1. deductible line and capping line standard: the deductible line and the maximum payment limit of medical insurance outpatient service for employees and retirees are the same, with deductible line 150 yuan and capping line of 2,000 yuan. Refers to the outpatient medical expenses incurred before applying for reimbursement within 150 yuan to 2,000 yuan;
2. Reimbursement ratio: the reimbursement ratio of employees and retirees is different, and the reimbursement ratio of different levels of medical institutions is also different. First-class medical institutions, the reimbursement rate of employees is 75%, and the reimbursement rate of retirees is 75%; In secondary medical institutions, the reimbursement rate for employees is 60%, and that for retirees is 65%; In tertiary medical institutions, the reimbursement rate for employees is 50%, and that for retirees is 55%.
The settlement procedures for hospitalization and outpatient treatment of special diseases are as follows:
1, before each month 10, the designated medical institutions shall submit the expense statement, hospitalization statement and related materials discharged from the hospital last month to the medical insurance agency, which will serve as the basis for monthly pre-allocation and year-end final accounts after review;
2, medical insurance agencies monthly pre-allocated last month's hospitalization and outpatient special disease co-ordination fees;
3. Insured persons who have been identified as suffering from special diseases shall go to the designated medical institutions designated by the labor and social security department for medical treatment and purchase medicines, and the medical expenses incurred shall be directly accounted for and settled immediately;
4. Emergency settlement procedure: the medical expenses incurred by the insured in emergency rescue to non-designated medical institutions in the city and medical institutions in different places shall be paid in advance by individuals or units. After the emergency rescue, the medical insurance agency shall go through the reimbursement procedures according to the regulations with emergency medical records, inspection, laboratory sheets, invoices and detailed list of medical expenses.
To sum up, due to the adjustment of medical insurance clinics and personal accounts, the reimbursement of medical insurance clinics in many areas has changed. The money reduced from the personal account of medical insurance goes into the medical insurance pooling fund, which can improve the outpatient treatment of employees' medical insurance.
Legal basis:
Article 23 of People's Republic of China (PRC) Social Insurance Law
Employees should participate in the basic medical insurance for employees, and employers and employees should pay the basic medical insurance premiums in accordance with state regulations.
Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.
Article 24
The state establishes and improves the new rural cooperative medical system.
Measures for the administration of the new rural cooperative medical system shall be formulated by the State Council.