1, qifubiaozhun in principle control in the city, county, autonomous county last year's average social wage of 9%-11%;
2, the maximum payment limit in principle control in the city, county, autonomous county last year, the average social wage of workers 3 to 5 times;
3, Qifubiaozhun above and below the maximum payment limit of medical expenses, mainly paid by the overall fund, personal burden of a certain proportion. Give appropriate care to the proportion of retirees who bear medical expenses. The scope of serious diseases, the specific standards of Qifubiaozhun and the maximum payment limit, and the proportion of sharing medical expenses above Qifubiaozhun and below the maximum payment limit shall be determined by the provincial people's government. After getting medical insurance, if you are an on-the-job employee, you can only reimburse more than 2,000 yuan for medical expenses in the emergency department of the hospital, and the reimbursement rate is 50%. For retirees under the age of 70, the expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%.
Limitation on the scope and proportion of medical insurance reimbursement:
(A), outpatient reimbursement ratio
After getting the basic medical insurance for urban workers, if they are on-the-job workers, they can only be reimbursed for medical expenses of more than 2,000 yuan in the outpatient and emergency departments of hospitals, and the reimbursement rate is 50%. For retirees under the age of 70, the expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed. No matter what kind of people, the maximum payment limit for outpatient and emergency medical expenses is 20 thousand yuan.
For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then 500 yuan can reimburse 50%, that is, 250 yuan.
(2) Proportion of hospitalization reimbursement
At present, when the basic medical insurance is first used within one year, the minimum payment for employees and retirees is 1300 yuan. And the second and subsequent hospitalization medical expenses, Qifubiaozhun is determined by 50%, which is 650 yuan. The maximum annual payment limit (hospitalization expenses) of the basic medical insurance pooling fund is currently 70,000 yuan.
(3), hospitalization Qifubiaozhun
Three-level hospitals and above: The deductible lines for multiple hospitalizations in 700 yuan within one year are 500 yuan, 400 yuan and 300 yuan, and the reimbursement rate of medical insurance for employees is 20 16.
Secondary hospitals include secondary specialized hospitals: 600 yuan was hospitalized several times in one year, followed by 400 yuan, 300 yuan and 200 yuan.
The first level includes the following hospitals: hospitalization in 500 yuan for many times within one year, and minimum compensation for 300 yuan and 200 yuan, 100 yuan.
Above the deductible and below the maximum payment limit, 85% of class A and general medical expenses are paid by on-the-job employees.
Retiree payment: 90%. Class B drugs pay 75% and cutting-edge drugs pay 70%.
Medical insurance for employees with chronic diseases, special diseases and major diseases, the annual Qifubiaozhun is 700 yuan. Class A and general diagnosis and treatment 80%, class B 75%, high accuracy 70%.
(IV) Scope of reimbursement
Outpatient and emergency medical expenses;
The cost of purchasing drugs at designated retail pharmacies;
Emergency rescue observation and income hospitalization, medical expenses within 7 days before hospitalization observation;
Outpatient medical expenses of taking anti-rejection drugs after radiotherapy and chemotherapy, renal dialysis and renal transplantation for malignant tumors.
The following items are not within the scope of reimbursement of medical insurance for urban workers:
(1) service items.
(1) Registration fee, out-of-hospital consultation fee, medical record fee, etc.
(2) Special medical services, such as visiting fees, expedited fees for examination and treatment, additional fees for roll-call surgery, high-quality and low-price fees, and self-invited intensive care.
(2) Non-disease treatment projects.
(1) all kinds of beauty and bodybuilding, as well as non-functional plastic surgery and orthopedic surgery;
(2) all kinds of weight loss, weight gain and height increase projects.
(3) various health checks;
(4) all kinds of preventive health care and diagnosis projects;
(5) all kinds of medical consultation and medical appraisal.
(3) Diagnostic equipment and medical materials.
To sum up, the scope of reimbursement includes outpatient and emergency medical expenses, drug purchase expenses in designated retail pharmacies and outpatient expenses for specific diseases.
Legal basis:
People's Republic of China (PRC) social insurance law
Article 26
The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.
Article 27
Individuals who participate in the basic medical insurance for employees will not pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with the provisions of the state if they reach the statutory retirement age and the accumulated payment has reached the fixed number of years stipulated by the state; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state.