Legal analysis: I. Basic medical insurance reimbursement
1, financing standards The individual contribution standard for urban and rural residents in 2021 is 280 yuan.
2, treatment enjoyment Basic medical insurance treatment for urban and rural residents includes general outpatient medical treatment, outpatient chronic disease medical treatment, medical treatment for serious diseases, and hospitalization medical treatment.
General outpatient medical expenses incurred by insured residents in outpatient coordinated designated medical institutions in 2021, there is no starting line within the scope of the policy, the reimbursement rate is 60%, and the cumulative maximum payment limit for a period of enjoyment is 340 yuan per person; insured residents covered under the "two diseases" coverage, the "two diseases" coverage, the "two diseases" coverage, the "two diseases" coverage, the "two diseases" coverage, the "two diseases" coverage, the "two diseases" coverage, the "two diseases" coverage. "There is no starting line for outpatient medication for the two diseases, and the reimbursement rate is 60% within the policy scope of the township-level medical institutions (community health service centers) and village-level medical institutions, with a cumulative maximum payment limit of RMB 200 per person within one entitlement period. The original individual (family) account balance will not be cleared, and can continue to be used in the designated medical institutions.
Outpatient chronic diseases At present, the city's basic medical insurance outpatient chronic disease categories are 26, respectively: malignant tumors; viral hepatitis C; liver, kidney, bone and bone marrow transplantation; tuberculosis; severe mental disorders; heart valve replacement; cardiac bypass surgery; vascular stenting after implantation; acute cerebrovascular disease sequelae; atherosclerotic heart disease of the coronary arteries; hypertensive diseases (with one of the complications of heart, brain and eyes); diabetes mellitus (with co-infection or with one of the complications of heart, brain and eyes); chronic obstructive pulmonary emphysema; chronic heart failure; cirrhosis of the liver; systemic lupus erythematosus (with one of the complications of heart, lungs, kidneys and nerves); myasthenia gravis; rheumatoid arthritis; obligatory spondylitis; chronic renal insufficiency (including renal complication of hypertension and renal complication of diabetes mellitus); interstitial lung fibrosis; epilepsy; Parkinson's disease; chronic glomerulonephritis; nephrotic syndrome; retinal vein occlusion. Insured residents suffering from the above diseases can visit the selected chronic disease designated medical institutions after identification of chronic diseases, and the outpatient medical expenses incurred in accordance with the regulations are not subject to a starting line, and the coordinated fund pays 70% of the total (80% of the total for radiotherapy for patients with malignant tumors).
Major Diseases There is no threshold for medical expenses incurred by insured residents who meet the provincial and municipal standards for major diseases.
There are 33 types of inpatient hospitalization for major diseases, and the medical expenses within the limit standard are paid by the basic medical insurance fund according to the proportion, and the proportion of payment is 80% for county medical institutions, 70% for municipal medical institutions, and 65% for provincial medical institutions; there are 35 types of outpatient outpatient diseases, and the outpatient medical expenses within the limit standard are included in the payment scope of the basic medical insurance fund, and the proportion of payment is 80% (80% of the outpatient medical expenses within the limit standard are paid by the basic medical insurance fund). The outpatient medical expenses within the limit standard that meets the requirements are included in the payment of the basic medical insurance coordinating fund, and the payment ratio is 80% (the payment ratio for outpatient peritoneal dialysis is 85%).
Legal basis: The Social Insurance Law of the People's Republic of China Article 25 The State establishes and improves the basic medical insurance system for urban residents.
Basic medical insurance for urban residents is a combination of individual contributions and government subsidies.
The government shall subsidize the portion of individual contributions required by those who are entitled to the minimum subsistence guarantee, persons with disabilities who have lost their ability to work, and elderly persons and minors over sixty years of age from low-income families.