The reimbursement rates are different depending on the situation.
I. Rural:
1. Outpatient
Village health clinics and village central health clinics are reimbursed 60% of the cost of each visit, with a limit of 10 yuan for prescription medication, and 50 yuan for temporary rehydration of prescription medication by a health center doctor; township health centers are reimbursed 40% of the cost of each visit, with a limit of 50 yuan for each examination and surgery, and 100 yuan for prescription medication; and second-tier hospitals are reimbursed 30% of the cost of each visit, with a limit of 50 yuan for each examination and surgery, and 100 yuan for each prescription medication. 30% reimbursement, with a limit of 50 yuan for each examination and operation and 200 yuan for prescription drugs per visit; 20% reimbursement for a visit to a tertiary hospital, with a limit of 50 yuan for each examination and operation and 200 yuan for prescription drugs per visit; a limit of 1 yuan for each sticker of prescription attached to an invoice of traditional Chinese medicines; and a limit of 5,000 yuan per annum of outpatient reimbursement for township-level cooperative medical care.
2. Hospitalization
Reimbursement scope: medicine: auxiliary examination: EKG, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, CT, MR*** vibration and other examination fees are limited to 200 yuan; surgical fees (with reference to the national standard, more than 1,000 yuan are reimbursed according to 1,000 yuan). 60 years of age or older hospitalized in a health center, the treatment and nursing care fees are reimbursed 10 yuan per day, limited to 200 yuan. 10 yuan, with a limit of 200 yuan.
Reimbursement rates: town health centers reimburse 60%; secondary hospitals reimburse 40%; tertiary hospitals reimburse 30%.
3. Major Diseases
Any hospitalized patient who participates in cooperative medical care will be reimbursed for the one-time or yearly cumulative reportable medical expenses of more than 5,000 yuan, i.e., 65% of 5,001-10,000 yuan, and 70% of 10,001-18,000 yuan. The annual limit of compensation for town-level cooperative medical care inpatient and outpatient blood dialysis for uremia, outpatient radiotherapy and chemotherapy for tumors is 11,000 yuan.
4. Exemptions
Self-medical treatment (without designated hospitals for medical treatment or without referral orders), self-purchased medicines, medicines that cannot be reimbursed under the public medical care regulations and medical expenses not in line with the family planning; outpatient treatment fees, consultation fees, hospitalization fees, meals, companion fees, nutritional fees, blood transfusion fees (except for those who have blood stored in their families, which are reimbursed in accordance with the relevant regulations), heating and cooling fees, ambulance fees, special other expenses such as nursing care; medical expenses for car accidents, fights, suicides, alcoholism, industrial accidents and medical accidents; orthopedics, plastic surgery, dentures, prosthetics, organ transplants, named surgery fees, consultation fees, etc.; and reimbursement of expenses within the scope of reimbursement, but not outside the limit.
Two, urban:
Urban residents who are hospitalized for more than two times in one billing year will no longer be charged the starting standard fee from the second hospitalization. If they are transferred or hospitalized for more than two times, the difference will be made up in accordance with the stipulated starting payment standard for the hospital to which they are transferred or re-admitted.
1. For students and children
In a settlement year, for medical expenses of less than 180,000 RMB incurred that are eligible for reimbursement, the starting standard for Level III hospitals is 650 RMB, and the reimbursement rate is 50%, with a ceiling of 2,000 RMB; the starting standard for Level II hospitals is 300 RMB, and the reimbursement rate is 60%; and Level I hospitals do not have a starting standard, and the reimbursement rate is 65%.
2, aged 70 and above
In a settlement year, if the medical expenses of less than 100,000 RMB that meet the scope of reimbursement are incurred, the starting standard for tertiary hospitals is 650 RMB, the reimbursement rate is 50%, and the upper limit is 2,000 RMB; for secondary hospitals, the starting standard is 300 RMB, and the reimbursement rate is 60%; and for first-class hospitals, there is no starting standard, and the reimbursement rate is 65%.
3. For other urban residents
In a billing year, if they incur medical expenses under 100,000 yuan that are eligible for reimbursement, the starting standard for third-level hospitals is 659 yuan, and the reimbursement rate is 50% with an upper limit of 2,000 yuan; the starting standard for second-level hospitals' inpatient hospitalization is 300 yuan, and the reimbursement rate is 55%; and the reimbursement rate for first-level hospitals does not have any starting standards, and the reimbursement rate is 60%.
Third, employees:
Generally speaking, the economic development of different regions is different, so the reimbursement rate also varies, the following on the situation of the proportion of Beijing employees' health insurance coverage.
After getting medical insurance, if you are an active employee, you can only be reimbursed for medical expenses of more than 1800 yuan after visiting the outpatient or emergency clinic of a hospital, and the reimbursement rate is 50%. If you are a retiree under the age of 70, you can be reimbursed for expenses over $1,300, and the reimbursement rate is 70%. If the retiree is over 70 years old, the reimbursement rate is 80 percent for expenses over $1,300.
And regardless of the type of person, the maximum limit for expenses paid for outpatient and emergency major medical expenses is 20,000 yuan. For example, if you are an active employee and you spend $2,500 on an outpatient visit, you can be reimbursed 50 percent of the $500 portion, which is $250.
In the case of hospitalization expenses, the starting amount is $1,300 for the first time you use basic medical insurance to pay in a 2009 year, whether you are an active employee or a retiree. And for the second and subsequent hospitalization medical expenses, the starting amount is determined at 50%, which is 650 yuan. And the maximum payment amount of the basic medical insurance fund (hospitalization expenses) is 70,000 yuan in 1 year.
The standard of hospitalization reimbursement is related to the level of the hospital where the insured person stays, such as staying in a tertiary hospital, from the starting standard to 30,000 yuan, the employee pays 15%, that is, 85% reimbursement; from 30,000 yuan to 40,000 yuan, the employee pays 10%, and 90% reimbursement; more than 40,000 yuan to the part of the maximum payment limit, it is 95% reimbursement, and the employee only has to pay 5%. And while retirees pay 60 percent of what active (that is, the aforementioned) employees pay individually, anything below the starting threshold is paid by the individual.
The diagnostic and therapeutic items that are not paid for by the basic medical insurance for employees are mainly non-clinically necessary and uncertain diagnostic and therapeutic items as well as diagnostic and therapeutic items for special medical services, including services such as registration fees, non-disease treatments such as cosmetic treatments, therapeutic equipment and materials such as hearing aids, therapeutic items such as magnetic therapy, and other categories such as infertility treatments, and so on. In accordance with the "national basic medical insurance treatment program scope", as follows:
(a) service category. (1) registration fee, out-of-hospital consultation fee, medical record cost, etc.; (2) visit fee, examination and treatment expediting fee, surcharge for named surgery, quality and premium fee, self-invited special nurse and other special medical services.
(2) Non-disease treatment program category. (1) a variety of cosmetic, bodybuilding and non-functional cosmetic, orthopedic surgery; (2) a variety of weight loss, weight gain, height increase program. (3) a variety of health checkups; (4) a variety of preventive, health care treatment programs; (5) a variety of medical consultation, medical appraisal.
(C) diagnostic equipment and medical materials. (1) the application of positron emission tomography device (PET), electron beam cT, ophthalmic excimer laser treatment instrument and other large-scale medical equipment for the examination and treatment program; (2) glasses, denture, eye prosthesis, prosthetic limbs, hearing aids and other rehabilitative appliances; (3) a variety of health care for their own use, massage, checking and treatment equipment; (4) the price of each province's provincial price departments can not be charged separately for disposable medical use.
(D) treatment program category. (1) all kinds of organ or tissue transplantation of organ source or tissue source; (2) in addition to kidney, heart valves, cornea skin, blood vessels, bone, bone marrow transplantation of other organs or tissue transplantation; (3) myopic eye orthopedics; (4) qigong therapy, music therapy, health care of nutritional therapy, magnetic therapy and other auxiliary therapeutic projects.
(v) Others. (1) a variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment program; (2) a variety of scientific research, clinical verification of the diagnosis and treatment program.
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