Yunnan Province rural medical insurance reimbursement scope and proportion
1, outpatient reimbursement:
(1) 60% reimbursement for visits to village health centers and village central health centers, with a limit of RMB 10 yuan in prescription drug fees per visit, and a limit of RMB 50 yuan in temporary rehydration of prescription drug fees by the doctors of the health centers.
(2) Township health centers will be reimbursed 40% of the cost for each visit, with a limit of 50 yuan for each examination and surgery, and a limit of 100 yuan for prescription drugs.
(3) Secondary hospitals are reimbursed 30% of the cost, with a limit of 50 yuan for each examination and operation and 200 yuan for prescription drugs.
(4) Tertiary hospitals will reimburse 20% of the fees, with a limit of 50 yuan for each examination and operation and 200 yuan for prescription drugs.
(5) Chinese medicine invoices with prescription attached are limited to RMB 1 yuan per sticker.
(6) The annual limit of outpatient compensation for township-level cooperative medical care is 5,000 yuan.
2. Hospitalization Compensation
(1) Reimbursement Scope:
A. Pharmaceutical Fees: Auxiliary Examinations: Limit of 200 RMB for each examination fee such as EKG, X-ray fluoroscopy, radiography, laboratory tests, physical therapy, acupuncture, CT, MRI*** vibration, and so on; Surgical Fees (with reference to the national standard, reimbursement for fees in excess of 1,000 RMB will be made in accordance with the limit of 1,000 RMB).
B, the elderly over 60 years of age hospitalized in Xingta Township Health Center, treatment and nursing care costs are compensated 10 yuan per day, with a limit of 200 yuan.
(2) Reimbursement rate: town health center reimbursement 60%; secondary hospital reimbursement 40%; tertiary hospital reimbursement 30%.
Yunnan health insurance reimbursement ratio in 2017
3, compensation for major illnesses
(1) town risk fund compensation: all hospitalized patients who participate in the rural cooperative medical insurance of the one-time or annual cumulative total of the reportable medical expenses exceeding more than 5,000 yuan segmented reimbursement, i.e., 5,001-10,000 yuan reimbursement of 65%, 10,001-18,000 yuan reimbursement of 70%.
(The hospitalized patients' medical expenses exceeding 5,000 yuan are compensated in segments.
(2) The annual limit of 11,000 yuan for compensation for township-level cooperative medical care inpatient and outpatient blood dialysis for uremia, and outpatient radiotherapy and chemotherapy for oncology.
Q&A about rural medical insurance in Yunnan Province
Q: Both my parents are now living in rural Anhui province and have enrolled in a new type of rural medical insurance. Is there a cap on the amount of reimbursement for this type of insurance, and what is the maximum amount that can be reimbursed? In addition, I would like to buy another medical insurance for them, will there be any conflict in the reimbursement of this kind of insurance in the future?
If I visit a hospital in my province, will the reimbursement rate be up to 50%? Besides, there is only one medical bill, if I apply for the rural medical insurance, is there any way to go to the insurance company to apply for the medical insurance?
Answer: The new rural medical insurance maximum ceiling is 40,000 yuan per year, the reimbursement rate is in addition to the starting line after the township hospitals for the highest 80% of the county 60% level and provincial 45%, and other commercial insurance does not conflict. Please keep a copy of all the information and let the New Agricultural Cooperative Office that receives your materials stamp their official seal to reimbursement of commercial insurance.
Warm tips for rural medical insurance in Yunnan Province
Compared with 2007 when the system was launched, the new version of the Anhui Provincial Drug Catalog for Basic Medical Insurance, Workers' Compensation Insurance and Maternity Insurance, released in 2010, has 2,422 varieties of drugs in categories A and B, an increase of more than 300 drugs compared with the previous version of the Drug Catalog. At the same time, the scope of payment by the medical insurance fund has been gradually expanded, and the scope of prescribed diseases for outpatient mega-diseases and chronic diseases has been increasing.
In addition, Yunnan Province, by doing a good job in the transfer of medical insurance relations and settlement services for medical treatment in other places, focusing on solving the transfer of medical insurance relations in rural areas of Anhui Province, which flows between urban and rural areas, and thus realizing the smooth transfer of medical insurance relations between different systems and different regions. Through the "Yangtze River Delta" region to carry out health insurance management collaboration and the docking of services, and constantly improve the settlement of foreign medical settlement methods, to facilitate the province's insured people can better enjoy the treatment of foreign medical insurance.
In 2015, Yunnan Province continued to implement the urban residents of the basic medical insurance system this livelihood project, and improve the reimbursement of medical insurance treatment. In order to help the majority of insured residents to further understand the residents of the health insurance policy, master how to enroll, consultation, reimbursement and other related procedures, so as to better enjoy the government's policy of benefit to the people, Yunnan Provincial Bureau of Human Resources and Social Security has announced the residents of the health insurance 2015-2016 annual treatment and reimbursement policy.
Treatment of participants in Yunnan Province
Participants in the insurance payment from October 1 of the current year to September 30 of the following year, the period, with the health insurance card, social security card, ID card (18 years of age or younger participants can be based on the hukou book, hereinafter referred to as: the validity of the documents), you can enjoy the following treatments:
①Hospitalization reimbursement ② outpatient treatment of special illnesses ③ outpatient treatment of ordinary ③General outpatient treatment ④Subsidized treatment for maternity expenses ⑤Subsidized treatment for the assembly of auxiliary aids for the disabled
●1. Hospitalization reimbursement treatment in Yunnan Province
Hospitalization in first-level hospitals:
90% of the costs covered by the medical insurance exceeding 200 yuan (the starting standard) and above;
Hospitalization in second-level hospitals:
80% of the costs covered by the medical insurance exceeding 400 yuan (the starting standard) and above. 80% reimbursement for the portion of the cost above 400 RMB (starting standard);
Tertiary hospitalization:
70% reimbursement for the portion of the cost above 600 RMB (starting standard);
Other-site hospitalization (transferring to other hospitals and other-site emergency treatment):
50% reimbursement for the portion of the cost above 600 RMB (starting standard).
The hospitalization starting standard and the fund's payment ratio are detailed in the following table:
Medical institutions starting standard for general residents (threshold fee) for schoolchildren and teenagers, children and residents under 18 years of age starting standard fund's payment ratio (reimbursement ratio)
Third-level hospitals 60030070%
Second-level hospitals 40020080%
First-level hospitals 20010090%
Off-site medical treatment 60030050%
1. The cumulative maximum fund payment limit for hospitalization, outpatient special diseases and general outpatient treatment for insured residents is 160,000 yuan in a settlement year.
2. Individuals are required to pay a certain amount of money out-of-pocket for the use of Class B drugs and diagnostic and therapeutic items.
●2. Outpatient Treatment for Special Diseases in Yunnan Province
Participants suffering from coronary heart disease, hypertension III, diabetes mellitus, mental illness, cirrhosis of the liver, malignant tumors, renal dialysis, kidney transplantation, Parkinson's disease, rheumatoid arthritis, systemic lupus erythematosus, aplastic anemia, hemophilia, breast cancer (endocrine therapy), hepatomegaly, chronic heart failure, chronic Renal Insufficiency, Hyperthyroidism, Epilepsy, Hepatitis C, Prostate Cancer (Endocrine Therapy), Bladder Tumor (Perfusion Therapy), Post Liver Transplantation, Post Hematopoietic Stem Cell Transplantation, Rehabilitation Therapy, Chronic Hepatitis B (Antiviral Therapy), Pediatric Cerebral Palsy, and other 27 medical conditions are entitled to reimbursement of 60% to 80% under the monthly limit after confirmation of application.
●3. General outpatient treatment in Yunnan Province
The coordinated fund pays 50% of the medical fees within the scope of the policy incurred by insured residents in the outpatient clinics of the community health service centers (general outpatient clinics incurred in other residents' designated hospitals are not entitled to this treatment). The maximum reimbursement limit for a single visit is 40 yuan. The maximum reimbursement limit for a single visit is RMB 40. The maximum reimbursement limit for a single year is RMB 160, of which the maximum reimbursement limit for insured residents aged 60 or above for men and 55 or above for women is RMB 240. The reimbursement for general outpatient services is not limited to any type of disease, and medical expenses are settled directly at community health centers.
●4. Yunnan Province Maternity Expense Subsidy Treatment
Participating residents who comply with the family planning policy and give birth to a child are entitled to a subsidy of 600 yuan for a normal delivery (including assisted delivery) and 1,200 yuan for a cesarean section.
●5. Subsidies for the assembly of auxiliary aids for insured persons with disabilities in Yunnan Province
Individuals with disabilities in the lower limbs and children with hearing impairment under the age of 7 who are holders of disability certificates will be given subsidies for the assembly of lower limb prostheses and the provision of hearing aids in designated institutions for the assembly of auxiliary aids for persons with disabilities. Every five years, the certificate holders of lower limb disabled persons fitted with ordinary thigh prostheses each subsidy of 2000 yuan, calf prostheses each subsidy of 1000 yuan, hearing impaired children under the age of 7 years old equipped with hearing aids each subsidy of 2400 yuan.
Yunnan Province medical insurance reimbursement processing instructions
●1. local hospitalization
Participants should be in the designated medical institutions for medical treatment, with valid documents in the hospital hospital hospitalization procedures, the medical costs incurred in the hospital when discharged from the hospital directly reimbursement settlement. If you do not seek medical treatment at the designated hospitals or do not go through the hospitalization procedures at the hospital, the medical expenses incurred will not be reimbursed.
●2. Application for Special Disease Outpatient Treatment
Participants fill out the "Application Form for Special Disease Outpatient Treatment under Yunnan Provincial Urban Residents' Basic Medical Insurance" and submit nearby medical records and medical examination reports to the Special Disease Appraisal Office of Yunnan Provincial Medical Insurance Center, which will then organize the appraisal of medical insurance experts by Yunnan Provincial Medical Insurance Center, and then issue an outpatient Special Disease Treatment Card to those who meet the requirements. Card", with the card to enjoy outpatient treatment of special diseases. The appraisal is organized once every three months.
●3. Procedures for medical treatment in other places
If the diseases suffered by the insured persons are difficult to be diagnosed in tertiary hospitals (including specialized hospitals) or if there is no treatment available, they can apply for hospitalization in a different place for diagnosis and treatment. The application form must be filled out and signed by the designated hospitals above the third level in Yunnan Province, and then reported to the medical insurance agency in Yunnan Province for examination and filing, and then transferred to a different place for treatment.
If the insured person has a sudden illness in a different place and really needs hospitalization, he should be hospitalized in the local designated medical institution, and make a telephone call to the medical insurance center for the record within 3 days after being admitted to the hospital.
The medical expenses for transferring to a hospital and for emergency medical treatment in a different place will be paid by the individual first. Within one month after discharge, bring the transfer approval form, detailed list of hospitalization expenses, invoice documents, discharge summary and valid documents to the medical insurance center for reimbursement and settlement.
●4. Maternity Expense Subsidy Treatment
Within one month after being discharged from the hospital with a valid ID, birth certificate, baby's birth certificate, medical invoice, detailed list of expenses, and discharge summary, you can file a claim with the medical insurance management center.
●5. Reimbursement of congenital diseases of newborns
Newborns with congenital diseases such as congenital heart disease who go through the procedure of enrollment of newborns in the health insurance program within three months from the date of birth are entitled to the residents' medical insurance benefits from the date of birth. Hospitalization medical expenses incurred due to congenital diseases shall be declared to the Medical Insurance Management Center within 30 days after discharge from the hospital with valid documents, hospitalization invoices, itemized lists of expenses and discharge summaries.
Medical Insurance Treatment for Major Diseases
Participants who are hospitalized due to illnesses and whose personal responsibility exceeds the threshold of 20,000 yuan within the scope of the policy are entitled to medical insurance treatment for major diseases, and are reimbursed according to the proportion of 50%-80%. Specific segmentation ratios are:
Policy scope of individual out-of-pocket payment of more than 20,000 yuan segmentation reimbursement ratio
0 ~ 50,000 yuan (inclusive) 50%
50,000 yuan ~ 100,000 yuan (inclusive) 60%
100,000 yuan ~ 300,000 yuan (inclusive) 70%
300,000 yuan (inclusive) 80%
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