Legal analysis: the difference between the first, different principles of access to medical care.
The first class of participants: the city of any designated medical institutions.
The second class of participants: outpatient treatment in the bound community health center, hospitalization in the city at any point in the medical institutions, outpatient major medical institutions in the provisions of the medical institutions.
Difference two, general outpatient treatment is different.
The first class participation: the person's personal account is used to pay the medical expenses within the scope of the general outpatient medical insurance catalog of the participants. The basic medical expenses of the social health center, 70% paid by the individual account, 30% paid by the integrated fund in accordance with the provisions.
Second-grade participants/third-grade participants:
Those belonging to Class A drugs and Class B drugs are paid for by the community outpatient co-ordination fund at the rate of 80% and 60%, respectively; those belonging to the single diagnosis and treatment or medical materials in the medical insurance catalog are paid for by the community outpatient co-ordination fund at the rate of 90%, but the maximum amount of payment is not more than 120 yuan; the community outpatient co-ordination fund is paid for the medical fees of each second-grade and third-grade participant. The total amount of outpatient medical expenses for each participant shall not exceed RMB 1,000 in a medical insurance year.
Difference three, individual account family **** relief is different.
Participants in the first tranche: the amount accumulated in the individual account exceeds 5% of the average salary of on-the-job workers in the previous year in the city, and the excess can be used to purchase non-prescription medicines within the scope of the medical insurance catalog at designated pharmacies. You can pay for the basic medical expenses and local supplementary medical expenses paid out-of-pocket by yourself and your spouse and immediate family members who have joined the city's basic medical insurance when you visit a designated medical institution.
This feature is not available to second-tier participants.
Difference four, personal account underpayment is different.
The first class of participants: the first class of participants in the continuous insurance for one year, in the same medical insurance year, out-of-pocket outpatient basic medical expenses and local supplemental medical expenses supermarkets on-the-job workers' average salary of 5%, the part of the excess by the integrated fund in accordance with the provisions of the 70% (70 years of age or older to pay 80%).
This feature is not available to second-class participants.
Difference 5: The costs incurred for outpatient large equipment examination and treatment are different.
Participants in the first tier: 80% of the costs will be paid by the integrated fund in accordance with the regulations.
The second class of participants: according to the unit price of general diagnostic and treatment items up to a maximum of 120 yuan.
Difference six, hospitalization treatment is different.
Participants in the first class: 95% or 90% of basic medical expenses and local supplementary medical expenses incurred in hospitalization will be paid above the starting line according to regulations.
Second-tier participants: 1, can be hospitalized in the binding social health center settlement hospitals, or through the settlement hospitals referred to the provisions of the hospital, the basic medical costs incurred in hospitalization and local supplemental medical costs, the hospitalization above the starting line of the partial reimbursement rate:
First-class hospitals: 85%
Second-class hospitals: 80%
Third-class hospitals: 75%
Third-class hospitals: 75%< /p>
2. If you are hospitalized in a prescribed hospital other than the billing hospital without referral, you will be paid 90% of the inpatient payment rate of the attending hospital (i.e., the payment rate in Article 1 above).
Difference VII. Different treatment for medical treatment outside the city.
First class participants: general outpatient expenses, outpatient expenses for major diseases, and hospitalization expenses are all reimbursed according to regulations.
The second class of participants: general outpatient costs will not be reimbursed; outpatient costs for major diseases and hospitalization costs will be reimbursed in accordance with the regulations.
Legal basis: "The People's Republic of China*** and the State Social Insurance Law" Article 30 The following medical expenses are not included in the scope of payment of the basic medical insurance fund:
(1) Those that should be paid from the Industrial Injury Insurance Fund;
(2) Those that should be borne by a third person;
(3) Those that should be borne by the public*** health;
(4 ) for medical treatment outside the country.
Medical expenses shall be borne by a third party in accordance with the law, and if the third party fails to pay or if the third party cannot be identified, the basic medical insurance fund shall pay in advance. The basic medical insurance fund shall have the right to recover the costs from the third party after the payment is made.