Medical Insurance Reimbursement Scope and Standards for Urban and Rural Employees and Urban and Rural Residents
Medical insurance generally refers to the basic medical insurance, which is a social insurance system established to compensate workers for the economic losses caused by the risk of illness. The following is my carefully organized health insurance reimbursement scope and standards for urban workers and urban and rural residents, I hope it will help you!
First, the scope of drug reimbursement: reimbursement in accordance with the "Sichuan Province, basic medical insurance, industrial injury insurance and maternity insurance drug catalog" (2010 version) (including Western medicine, proprietary Chinese medicines, ethnic medicines*** 2373, of which: 1817 types of Category B medicines) standard reimbursement, divided into Category A and B, and adjusted periodically. Category A all included in the scope of reimbursement, Category B first out-of-pocket a certain percentage of the scope of reimbursement (10% out-of-pocket Category B drugs, Category B drugs in the smallest package unit price of more than 100 yuan in accordance with the special use of drugs out-of-pocket 15%).
Second, the reimbursement scope of diagnostic and treatment items: The standard reimbursement of diagnostic and treatment items according to the "Sichuan Provincial Urban Workers' Basic Medical Insurance Diagnostic and Treatment Items Catalog" determined by the basic medical insurance is permitted to pay the cost, permitted to partially pay the cost and not to pay the cost of the diagnostic and treatment items. Attached to the basic medical insurance diagnosis and treatment items catalog of Sichuan Province:
Basic medical insurance does not pay the cost of diagnosis and treatment items
(a) service items:
1. Registration fee, consultation fee, consultation fee, outpatient diagnosis and treatment fee, remote diagnosis and treatment fee, guide service fee, etc.
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2. Expedited examination and treatment fees, naming (appointment) medical service fees, check-up fees, special nurse fees, door-to-door service fees, discharge follow-up fees, mother and child system of the whole service and other special medical service fees.
3. Labor cost of medical records, microcomputer query and management fees, and labor cost of various bills.
(B) non-disease treatment items:
1. Various cosmetic such as freckles, acne, black spots, warts, acne, blemishes, pigmentation and alopecia (including baldness), white hair, nevus, piercing the ears, saddle nose, breast augmentation, single eyelid to double eyelid, massage and other cosmetic items.
2. A variety of cosmetic, orthopedic (except for the sequelae of polio) and physiological defects in the treatment of such cuts as fox-smell, make up for the hare lip, stuttering, orthopedic strabismus, cut more than one finger (toes), circumcision, "O" shaped legs, "X" shaped legs, refractive error, The surgery program of vision correction, etc..
3. Diabetes decision support system, sleep and respiration monitoring system, trace element testing, bone densitometry, body information diagnosis, computerized selection of the optimal period of gestation, fetal gender and fetal development checkups and other diagnostic and therapeutic programs.
4. A variety of weight loss, fat, height, bodybuilding, smoking cessation treatment programs.
5. All kinds of health checkups.
6. A variety of preventive health care treatment programs.
7. A variety of medical consultations (including psychological forecasting, health forecasting, dietary advice, disease counseling), a variety of predictions (including stroke prediction, health prediction, disease prediction,) a variety of appraisal (forensic appraisal, industrial injury appraisal, labor appraisal, medical appraisal, paternity appraisal), health guidance and other projects.
(C) therapeutic equipment and medical materials:
1. Cell knife, positron emission segmentation device PET, electron beam CT, ophthalmic excimer laser treatment device and other large-scale medical equipment for the inspection and treatment program.
2. Eyeglasses, prosthetic eyes, prosthetic teeth, prosthetic limbs, hearing aids, brain fitness, leather (steel) undershirts, steel girth, steel head and neck, gastric support, kidney support, scrotum support, uterine support, crutches, wheelchairs, deformed insoles, pill pillows, pill pads, hot packs, pressure pulse belt, infusion net, testicular belt, hernia belt, knee belt, artificial anal bag and other appliances.
3. A variety of home inspection detector (device), treatment instrument (device) physiotherapy instrument (device), massagers and magnetic therapy supplies and other therapeutic appliances.
4. The use of medical instruments, equipment and medical materials do not meet the national or provincial supervision of the management of medical instruments, equipment and medical materials for diagnosis and treatment programs.
5. Provincial price departments can not be charged separately for disposable medical materials.
(D) therapeutic project category:
1. Various types of organ or tissue transplantation organ source or tissue source and access to organ source, tissue source of the relevant surgery.
2. In addition to kidney, heart valve flap, cornea, skin, blood vessels, bone, bone marrow transplantation of other organs or tissues transplantation of urban workers and urban and rural residents of the medical insurance reimbursement scope and standard urban workers and urban and rural residents of the medical insurance reimbursement scope and standard.
3. Prostate hyperplasia microwave (radiofrequency) treatment, helium-neon laser intravascular irradiation (hemotherapy), new technology of analgesia after anesthesia surgery (pain beds), endoscopic retrograde appendicography and other diagnostic and treatment items.
4. Dentures, dental implants, teeth, teeth, teeth, yellow and black teeth, dental defects, stained teeth, grilled magnetic teeth and other diagnostic and treatment programs.
5. Qigong therapy, music therapy, hypnotherapy, magnetic therapy, water bar therapy, oxygen bar therapy, positional therapy, psychotherapy and suggestive therapy (except for psychiatric patients), food therapy, nutritional therapy and other auxiliary treatment programs.
6. A variety of infertility (pregnancy), sexual dysfunction and family planning programs.
7. A variety of scientific research, teaching, clinical verification of the diagnosis and treatment program.
Basic medical insurance to pay part of the cost of diagnostic and treatment projects
(a) diagnostic and treatment equipment and medical materials:
1. The application of the r-knife, x-knife, x-ray computed tomography (CT), cardiac and angiographic x-ray machine (including digital subtraction equipment), magnetic **** vibration imaging device (MRI), monoclonal imaging device (CT), digital subtraction equipment (including digital subtraction equipment). MRI), single photon emission computer scanning device (SPECT), color Doppler, medical linear gas pedal and other large medical equipment for examination and treatment projects.
2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy program.
3. All kinds of clinical monitoring (except intraoperative and postoperative monitoring).
4. Provincial price departments can be charged separately for disposable medical materials.
(B) treatment program category:
1. Hemodialysis, peritoneal dialysis treatment program.
2. For kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow transplantation project.
3. Pacemakers, artificial valves, artificial joints, artificial crystals, a variety of stents, a variety of anastomoses, a variety of catheters, implanted drug delivery devices and other internal replacement of artificial organs, materials and installation or placement of the body surgery program.
4. Heart bypass, cardiac catheterization balloon dilatation, cardiac radiofrequency ablation and other surgical projects.
5. Coronary angiography, laparoscopic and thoracoscopic surgery, cardiac laser perforation, T-lymphocyte infusion method in tumor biotherapy, prostate electrocision, tumor thermotherapy and other diagnostic and therapeutic projects.
6. A variety of microwave, spectrum, far-infrared, light quantum (liquid therapy) and other auxiliary treatment programs.
Third, the scope of reimbursement of medical services and facilities: reimbursement according to the "Interim Measures of Sichuan Provincial Urban Workers' Basic Medical Insurance Medical Services and Facilities" standard.
4. Critical care ward beds (CCU, ICU)
(b) Payment standards:
1. General ward beds in accordance with the price policy stipulated by the price of general ward beds for three or more people. Specialty and grade hospitals can be provided by the price policy 'upward proportion of payment.
2. Outpatient (emergency) detention beds are paid according to the price policy. However, the maximum price also does not exceed the payment standard of the general ward bed fee.
3. The need for isolation and critical rescue ward bed fee payment standards are appropriately relaxed, and by the co-ordination area according to the actual determination.
Basic medical insurance does not pay the cost of medical services and facilities project scope
1. Consultation (referral) transportation fees, emergency vehicle fees.
2. Air conditioning, heating, television, telephone, electric stove, refrigerator, baby warmer, food warmer, and damage to public property compensation, as well as water, electricity, gas and other fees.
3. Accompanying fee, accompanying bed fee, nursing fee, cleaning fee, bathing fee, medicinal bath fee, disinfection fee, hairdressing fee, washing fee, etc. 4. Outpatient decoction fee, traditional Chinese medicine processing fee.
5. Recreational activities, newspapers and magazines, fitness activities. 6. Meals.
7. Flower and arrangement fees.
8. The cost of disposable items such as sanitary tableware, washbasin, mouth cup, toilet paper, bed sheet, pillowcase, bed sweeper, diaper and so on.
9. The cost of daily necessities such as soap and water, detergent, garbage bags, mosquito killer.
10. Other living service costs of urban workers and urban and rural residents health insurance reimbursement scope and standards wikipedia.
Fourth, special medical materials, disposable medical materials and hospital bed reimbursement standards: According to the "Ganzi State medical insurance to pay hospital bed fees, special medical materials and disposable medical materials standards" (Gan Medical Insurance Center [2006] No. 29) and "on the adjustment of medical insurance hospital bed fees and medical materials payment standards Approval of the Opinions on Adjusting the Payment of Medical Insurance Hospitalization Bed Charges and Medical Material Charges" (Ganshan Social Insurance [2014] No. 28) are implemented.
(a) hospitalization bed fee payment standards
1, hospitalization bed fee basic medical insurance co-ordination fund payment standards are unified, the specific payment standards are as follows: third-level hospitals: 35 yuan / bed day; second-level hospitals: 25 yuan / bed day; first-level and unclassified hospitals: 15 yuan / per bed day; critical rescue ward beds ( ICU, CCU). ICU, CCU): 60 yuan/bed day. Participants hospitalization bed cost is lower than the payment standard, according to the actual bed cost, higher than the payment standard is calculated according to the payment standard.
2, the enjoyment of civil service medical subsidies for county-level cadres in excess of the standard hospitalization bed costs are included in the official medical subsidies alone to give the price limit to make up for the difference (deputy director level and above to enjoy the subsidies of cadres at the district level alone). Specific subsidies limit standards are as follows: three hospitals not more than 30 yuan / bed day; two A hospitals not more than 20 yuan / bed day; two B hospitals not more than 15 yuan / bed day: two B the following hospitals not more than 10 yuan / bed day; critical rescue ward beds (ICU, CCU) not more than 20 yuan / bed day
(B) special medical materials fee payment standards
(B) special medical materials fee payment standards
(B) special medical materials fee payment standards
Specialized medical materials fee payment standards
1, implanted human materials and artificial organs and other special medical materials costs, according to the following standards into the basic medical insurance fund to pay:
(1) unit price of less than 100 yuan (including 100 yuan) is included in 100%;
(2) unit price of more than 100 yuan to 10000 yuan (including 10,000 yuan)
(3) unit price of more than 10,000 yuan to 50,000 yuan (including 50,000 yuan) is included at 70%, 30% out-of-pocket;
(4) unit price of more than 50,000 yuan is included at 60%, 40% out-of-pocket.
2. The implanted human body materials and artificial organs and other special medical materials currently included in the scope of payment of the basic medical insurance fund to clarify the unspecified implanted human body materials and artificial organs and other special medical materials are not included in the scope of payment of the basic medical insurance for the time being.
(C) disposable medical materials fee payment standards
hospitalization medical materials used in the treatment of disposable medical material costs at a unit price of less than 10 yuan 100% into the basic medical insurance fund to pay for the scope of the unit price of more than 10 yuan (including 10 yuan) included in the special items out-of-pocket 20% into the basic medical insurance fund to pay for the scope of the unit price of more than 10 yuan (including 10 yuan) included in the special items out-of-pocket 20%. The unit price of more than 10 yuan (including 10 yuan) is included in the special items with 20% out-of-pocket payment and then included in the scope of payment of the basic medical insurance co-ordination fund. The cost of disposable medical materials for non-therapeutic use is not included in the scope of payment of the basic medical insurance fund.
V. According to the "Notice on the inclusion of new diagnostic and therapeutic items in the basic medical insurance reimbursement" (Ganlao Social Insurance [2010] No. 38), the costs of new diagnostic and therapeutic items (including diagnostic and therapeutic surgeries and the corresponding costs of diagnostic and therapeutic materials) are included in the reimbursement of special items of basic medical insurance according to the relevant provisions of the current medical insurance policy.
Disclaimer: This article represents the author's personal views and has nothing to do with this website.
Reimbursement Ratio
1, outpatient, emergency medical expenses: in the year of the active employees (January 1 ~ December 31) in line with the provisions of the basic medical insurance coverage of the medical expenses accumulated more than 2000 yuan above the part.
2. Settlement ratio: 50% reimbursement for the part above 2000 RMB for dispatched staff during the contract period, and 50% out-of-pocket payment for individuals; the maximum amount of outpatient and emergency reimbursement for dispatched staff is 20,000 RMB for a cumulative payment in a year.
3. The insured personnel should keep the outpatient medical bills (including receipts, prescription bottoms, etc.) of the outpatient treatment in the designated hospitals as the vouchers for reimbursement of medical expenses.
4, three kinds of special disease outpatient medical treatment: participants suffering from malignant tumors radiation therapy and chemotherapy, renal dialysis, kidney transplantation to take anti-rejection drugs need to be in the outpatient medical treatment, by the participants in the second and third-class designated hospitals for medical treatment to issue a "certificate of diagnosis of the disease" and fill out the "medical insurance special disease declaration and approval form", reported to the regional medical insurance center for approval and filing. The form will be submitted to the district medical insurance center for approval and filing. Outpatient medical treatment and medicine collection for these three special diseases are limited to the approved designated hospitals, and cannot be purchased at designated retail pharmacies. If the medical expenses incurred are within the scope of the outpatient special diseases, they will be settled with reference to hospitalization.
5. Hospitalization.
The medical insurance payment is enough for 20 years in order to enjoy the medical insurance reimbursement after retirement.
The range of reimbursement rates for medical insurance varies from place to place, so please refer to the local policy.
Role
First, it is conducive to improving labor productivity and promoting the development of production.
Medical insurance is the inevitable result of social progress and production development. In turn, the establishment and improvement of the medical insurance system will further promote social progress and the development of production. On the one hand, medical insurance relieves workers of their worries, so that they can work without fear, which can improve labor productivity and promote the development of production; on the other hand, it also ensures the physical and mental health of workers, and ensures the normal reproduction of labor.
Second, to regulate income differences, reflecting social fairness.
Medical insurance is an important means of income redistribution through the collection of medical insurance premiums and reimbursement of medical insurance service fees to regulate income differences.
Third, the maintenance of social stability is an important guarantee.
Medical insurance provides financial assistance to sick workers and helps to eliminate social instability caused by illness, and is an important social mechanism for adjusting social relations and social conflicts.
Fourth, an important means of promoting social civilization and progress.
The social system of medical insurance and social mutual **** relief, by sharing the risk of disease costs among the participants, reflecting the "one party in trouble, eight parties to support" a new type of social relations, is conducive to the promotion of social civilization and progress.
V. An important guarantee to promote the reform of the economic system, especially the reform of state-owned enterprises.
How to pay basic medical insurance premiums
First of all, the coordinated areas to determine a suitable level of burden for the local workers of the individual basic medical insurance contribution rate, generally for the wage income of 2%. Secondly, the individual will pay the basic medical insurance premiums according to the local individual contribution rate based on his/her salary income. The individual contribution base should be based on the statistical caliber of wage income stipulated by the National Bureau of Statistics, i.e., all wage income, including all kinds of bonuses, labor income and in-kind income, multiplied by the stipulated individual contribution rate, i.e., the basic medical insurance premiums to be paid by the individual. Thirdly, the individual contributions are generally not required to go to the social insurance agency to pay, but by the unit from the wages of the withholding agent.
How to set up a basic medical insurance fund and individual account
According to the Decision of the State Council on the Establishment of a Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No. 44), the funds injected into the individual account come from the individual's contribution and the unit's contribution: the individual's contribution is credited to the individual account, and the unit's contribution is credited to the individual account. The entire amount of the individual's contribution is credited to the individual account, and a portion of the unit's contribution is credited to the individual account. The unit contribution is generally allocated to the individual account at about 30%. However, since there are great differences in the level of medical consumption expenditures for each age group, when determining the proportion of unit contributions to be credited to each employee's account in a co-ordinated area, the age factor should be taken into account to determine different crediting ratios for different age groups. To determine the specific proportion of unit contributions to be credited to the individual account, the co-ordinated area shall be determined according to the scope of payment of the individual account and the age of the employee and other factors.
The injection of funds into the integrated fund mainly comes from the unit contribution part. The remaining portion after the unit contribution is used to transfer to the individual account is the capital of the unified fund.
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