General outpatient clinic:
First-class fixed-point medical institutions: the payment ratio is 60%
Second-class fixed-point medical institutions: the payment ratio is 55%
Third-class fixed-point medical institutions: the payment ratio is 50%
Retired workers pay a higher ratio than that of the active workers by 5 percentage points
Annual integrated fund payment limit: 1,800 yuan for active workers and 2,000 yuan for retired workers. percentage points
Annual integrated fund payment limit: 1,800 yuan for active employees and 2,000 yuan for retirees
Personal account transfer:
Active employees: the personal account transfer ratio is 2% of the individual's contribution base
Retirees: a fixed amount of 77 yuan per person per month
Personal account **** relief use: Realized by the end of January 2023, the balance of the individual account of the employee health insurance participants can be used not only by themselves, but also between their spouses, parents and children **** relief use.
The conditions and process of outpatient reimbursement for medical insurance are as follows:
Conditions for medical treatment: You must seek medical treatment at medical institutions that meet the requirements, such as designated medical institutions, specialized hospitals, and Chinese medicine hospitals.
Conditions for expenses: outpatient expenses must be in line with the scope of reimbursement by the medical insurance, and the excess will not be reimbursed by the medical insurance.
Documentation conditions: you must bring a valid ID and health insurance card and other relevant information when you visit the doctor.
Reimbursement process: the insured person will submit the documents to the unit or social security office, the unit or social security office 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.
Declaration materials: receipts for general outpatient and emergency treatment, medical insurance prescriptions, and details of expenses for examination and treatment.
Declaration date: 1-20 of each month, expenses of the current month to be declared the following month, and expenses of the current year need to be declared before January 20 of the next year.
In summary, in the normal enjoyment of health insurance treatment period, that is, health insurance did not break the payment of the case, as long as it is in the designated medical institutions, in line with the scope of the three directories of health insurance, can be reimbursed according to the provisions.
Legal basis:
The Social Insurance Law of the People's Republic of China
Article 28
Medical expenses that are in line with the basic medical insurance drug catalogs, diagnostic and therapeutic items, medical service facility standards, as well as those for emergency and rescue, shall be paid out of the basic medical insurance fund in accordance with state regulations.