out-of-pocket expenses within the scope of payment of the coordinated fund:
(1) Starting standard: Xiaowang lives in a second-class medical institution, and the starting standard is 9% of the previous year's average social wage of 10,000 yuan, i.e. 10,000×9%=900 (yuan)
(2) Xiaowang is a working Excessive portion plus the individual's own portion within the scope of payment of the integrated fund, that is: 500 + 2154 = 2654
King the excess medical expenses of 2654 yuan, the integrated fund to pay:
9760-2654 = 7160 (yuan)
Example 2: Wang is a retired employee of a certain unit, participated in the city's basic medical insurance and assistance for large medical expenses, and was hospitalized in our city due to cancer this year. This year, due to cancer in our city, a third-class A-class cancer hospital, before and after *** spent 78,000 yuan, including the use of anti-tumor cellular immunotherapy costs 6,500 yuan (40% of the proportion of self-responsibility), 4,000 yuan of Class B drugs (15% of the proportion of self-responsibility), 4,000 yuan of out-of-pocket expenses for drugs, air-conditioning costs of 350 yuan, 200 yuan of herbal processing costs, asked how much the integrated fund to pay for the yuan? How much should Lao Wang be responsible for his own medical expenses?
Analysis:
1. Deducting the individual's own expenses before payment by the integrated fund:
Out-of-pocket expenses for medicines: 4,000 yuan
Air-conditioning fee and processing fee for traditional Chinese medicine at the individual's own expense, i.e., 350+200=550 yuan
Out-of-pocket expenses for anti-tumor cellular immunotherapy: 6,500×40%=2,600 yuan<
Category B drugs personal responsibility: 4000 × 15% = 600 (yuan)
Deduction of the total cost: 4000 + 550 + 2600 + 600 = 7750 (yuan)
2, into the integrated fund and large-scale assistance to pay for the scope of the cost of:
78,000-7750=70250 (yuan)
3, the coordinated fund to pay for the scope of personal out-of-pocket expenses:
(1) the starting standard: Lao Wang lived in a third-class medical institutions, the starting standard for the previous year's average social wage of 10,000 yuan 12%, ie: 10,000 × 12% = 1200 (yuan)
(2) Lao Wang is a retired employee, the starting standard up to the 10,000 yuan within the personal out-of-pocket 12%, ie. (10,000-1,200) × 12% = 1056 (yuan)
(3) the maximum payment limit for the previous year's average social wage of 10,000 yuan four times that of 40,000 yuan, 10,000 yuan more than 40,000 yuan below the personal responsibility of 9%, the personal responsibility of this paragraph: (40,000 - 10,000) × 9% = 2,700 (yuan)
(4) (4) Coordination Fund within the scope of personal responsibility for the total costs: 1200 + 1056 + 2700 = 4956 (yuan)
4, large amount of aid within the scope of personal responsibility for the costs:
Large amount of aid within the scope of personal responsibility for 10%, the old king large amount of aid within the scope of the costs of 70,250 - 40,000 = 30,250 yuan, this paragraph Individual responsibility: 30250×10%=3025 (yuan)
5, Lao Wang's individual responsibility for the total cost:
The individual responsibility for the part deducted before the payment of the integrated fund + the individual responsibility for the part of the integrated fund within the scope of the payment of the individual responsibility for the part of the payment of the large amount of aid fund within the scope of the individual responsibility for the part of the payment of the individual responsibility for the part of the payment of the large amount of aid fund, that is:
7750+4956+3025=15731 (yuan) )
Lao Wang should be responsible for the medical expenses 15731 yuan
Coordinated fund and large amount of aid payment: 78,000-15731=62,269 (yuan)
Example 3: the patient Zhang San is a unit of the active employees, participated in the city's basic medical insurance and large medical expenses assistance. Last year due to cancer hospitalized for surgical treatment, this year in the outpatient surgery after radiotherapy treatment, annual medical expenses ***51,200 yuan. The unit owed basic medical insurance premiums in March, May to make up payments, according to the policy, since the month following the full payment of arrears resumed enjoyment of basic medical insurance treatment, of which 200 yuan in April medical costs, five copies of the medical costs of 100 yuan, in addition to the treatment of chronic appendicitis costs of 1,000 yuan, outside the directory costs of 900 yuan, radiotherapy costs of 32,000 yuan (of which 1,200 yuan to do the linear acceleration of fixed irradiation, 10% of the deductible), radiotherapy costs of 32,000 yuan (of which do linear acceleration of fixed irradiation. The deductible ratio is 10%), chemotherapy costs 17,000 yuan (including the use of Class B drugs 13,000 yuan, the deductible ratio is 15%), ask the health insurance agency should pay how many yuan? How much is Zhang San's out-of-pocket medical expenses?
Analysis:
1. Deduct the individual's out-of-pocket portion before the integrated fund pays:
Costs during the gray list period: 200+100=300 (yuan)
Chronic appendicitis, out-of-directory costs: 1,000+900=1,900 (yuan)
Linear Accelerated Fixed Irradiation: 1,200×10%=120 (yuan)
Personal responsibility for Class B drugs: 13,000×15%=1,950 (yuan)
Total deductions: 300+1,900+120+1,950=4,270 (yuan)
2. Expenses covered by the integrated fund and the large-scale assistance fund are:
51,200-4270=46,930 (yuan)
3, the coordinated fund to pay for the scope of personal expenses:
(1) the starting standard: Zhang San for outpatient patients, the starting standard for the previous year's average social wage of 10,000 yuan 6%, that is: 10,000 × 6% = 600 (yuan)
(2) Zhang San is a working employee, the starting standard to more than 10,000 yuan within the personal responsibility for 15%, that is: (10,000-600 yuan). That is: (10000-600) × 15% = 1410 (yuan)
(3) the maximum payment limit for the previous year's average social wage of 10,000 yuan four times, that is, 40,000 yuan, 10,000 yuan or more than the maximum payment limit of the following personal responsibility 12%, the individual responsibility for this paragraph: (40,000 - 10,000) × 12% = 3600 (yuan)
(4) The total personal responsibility for the expenses within the scope of payment by the coordinated fund:
600+1410+3600=5610 (yuan)
4. Personal responsibility for the expenses within the scope of payment by the large amount of aid funds:
The expenses within the scope of payment by the large amount of aid funds are:
46930-40,000=6930 (yuan)
Large amount of aid funds The personal responsibility of 10% within the scope of the individual, that is: 6930 × 10% = 693 (yuan)
5, Zhang three people's total responsibility for the costs:
Coordinated fund deducted before payment of the personal responsibility of the individual + coordinated fund within the scope of the personal responsibility of the individual responsibility of the individual responsibility of the scope of the payment of the large aid fund, that is:
4,270+5,610+693= 10,573 (yuan)
A: Zhang San needs to bear the medical expenses:10,573 (yuan)
The medical insurance organization should pay 51,200-10,573=40,627 (yuan).
What about when you reach retirement age?
According to the regulations, retirees do not pay the basic medical insurance premiums, as long as their units have participated in the basic medical insurance and paid the full amount of contributions, their retirees can enjoy the benefits, otherwise they do not enjoy.
Under the same circumstances, the retiree's personal account is injected two and a half percent more than the retirement, and the medical expenses are reported three percent more. However, four dollars a month for the large amount of aid individuals have to pay.
1. What are the minimum contribution years for participants?
The participants reached the retirement age, enjoy the retiree basic medical insurance benefits of the cumulative minimum contribution period: men full 30 years, women full 25 years.
If the minimum contribution period is not reached, the employer and the insured will make up the difference in the basic medical insurance premiums of the previous year's average monthly salary of the employees in the city at the time of the retirement formalities before enjoying the basic medical insurance benefits for the retirees. Before making up the full amount, the individual account fund can continue to be used, but the enjoyment of basic medical insurance treatment is suspended.
The basic medical insurance premiums will be transferred to the personal account in accordance with the relevant regulations.
Before an employer enrolls in basic medical insurance, its employees who meet the state regulations on the number of consecutive years of service, the number of years of work or the number of years of basic pension insurance contributions are counted as the minimum number of years of basic medical insurance contributions.
2, the participants from what time to start enjoying the basic medical insurance for retirees?
People who have reached the normal retirement age (including deferred retirement) for retirement formalities, in line with the minimum number of years of basic medical insurance contributions, from the month following the approval of their retirement to enjoy the basic medical insurance for retirees.
Those who are approved to go through the procedure of deferred retirement shall be entitled to the basic medical insurance treatment of active employees during the period of deferred retirement.
3. What about retired workers of bankrupt enterprises?
In accordance with the provisions of Lu Zheng Fa & lt; 1999 & gt; 94 documents, the retirees of bankruptcy enterprises, medical fees according to the average amount of the city's retirees in the previous year to pay the medical fee for ten years, and thereafter, the medical costs by the medical insurance agency responsible for.
4, the insured unit retirees abnormal large increase, more than 30% of the active staff how to do?
When there is an abnormal large increase in the number of retirees in the insured units, more than 30% of the active staff, in accordance with each more than one person, that is, the city's per capita medical costs of retirees in the previous year, the city's retirees to pay ten years of basic medical insurance premiums, before enjoying the basic medical insurance benefits.
5. What about special groups?
Special personnel refers to the retirees, the old Red Army, the second class B above the revolutionary disabled soldiers and the revolutionary work before the founding of the country and according to the original salary of 100% of their enjoyment of the retirement benefits, this part of the personnel do not participate in the basic medical insurance, the implementation of special policies for special personnel, its medical treatment remains unchanged, the medical costs in accordance with the original consultative channel to solve the problem of the implementation of a special fund-raising by the medical insurance agency separate The medical expenses will be solved by the original consulting channels, and the special fund-raising will be implemented and managed by the medical insurance agency in a separate account.