Legal analysis:
A general outpatient clinic: (a) First, the individual will bear the medical expenses of one outpatient starting standard, specifically 300 yuan. (ii)The part of the medical expenses above the outpatient starting standard shall be borne by the coordinated fund and the individual*** together, and the proportion borne by the coordinated fund shall be as follows: 40% for third-level and corresponding medical institutions (hereinafter referred to as the third-level medical institutions), 60% for other medical institutions (including the second-level and corresponding medical institutions, hereinafter referred to as the same), and 70% for the community health service institutions. (c) For insured children and adolescents who choose the contracted services of general practitioners, the proportion borne by the integrated fund for their outpatient medical treatment at contracted community health service organizations shall be increased by 3 percentage points on the basis of the provisions in (b) of this Article. If an insured child or adolescent first consults a contracted community health service organization, or is referred by a contracted community health service organization to another medical institution for further treatment, the starting payment standard for outpatient medical insurance will be reduced or waived by 300 yuan. Hospitalization reimbursement: (1) The maximum limit of hospitalization medical fees paid by the integrated fund is 250,000 RMB for children's health insurance. (ii) Assuming one hospitalization starting standard, for two or more hospitalizations, the starting standard is calculated according to the standard of the highest level medical institution. Specifically: 800 yuan for tertiary medical institutions, 500 yuan for other medical institutions, and 300 for community health service institutions.(iii) The part of the medical fees below the maximum limit above the hospitalization starting standard shall be borne by the co-ordinated fund and the individual*** together. The proportion borne by the Coordinated Rent Repentance Date Fund is 70% for tertiary medical institutions, 75% for other medical institutions, and 80% for community health service institutions. (D) 250,000 or more part of the medical expenses, in line with the provisions of the major medical insurance, by the major medical insurance fund in accordance with the proportion of 70% to be borne.
Legal basis:
The Social Insurance Law of the People's Republic of China
Article 2 The State establishes a social insurance system for basic old-age pension insurance, basic medical insurance, industrial injury insurance, unemployment insurance, maternity insurance and other social insurance systems, and guarantees the right of citizens to receive material assistance from the State and society in accordance with the law in the event of old age, sickness, industrial injury, unemployment and childbirth.
Article 26 The standards of treatment for basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with the provisions of the State.
Article 28 Medical expenses that conform to the basic medical insurance drug catalog, diagnostic and treatment items, standards of medical service facilities, as well as those for emergencies and salvages, shall be paid out of the basic medical insurance fund in accordance with the state regulations.
Derivative question:
What is the reimbursement rate of medical insurance for over-transferees?
Reimbursement ratio:
The general outpatient emergency expenses incurred in a natural year for the staff accumulated more than 2000 yuan, 2000 yuan or more of the part of the large medical mutual fund to pay for 50% of the former sell, the individual to pay 50% out-of-pocket. The medical insurance is not reimbursed the following costs: 1, the service category: registration fees, out-of-hospital consultation fees, medical records cost, etc.; clinic fees, examination and treatment of the expedited fee, named surgery surcharge, named surgery surcharge, quality premium fee, self-requested special nurses and other special medical services. 2, diagnostic and therapeutic ills and demolition of the equipment and medically useful materials: the application of positron emission tomography device (pet), electron beam ct, ophthalmologic Excimer laser therapy instrument and other large-scale medical equipment for examination, treatment programs. Eyeglasses, denture, eye prosthesis, prosthetic limbs, hearing aids and other rehabilitation devices. All kinds of self-use health care, massage, examination and treatment equipment. Provincial pricing departments do not charge separately for disposable medical materials. 3, the treatment project category: all types of organ or tissue transplantation of organ or tissue source; in addition to kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow transplantation; myopic orthopedics; qigong therapy, music therapy, health care of nutritional therapy, magnetic therapy and other complementary therapeutic projects.
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