(1) Scope of Reimbursement: General outpatient and emergency expenses incurred by insured persons at medical insurance designated hospitals or specialized hospitals of their personal choice, Chinese medicine hospitals and Class A hospitals (Youyi, Xuanwu, Guang'anmen Traditional Chinese Medicine Hospital, Tongren, Xiehe, Peking Third Hospital, Peking University People's Hospital, Peking University No.1, Jishuitan, Chaoyang, Jingu, and Liangxiang).
(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 will be paid 50%, and the individual will pay 50% out of his own pocket. For retirees, the total amount exceeds RMB 1,300 yuan, and the part of RMB 1,300 yuan or more is 70% paid by the Large Medical Mutual Aid Fund for those who have reached the age of 70, and 30% paid by individuals, and 80% paid by the Large Medical Mutual Aid Fund for those who have reached the age of 70, and 20% paid by individuals. The maximum payment limit is 20,000 yuan in a natural year.
(3) Management of medical care: general outpatient, emergency expenses paid in cash by individuals, medical expenses incurred should be in line with the scope of the three major directories of medical insurance library, purchasing drugs should be first 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 (prescription with double scratch), and details of expenses for examination and treatment.
(F) the date of declaration: 1-20 days a month, the current month's costs the next month to declare, the current year's costs 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 the medical insurance of their personal choice, Chinese medicine hospitals and hospitals of A category.
(2) Reimbursement rate: The starting payment rate 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: 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, 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 will settle the amount of out-of-pocket expenses and self-payment, and the amount of reimbursement from the integrated fund will be settled between the hospital and the district medical insurance center.
Third, outpatient special diseases
(a) the scope of reimbursement: malignant tumors, radiotherapy, kidney dialysis, kidney transplantation after taking anti-rejection drugs of the insured, in the approval procedures for special diseases, outpatient special diseases occurring within the scope of outpatient medical costs of medication.
(2) Reimbursement rate: The reimbursement rate is the same as that of 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 amount of personal out-of-pocket expenses and the amount of out-of-pocket expenses, and the amount of reimbursement from the integrated fund will be settled by the hospital and the district medical insurance center.
(4) Reimbursement process: the participant 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 completes the audit, settlement and payment work on the same day