Medical reimbursement scope: rural medical insurance reimbursement scope 1, outpatient reimbursement: (1) 60% reimbursement for visits to village clinics and village center clinics, prescription drug expense limit for each visit 10 yuan, and prescription drug expense limit for temporary rehydration for doctors in health centers in 50 yuan. (2) Reimbursement for medical treatment in town health centers is 40%. The limit of examination fee and operation fee for each visit is 50 yuan, and the limit of prescription drug fee is 100 yuan. (3) The reimbursement for medical treatment in secondary hospitals is 30%, and the limit of each examination fee and operation fee is 50 yuan, and the limit of prescription drug fee is 200 yuan. (4) 20% reimbursement for medical treatment in tertiary hospitals, with the limit of each examination fee and operation fee in 50 yuan and the limit of prescription drug fee in 200 yuan. (5) The prescription attached to the invoice of traditional Chinese medicine is limited to 1 yuan. (6) The annual compensation limit for rural cooperative medical clinics is 5,000 yuan.
2. Reimbursement scope of hospitalization compensation (1): a. Drug expenses: auxiliary examination: examination expenses such as electrocardiogram, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, ct, nuclear magnetic resonance, etc. 200 yuan; Surgical expenses (refer to the national standard, reimbursement exceeding 1000 yuan 1000 yuan). B, the elderly over 60 years old are hospitalized in Xingta Town Health Center, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan. (2) Reimbursement ratio: town hospitals reimburse 60%; 40% reimbursement for secondary hospitals; Third-level hospitals are reimbursed 30%.
3. Compensation for serious illness
(1) town risk fund compensation: where the medical expenses of inpatients participating in rural cooperative medical insurance exceed 5,000 yuan at one time or throughout the year, they should be compensated by stages, that is, 5001-kloc-0/0000 yuan will be compensated by 65%,10001-.
(2) The annual compensation limit for hemodialysis, radiotherapy and chemotherapy in the town-level cooperative medical system inpatient and uremia clinic is1.65,438+0.000 yuan. The following do not belong to the reimbursement scope of rural cooperative medical insurance: 1, self-seeking medical treatment (no designated hospital or referral form), self-purchased drugs, drugs that cannot be reimbursed according to the provisions of public medical care, and medical expenses that do not conform to family planning; 2, outpatient treatment fees, visits, hospitalization fees, meals, escort fees, nutrition fees, blood transfusion fees (except for family blood storage, according to the relevant provisions of reimbursement), heating and cooling fees, ambulance fees, allowances and other expenses; 3. Medical expenses for car accidents, fights, suicides, alcoholism, industrial accidents and medical accidents; 4. Orthopedics, cosmetic surgery, dental implants, artificial limbs, organ transplantation, roll call surgery fees, consulting fees, etc. ;
5, within the scope of reimbursement, beyond the limit. The scope of urban medical insurance reimbursement refers to all employers in cities and towns, as shown in the following figure: 1. Including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises, etc. ); 2 organs, institutions, social organizations, private non-enterprise units and their employees shall participate in the basic medical insurance; 3. Some towns and villages stipulate that township enterprises and their employees, owners of urban individual economic organizations and their employees should be gradually incorporated into the basic medical insurance coverage (the last one depends on different local policies), so that they can enjoy medical reimbursement. Urban medical reimbursement mainly refers to medical treatment, medication, hospitalization, surgery, etc. And medical expenses can be reimbursed by medical insurance card in accordance with relevant regulations. Urban medical insurance is relatively specific, with large project scale and coverage, but limited compensation for major diseases or accidents. At this time, it is suggested that the insured can purchase commercial supplementary medical insurance and social security to reduce their economic losses. Reimbursement scope of employee medical insurance 1. The scope of diagnosis and treatment items for which the basic insurance does not pay.
(1) Service category 1, registration fee, out-of-hospital consultation fee, medical record fee, etc. ; 2. Special medical services such as visiting fees, urgent fees for examination and treatment (except for emergency), surcharge for roll call operation, high quality and good price, and special care by oneself.
(2) Non-disease treatment items 1, various beauty (life beauty, medical beauty) bodybuilding items, and disorderly non-functional plastic surgery and orthopedic surgery; 2. Various weight loss, weight gain and height increase projects; 3. Various health checks; 4, all kinds of prevention and health care projects; 5, tooth deformity, dental porcelain; 6, all kinds of medical consultation (excluding psychiatric consultation), medical appraisal.
(3) diagnosis and treatment equipment and medical materials 1, and projects for examination and treatment with large medical equipment such as positron emission tomography, electron beam ct and ophthalmic excimer laser therapeutic apparatus; 2, glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation equipment; 3, all kinds of self-use health care, massage, rehabilitation and treatment equipment.
(four) the treatment project category 1, the organ source or tissue source of various organ transplants 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.
(5) 1, and other diagnosis and treatment projects for infertility (pregnancy) and sexual dysfunction; 2, all kinds of scientific research, clinical verification of diagnosis and treatment projects;
Two. Scope of basic medical insurance diagnosis and treatment items (1) diagnosis and treatment equipment and medical materials.
1, using X-ray computed tomography (ct), stereotactic radiotherapy device (γ knife, χ knife), cardiac and angiographic X-ray machine (including digital subtraction equipment), magnetic resonance imaging device (mei), single photon emission computerized scanning device (spect), color Doppler instrument, medical linear accelerator and other large medical equipment.
2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy;
3. Pacemakers, artificial joints, intraocular lenses, vascular stents, etc. replace artificial organs in vivo and place materials in vivo;
4, the provisions of the provincial price department can be charged separately for disposable medical materials. (2) Treatment items 1, hemodialysis and peritoneal dialysis; 2. Transplantation of kidney, heart valve, cornea, skin, blood vessels, bone and bone marrow; 3. Cardiac laser drilling, anti-tumor cellular immunotherapy and fast neutron therapy projects.