Description of the problem:
Although the unit to the staff have bought health insurance, but I have very little knowledge of health insurance, usually sick are to go to the clinic to see, there is no reimbursement of the awareness of the health insurance do not know how to use the correct because no one has been given to us to publicize this point. Now I would like to ask, can I be reimbursed in the health insurance for the birth of a child?
Analysis:
District medical insurance
A basic medical insurance treatment
(a) the source of funds for personal account
1, the basic medical insurance premiums paid by the employee's personal 2% of my gross salary all transferred to the personal account.
2, the employer to pay the basic medical insurance premiums of 8% of the total wages (6% in 2002), according to the provisions of the part of the transfer to the personal account, the specific method of transferring 45 years of age and the following 0.5%; 46 years of age to the age of 59 years of 1%; 60 years of age and older 1.5%.
(2) The source of the integrated fund
The basic medical insurance premiums paid by the employer, in addition to the required part of the transfer to the individual account, the rest into the basic medical insurance integrated fund.
(3) Scope of payment of individual account
The individual account is mainly used to pay for outpatient medical expenses in line with the basic medical insurance drug list and diagnostic and treatment items; to pay for inpatient hospitalization medical expenses to be paid by the individual; and to pay for the costs of special examinations and special treatments, as well as some of the outpatient medical expenses of chronic outpatient patients.
(D) the scope of payment of the integrated fund
1, hospitalization medical expenses: hospitalization medical expenses incurred in accordance with the provisions of the basic medical insurance: above the starting standard, the maximum payment limit of the integrated fund in accordance with the cumulative approach to pay the majority of the individual also has to pay a certain percentage of out-of-pocket payment
The proportion of the integrated fund to pay the proportion of individuals to pay the proportion of
Hospitalization medical fees Active Retirement Active Retirement
Above the threshold to 5,000 yuan 70 75 20 15
5,000-10,000 yuan 75 80 15 10
10,000 yuan to the maximum limit of 80 85 10 5
2, a year of the integrated fund of the maximum payment limit of the employee's annual salary four times Participants pay in cash, and through commercial medical insurance and other ways to solve the problem.
2. Interim Provisions on Medical Benefits for State Civil Servants
(1) Scope of Benefits
1. Medical expenses and drug catalogs in line with the standards of the basic medical insurance for diagnostic and treatment items and medical services facilities.
2. Part of the medical expenses exceeding the maximum payment limit of the basic medical insurance fund.
3. Medical expenses that exceed a certain amount of personal out-of-pocket payment within the scope of basic medical insurance.
4. Medical expenses incurred by medical care personnel who are entitled to medical care according to regulations.
5, in line with the national civil service medical assistance for work (public) injury. Maternity medical expenses.
(B) outpatient medical subsidies
In line with the provisions of the basic medical insurance, a medical expenses:
55% of the subsidy for the active personnel (outpatient medical expenses within a year totaling more than 1,600 yuan or more) is no longer subsidized.
Retirees are subsidized 65% (outpatient medical expenses totaling more than 1800 yuan in a year) no longer subsidized.
90% of the subsidy for medical caregivers (total outpatient medical expenses of more than 2,000 yuan in a year) is no longer subsidized.
(C) hospitalization subsidies
1, inpatient bed fee subsidies: more than 15 yuan of basic medical insurance bed fee part of the daily subsidies for: 10 yuan of subsidies for employees, 15 yuan of subsidies for retirees, 25 yuan of subsidies for medical care personnel.
2. For the medical expenses incurred in hospitalization within one year, the subsidies for the part of medical expenses borne by individuals above the starting standard and below the maximum payment limit of the basic medical insurance co-ordination fund, such as the part of Class B medicines, Class B materials, Class B diagnostic and therapeutic items, and the segmented cumulative out-of-pocket part of the expenses, are as follows: 85% of subsidy for the incumbent, 90% of subsidy for the retired, 95% of subsidy for the medical caregiver, and 100% of subsidy for health care recipients. The subsidies are: 85% for employees, 90% for retirees, 95% for medical caregivers and 100% for health care recipients.
3. The subsidies for the use of medicines other than those in the basic medical insurance drug list in critical condition are: 50% for employees, 60% for retirees, and 90% for medical caregivers. The subsidy method is to fill in the application form by the doctor, reported to the medical insurance center for approval after the cash settlement, with hospital invoices and application consent form to the medical insurance center in accordance with the provisions of the reimbursement.
Third, part of the outpatient chronic patients medical treatment
1, included in the outpatient chronic diseases are: coronary heart disease, diabetes mellitus, a variety of malignant tumors, chronic obstructive pulmonary emphysema, hypertension, Parkinson's syndrome, cirrhosis uncompensated period, uremia stage, chronic heart failure, organ transplantation, anti-rejection of immune modulation therapy.
2. Each insured person can declare a maximum of 3 diseases.
3, outpatient chronic diseases in accordance with the provisions of the chronic disease can only enjoy the scope of the provisions of the health insurance drug catalog drugs.
4, into the chronic disease subsidies before the individual out-of-pocket payment of drugs below the starting standard, that is, 8% of the employee's annual average gross salary, and the rest of the drug costs into the integrated fund in proportion to the payment.
Fourth, the proportion of payment of special inspection and treatment programs
1, according to the provisions of the part of the special inspection and treatment first by the individual to pay 40% of the cost of the remaining costs of the basic medical insurance to pay the proportion of the individual to pay part of the civil service subsidies in accordance with the proportion and limit of subsidies.
2, the use of imported materials by the individual first 50% of the proportion of cash payments, the remaining costs in accordance with the provisions of Article 1 approach to subsidies.
Fifth, in the region directly in the Yong organs and institutions employees (public) injury medical treatment
According to the spirit of the Guilao social medical insurance (2002) No. 9 document:
1, in the region directly in the Yong organs and institutions eligible to enjoy the national civil service medical subsidies for the employees, incurred in line with the provisions of the medical expenses of the injury, in the national civil service medical subsidies for the funds to reimbursement.
2, in the region directly in the Yong organs and institutions in the occurrence of work (public) injury accidents must be reported within 48 hours by telephone to the District Labor Office of the Medical Insurance Office, and within 15 days to fill out (in the region directly in the Yong unit employees work (public) injury accident report form in triplicate, by the autonomous region of the Office of Labor and Social Security Administration recognized as a work-related injuries of the employees, in accordance with the provisions of the enjoyment of the medical treatment of work (public) injuries.
3, the employer and the injured worker must provide the following proof
Work (public) injury accident report form, the designated hospital diagnosis or proof of diagnosis of occupational diseases, the relevant interrogation and circumstantial materials; traffic accidents, traffic police department to deal with accidents, such as the certificate of responsibility for the materials.
4, in the regional institutions in Yong organs and institutions after the occurrence of industrial (public) injury accidents, the current fixed-point hospital is set as the First Affiliated Hospital of Guangxi Medical University (including the Second Affiliated Hospital, that is, the West Hospital). Guangxi District People's Hospital, Guangxi Workers' Hospital, Nanning Second People's Hospital. Critically injured can be the nearest hospital rescue, to be stabilized and then transferred to the designated hospital to continue treatment.
5, industrial (public) injured workers during the implementation of the Guangxi Zhuang Autonomous Region urban workers basic medical insurance diagnosis and treatment projects, medical services and facilities range and payment standards, Guangxi District basic medical insurance drug directory. The use of drugs required during the rescue period can be appropriately relaxed, but must be declared to the Autonomous Region Social Security Bureau for approval.
6, work-related injuries during treatment in line with the relevant provisions of the basic medical insurance hospitalization medical expenses, in the national civil service medical assistance in full reimbursement.
7, recognized as a work (public) injury employees in the outpatient and hospitalization expenses incurred during the unit cash advance, and then with the approval form of work-related injuries, medical insurance certificate, hospital certificates, medical bills, etc. to the Autonomous Region Social Security Bureau to apply for reimbursement of the audit.
Sixth, the management of the individual health insurance IC card
1, individual health insurance IC card records of the medical insurance file information, personal account funds and the use of the status of the use of personal custody by the individual.
2. The principal and interest of the individual account are owned by the individual, and in principle, no cash can be withdrawn.
3, lost or damaged IC card, with a personal ID card to the district health insurance center lost, a moment failed to handle the lost, can be notified by phone in advance of the district health insurance center lost, so as to avoid unnecessary losses, lost telephone 2853836.
Municipal health insurance
First, outpatient specific items of medical treatment
1, the scope of the specific items Yes: radiotherapy for malignant tumors, dialysis treatment for uremia, anti-rejection treatment after organ transplantation.
2. Participants eligible for the specific program will be required to submit a written application by the doctor for each visit, and the expenses incurred after the approval procedures will be borne by 15% for active employees and 8% for retirees, with the rest of the expenses to be paid by the integrated fund.
3, 50 years of age or older insured persons with serious chronic diseases in the 30-day outpatient cumulative cost of medicines with health insurance more than 500 yuan, with outpatient drug invoices, medical records to the city health insurance center to fill in the reimbursement of drug costs and reimbursement in accordance with the provisions.
Second, the management of special examination and treatment and payment
1, the application for approval of the special examination and treatment program, 30% of the active staff out-of-pocket; retirees out-of-pocket payment of 15%.
2, hospitalized patients due to the needs of the condition, approved the use of imported artificial organs, the cost of materials placed in the body by the individual cash advance, and then reimbursement of other relevant information to the Municipal Health Insurance Center in accordance with the provisions.
Third, the medical mutual aid payment treatment
1, participate in the medical mutual aid employees, such as the occurrence of more than the integrated fund to pay the maximum limit, the excess medical expenses in cash, with a ticket to the municipal health insurance center in accordance with the provisions of the reimbursement from the medical mutual aid fund.
2. The maximum payment limit of the integrated fund is 4 times of the average gross salary of the employees in the previous year.
3, hospitalization expenses incurred in the coordinated area in the first half of the average salary of employees below 9 times (including 9 times) medical mutual fund to pay 70%, the individual out-of-pocket payment of 30%; average salary of 9 times more than 13 times below (including 13 times) medical mutual fund to pay 80%, the individual out-of-pocket payment of 20%; more than 13 times the average salary of the average 15 times medical mutual fund to pay 90%, the individual out-of-pocket payment of 10%.
The range of treatment items not covered by basic medical insurance is divided into the following major categories
I. Service items
1. Registration fee, out-of-hospital consultation fee, consultation fee, examination and treatment of expedited fees, surcharge on surgery by name, and self-employed nurses for special medical services.
2. All kinds of beauty, fitness and non-functional cosmetic and orthopedic surgery.
3. All kinds of weight loss, fat gain, height increase programs.
4. All kinds of health checkups, medical appraisal costs.
II. Diagnostic and therapeutic equipment and medical materials
1. Applied electron emission tomography device (PET), ophthalmic excimer laser treatment.
2. Eyeglasses, dentures, prosthetic eyes, hearing aids.
3. A variety of self-use health care, ***, examination and treatment of equipment.
III. Therapeutic items
1. All kinds of organ or tissue transplantation of organ source or tissue source.
2. Transplantation of organs or tissues other than kidney, heart, cornea, skin, blood vessels, bone and bone marrow transplantation.
3. Orthopedic surgery for myopia.
4. Qigong, music therapy, spectrum therapy, laser therapy, light quantum therapy.
5. A variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment programs, venereal disease examination and treatment costs.
4. Life service items
1. Referral transportation fees, emergency vehicle fees.
2. Hospitalization air-conditioning fees, escort fees, escort fees.
3. Expensive special services.
V. Others
1. Medical expenses incurred when not in the designated medical institutions (except for rescue).
2. Expenses incurred without the approval of the relevant departments for overseas medical treatment.
3. Medical expenses incurred in foreign countries, Hong Kong, Macao and Taiwan.
4. Medical expenses incurred by female workers for childbirth (separately reimbursed in accordance with the relevant policies on childbirth).
5. Expenses incurred as a result of work-related accidents (reimbursed in accordance with the relevant regulations on work-related injuries).
6. Medical expenses incurred in traffic accidents, medical accidents, suicides, self-inflicted injuries, alcoholism and fights.
7. Dental cleaning, dental implantation, fitting of artificial eyes and limbs.
8. Expenses for medicines other than those listed in the Guangxi Zhuang Autonomous Region Basic Medical Insurance Drug Catalog.
9. Self-made medicines, self-defined items, and new inspection and treatment items that are not approved by the authorities in charge of health, drug supervision and management, price and the district social security bureau.
After paying the medical insurance, as long as the hospitalization meets the standard of volatility can be reimbursed, the average reimbursement can reach more than 80%.
In accordance with national regulations, the social security fund to pay for the hospitalization of medical expenses starting standard, according to the average salary of local workers about 10% to determine. The city's original provisions of the first, second and third level of medical institutions for the previous year, respectively, 6% of the average salary of employees, 8%, 10%, with the average salary of employees increased year by year, should be adjusted annually. However, taking into account not to increase the burden on employees, the city has been calculated in accordance with the 2000 social wage standard implementation, did not adjust with the increase in social wage, the starting standard were 500 yuan, 670 yuan, 840 yuan. From the viewpoint of reducing the burden on employees, this revision will decouple the starting standard from the average salary of employees, and the first, second and third-level medical institutions will still maintain the current standard: 500 yuan, 670 yuan and 840 yuan, and will be adjusted appropriately according to the income of employees and the income and expenditure of the health insurance fund. For the first hospitalization in a medical year, the starting standard is 100%, for the second hospitalization, the starting standard is 50%, and for the third or more hospitalizations, there is no longer a starting standard.