Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Proportion of medical insurance reimbursement in Zibo
Medical insurance for urban and rural residents
Within a year, the maximum payment limit of the basic medical insurance fund is 200,000 yuan.
Hospitalization:
For urban and rural residents who are hospitalized for the first time this year, the minimum payment standard for medical expenses: urban and rural residents pay according to 220 yuan standards: first-class hospital 100 yuan, second-class hospital 300 yuan, third-class hospital 700 yuan; According to the standard of 100 yuan, the first-level hospital is 200 yuan, the second-level hospital is 500 yuan, and the third-level hospital is 700 yuan; The threshold for medical expenses for students and children in hospital is 100 yuan. If you are hospitalized for the second time within one year, the minimum qifubiaozhun will be halved, and if you are hospitalized for the third time, the minimum qifubiaozhun will be cancelled. Urban and rural minimum living security residents and rural five-guarantee recipients are hospitalized in designated special care hospitals, and the deductible is cancelled.
In the first-class hospitals (community health service centers and town health centers) that implement the basic drug system, the reimbursement ratio of hospitalization medical expenses between Qifubiaozhun and maximum payment limit is 85%.
The reimbursement rate of other first-level hospitals is 75%, that of second-level hospitals is 70%, and that of third-level hospitals is 55%. If payment is made according to the standard of 150 yuan, the reimbursement rate will be reduced by 5 percentage points accordingly.
Outpatient medical treatment for chronic diseases:
It is confirmed that he has malignant tumor (including leukemia), uremia, organ transplantation, diabetes (complicated with infection or one of the complications of heart, kidney, eyes and nervous system), stage III hypertension (one of the complications of heart, brain and kidney), rheumatoid disease (active stage), cor pulmonale (right ventricular failure), cerebral hemorrhage (including cerebral infarction), chronic viral hepatitis and coronary heart disease (coronary heart disease).
Within one year, the deductible standard of outpatient chronic medical expenses is 500 yuan, which is calculated separately from the deductible standard of hospitalization.
For outpatient medical expenses subsidies for chronic diseases between Qifubiaozhun and the maximum payment limit, the second subsidy method is implemented, and the initial subsidy ratio is 30%. If the payment is made according to the standard of 150 yuan, the initial subsidy ratio will be 25%. The proportion of secondary subsidies depends on the balance of the fund.
Insured persons seeking medical treatment outside the city shall go through the relevant referral procedures. With the consent of the designated referral hospital, the medical insurance agency shall go through the referral procedures, and if it goes to an agreed medical institution outside the city for medical treatment, the individual shall bear 15% of the medical expenses in line with the policy, and if it goes to a non-agreed medical institution outside the city for medical treatment, the individual shall bear 30% of the medical expenses in line with the policy, and the balance in line with the policy shall be reimbursed according to the relevant provisions of the basic medical insurance for urban and rural residents.
Employee medical insurance
First, the insured's hospitalization medical expenses are reviewed by the municipal, district and county medical insurance departments in accordance with the provisions of the "three catalogues" of medical insurance, and after deducting self-funded and part of self-funded medical expenses, they enter the reimbursement procedure.
Two, the insured hospitalization medical expenses set deductible. The Qifubiaozhun for the first hospitalization of urban workers this year is tertiary hospital 700 yuan, secondary hospital 500 yuan, and primary hospital 300 yuan; The deductible standard for the second hospitalization will be halved, and the deductible will be cancelled for the third time.
3. If the insured person is referred to a non-networked protocol hospital for hospitalization, he/she must bear 10% of the hospitalization expenses first; When referring to a non-agreement hospital, it is necessary to bear 20% of the hospitalization expenses of the individual first, and then reimburse it in the form of hospitalization in the city; Did not go through the referral procedures, the cost of compliance with the policy shall be borne by the individual 30%, and the balance of compliance with the policy shall be reimbursed according to the relevant provisions; Those who live in other places for a long time, after going through the registration formalities in different places, will be hospitalized in the selected designated hospitals in different places without having to bear the referral fee.
Four, the city, district, county medical insurance department audit deduction of self-funded projects and part of the self-funded projects of hospitalization medical expenses, above the Qifubiaozhun, according to the proportion of the following table paid by the medical insurance fund.
Table of Personal Burden Proportion of Inpatient Medical Expenses of Insured Persons
Remarks: The self-funded items are as follows:
1, drugs outside the drug list in Shandong and Zibo.
2. Service items:
Registration fee, referral transportation fee, first aid fee, out-of-hospital consultation fee, medical record making fee, examination and treatment expedited fee, name-calling operation surcharge and other special medical services, air conditioning fee, TV fee, telephone fee, incubator fee, escort fee, nursing fee, meal fee, washing fee, decoction fee, etc.
3, diagnosis and treatment equipment and medical materials:
(1) Examination and treatment items of large medical equipment such as positron emission tomography (PET), electron beam CT and ophthalmic excimer laser therapeutic instrument;
(2) glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation devices;
(3) all kinds of self-use health care, massage, examination and treatment instruments.
4, treatment project category:
(1) The organ source or tissue source of various organ or tissue transplants;
(2) Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow;
(3) Orthopedic surgery for myopia;
(4) Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.