I. Outpatient Expenses
(1) Reimbursement Scope: Participants in the medical insurance designated hospitals or specialized hospitals of their personal choice, traditional Chinese medicine hospitals and hospitals of category A (Youyi, Xuanwu, Guang'anmen Traditional Chinese Medicine, Tongren, Xiehe, Peking Third Hospital, Beidai People's Hospital, Peking University No.
I, Jishuitan, Chaoyang, Jianshegong, Liangxiang) incurred for general outpatient and emergency treatment.
(2) Reimbursement Ratio: 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 will be paid 50%, and the individual will 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 above is 70% paid by the large medical mutual fund for those who are 70 years old, and 30% paid by the individual, and 80% paid by the large medical mutual fund for those who are 70 years old or above, and 20% paid by the individual. 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 the notice" (Beijing Health Public Character [1997] No. 15) and "dry implementation of the supplementary views" (Beijing Health Public Character [1998] No. 2) document implementation. In the case of medicines that state that the cost is "partially borne by the individual", the individual must first bear 10% of the cost, and the rest of the cost will be included in the scope of payment by the basic medical insurance fund.
(ii) hospital preparations; according to the Municipal Health Bureau "on the implementation of the notice" (Beijing Health Public Character [1999] No. 2) document implementation.
(C) the scope of payment and use of Chinese herbal medicinal tablets 1. Chinese herbal medicinal tablets to be borne by individuals, according to the Municipal Bureau of Health, "Notice on the Inspection and Issuance of" (Beijing Health and Finance [77] No. 267) document, Article 1 implementation. 2. single flavor use and because of the condition of the need to be in the reasonable use of Chinese herbal medicinal tablets in the compound prescription (not exceeding the normal dosage), according to the Municipal Bureau of Health, "Notice on the Inspection and Issuance of" (Beijing Health and Finance [77] No. 267) document, Article 1 implementation. 3. No. 267), the second article of the document is implemented.3. The costs of 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) Outpatient radiotherapy and chemotherapy for malignant tumors: The following medicines can be included in the scope of payment of the basic medical insurance fund for outpatient radiotherapy and chemotherapy for malignant tumors of the insured: 1. Oncology medicines: "The eleventh category of oncology medicines" in the "Reimbursement Scope of Medicines Used in Beijing Municipality's Public Medical Care and Labor Insurance" for both western and traditional medicines. 2. Tumor drugs" in the "Beijing public medical treatment, labor insurance medical drug reimbursement scope" of Chinese and Western medicines, "the eleventh category of tumor drugs" in the removal of methylbenzofuran tablets, immune ribonucleic acid injection, thymus peptide injection of three kinds of drugs, the other 59 kinds of oncology drugs. 2. Promote leukocytosis drugs granulocyte colony-stimulating factor [special] injection (imported), leukocytes, Shalasun tablets, shark liver alcohol tablets, inosine tablets injection of four kinds of drugs. 3. anti-infective drugs" Beijing public medical treatment, labor insurance medical drug reimbursement scope" in the "first type of anti-infective drugs Antibiotics" (45 kinds) and "antifungal drugs" (5 kinds) in "Class I Anti-infective Drugs" of "Beijing Public Healthcare and Labor Insurance Medical Reimbursement Scope". ***50 medicines.
(E) Kidney transplant clinic anti-rejection drugs range of cyclosporine, prednisone, dexamethasone, methylprednisolone, azathioprine **** 5 kinds.
Two, the scope and standard of basic medical insurance services and facilities
(a) ordinary bed fee ordinary bed fee is included in the scope of payment of the basic medical insurance 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.
(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. Pacemaker: 14,000 yuan per set of single-chambered, 18,000 yuan per set of double-chambered, 6,000 yuan per set of temporary; 2. Heart valves: 7,000 yuan per set of bio-membrane, 8,000 yuan per set of mechanical membrane; 3. Artificial crystals 668 yuan each; 4. Artificial joints: artificial hip joints 4,500 yuan per set, artificial knee joints 5,000 yuan per set, artificial femoral head 3,300 yuan per set;
5. Installation of other artificial organs in the body of the maximum payment of the cost of standard 18,000 yuan; the above actual charges are lower than the above standards, according to the actual charges paid.
(2) organ transplantation, tissue transplantation into the scope of payment and cost standards are as follows:
1. The scope of payment in accordance with the Municipal Bureau of Labor and Social Security, "on the further deepening of the reform of the public medical care of the relevant issues in the notice" (Beijing Labor and Social Medical Development [2000] No. 86) in the implementation of the third article;
2. Organ transplants, tissue transplants of inpatient medical costs, the individual to bear the first 2% of the rest of the cost of the cost of the payment into the first 2% of the cost. scope.
(3) large medical equipment and medical materials large medical equipment reimbursement scope and use, according to the Municipal Health Bureau "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. For the cost of examination and treatment (including items approved for reimbursement where the cost of a single item of examination and treatment is more than 200 yuan) using the equipment listed in Article 2 of the abovementioned document (which is included in the scope of reimbursement for large-scale medical equipment) due to a medical condition, an individual shall first bear 8% of the cost and the rest of the cost shall then be included in the scope of payment by the basic medical insurance fund. The remaining costs will then 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, medical insurance for the sick community health services management of the relevant issues of the notice" (Beijing Labour and Social Development [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 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 Public Health Care Reimbursement Scope" (Beijing Health Public Character [1996] No. 7) document implementation; 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: the basic medical insurance fund does not pay the project, according to the Municipal Health Bureau "on the issuance of the notice" ([90] Beijing Wei Gong Zi No. 100) attached to the "Beijing Municipal Public Medical Treatment Management Measures," the fourth and the Municipal Bureau of Labor and Social Security "on the strengthening of the public medical care, the major illnesses of the notice of the relevant issues of the management of medical insurance "(Beijing Labor and Social Medical Development [1996] No. 7) document. Beijing Labor and Social Security Medical Development [2000] No. 90) of the second article of the implementation.
Legal basis:
Article 30 of the Social Insurance Law of the People's Republic of China*** and the State of China, the following medical expenses are not included in the scope of payment by the basic medical insurance fund:
(1) Those that should be paid out of the Workers' Injury Insurance Fund;
(2) Those that should be borne by a third person;
( (iii) Should be borne by the public ****health;
(iv) Medical treatment outside the country.
Medical expenses shall be borne by a third person in accordance with the law, and if the third person fails to pay or if the third person cannot be identified, the basic medical insurance fund shall pay in advance. The basic medical insurance fund shall have the right to recover the costs from the third party after the first payment.