Medical insurance Nanjing urban workers medical insurance policy and reimbursement ratio are how to do

The urban workers' medical insurance is implemented at the municipal level, the city's unified policy, unified standards, unified handling process. The city's urban workers' health insurance policy is based on a unified policy and standardized handling process. The reimbursement ratio of Nanjing's workers' and residents' health insurance:The starting standard for major medical insurance is set at about 50% of the per capita disposable income of urban residents in the city in the previous year (now set at 20,000 yuan for the time being). For the expenses above the starting standard, "segmented calculation, accumulative ... Want to know more about the Nanjing urban workers health insurance policy and reimbursement ratio are how the knowledge, follow me together to see it.

The urban workers' health insurance is a municipal-level coordination, the city's unified policy, unified standards, unified management process.

Nanjing urban workers health insurance policy

Nanjing workers and residents health insurance reimbursement ratio:

The starting standard for major medical insurance is set at about 50% of the per capita disposable income of urban residents in the previous year in the city (now set at 20,000 yuan for the time being). For the starting standard above the cost of the implementation of "segmented calculation, cumulative payment", without a maximum payment limit.

Employee health insurance: more than 20,000 yuan (excluding 20,000 yuan, the same below) to 40,000 yuan (including 40,000 yuan, the same below) part of the payment of 60%; 40,000 yuan to 60,000 yuan part of the payment of 65%; 60,000 yuan part of the payment of 80,000 yuan part of the payment of 70%; 80,000 yuan part of the payment of 100,000 yuan part of the payment of 75%; more than 100,000 yuan part, payment of 80%.

Resident health insurance:Above 20,000 yuan to 40,000 yuan part, pay 50%; Above 40,000 yuan to 60,000 yuan part, pay 55%; Above 60,000 yuan to 80,000 yuan part, pay 60%; Above 80,000 yuan to 100,000 yuan part, pay 65%; Above 100,000 yuan part, pay 70%.

"According to the current policy, Nanjing employee health insurance reimbursement is not capped, while the residents of the health insurance has a maximum reimbursement limit, according to the different contribution limits, the reimbursement of the ceiling line for 290,000 yuan - 360,000 yuan ranging." A source from the Municipal Social Security Center's health insurance department explained that there is no reimbursement ceiling line for major medical insurance, and the higher the medical expenses, the higher the reimbursement rate. "Individuals can be reimbursed if their personal burden is 20,000 yuan or more. According to data estimates from previous years, hospitalized individuals spending more than 20,000 yuan in about 10,000 people."

The funds for major disease insurance are allocated from the Employee Health Insurance Fund and the Resident Health Insurance Fund respectively, and the establishment of major disease insurance funds, unified purchase of major disease insurance, according to the Employee Health Insurance and the Resident Health Insurance medical expenses are reasonably estimated funding standards, and the specific funding standards are determined through the form of government bidding. This also means that the employee health insurance, resident health insurance participants do not need to pay another fee to enjoy the big disease insurance.

Nanjing: last year, the city's employee health insurance hospitalization reimbursement ratio of more than 85%

hospitalization maximum reimbursement of 180,000 yuan/year

It is understood that the Nanjing employee health insurance participants with the social security card can be directly to the hospital inpatient registration, do not need to deal with the same referral as outpatient co-ordination. The maximum payment limit of the basic medical insurance co-ordination fund is 180,000 yuan/year. There are four types of costs that individuals need to pay for.

"The first is the part below the starting standard. The starting standard varies according to the level of medical institutions. The starting standard for a third-level hospital is 1,000 yuan, and second-level and first-level are 500 yuan and 300 yuan respectively." The Nanjing Social Security Center said that individuals also need to pay for the following parts: the personal out-of-pocket portion outside the scope of basic medical insurance; the out-of-pocket portion of Class B medicines, diagnostic and treatment items, and service facilities that should be borne proportionally by the individual; and the portion of the total medical cost that needs to be shared proportionally by the individual after the deduction of the above three items. The proportion of the individual's share, and the level of medical institutions and whether or not active and retired, the proportion is also different, the lowest 2%, the highest is 10%.

Reimbursement ratio

Third-level hospitals, individuals pay more than 1,000 yuan

"Under the same circumstances, hospitalized in a second-level hospital than a third-level hospital, the personal burden will be much lighter." Nanjing Social Security Center staff said. Hospitalization health insurance individuals need to pay the cost of exactly how to calculate it?

For example, a retired insured person for the first time this year, Nanjing Gulou Hospital (Level III), hospitalization costs 16,000 yuan, of which the amount of hospitalization costs of the individual part of the total amount of 950 yuan. Then the participant's personal burden according to the health insurance policy is 2933.5 yuan. This cost is so calculated, first of all, individuals have to pay the first hospitalization in a tertiary hospital in the starting standard of 1,000 yuan; secondly, individuals pay the self-care part of 950 yuan; there is a deduction of 1,950 after the individual needs to be proportionately shared by the medical costs, retired employees hospitalized in a tertiary hospital individual proportion is 7%, that is (16,000-1000) × 7%, that is (16,000-150) × 7%, that is (16,000-1,000) × 7%. -950) × 7% = 983.5 yuan. So, the three types of costs combined individual this hospitalization to pay 2933.5 yuan.

What if you were hospitalized in a secondary hospital? The same hospitalization total cost of 16,000 yuan, personal out of pocket is the same 950 yuan. However, in accordance with the health insurance policy, the starting standard for secondary hospitals is 500 yuan, while the proportion of retired workers' personal share of medical expenses is 3%, so the retiree hospitalized this time, individuals need to bear only 500 yuan of the starting standard and 950 yuan of personal expenses, and then the burden of the (16,000 - 500 - 950) x 3% = 436.5 yuan, totaling 1886.5 yuan, 1047 yuan less than in a tertiary hospital.

Therefore, when patients with health insurance are sick, do not focus on large hospitals, symptomatic hospitalization can effectively reduce the personal burden of patients with health insurance.

No maximum payment limit for major medical insurance

The hospitalization fee is too high, more than the maximum payment limit of the employee health insurance fund how to do? The reporter learned that, such as employee health insurance participants in a natural year due to major diseases, serious illnesses, incurred more than 18 million / year more than the medical costs, personal out-of-pocket expenses more than the starting standard of major medical insurance above the part of the major medical insurance to be paid in accordance with the provisions of the implementation of the "segmentation, cumulative payment", does not set a maximum payment limit.

Currently, the starting standard for major medical insurance is 20,000 yuan. 20,000 yuan (excluding 20,000 yuan) to 40,000 yuan (including 40,000 yuan) part of the payment of 60%; 40,000 yuan to 60,000 yuan part of the payment of 65%; 60,000 yuan to 80,000 yuan part of the payment of 70%; 80,000 yuan to 100,000 yuan part of the payment of 75%; more than 100,000 yuan part of the payment of 80%.

If the participant's unit has established a supplementary medical insurance (secondary reimbursement) or has participated in commercial insurance, please keep the hospitalization bills and invoices, itemized lists in the unit or commercial insurance company secondary reimbursement. Our laws are gradually improving, and we look forward to helping more people.