1. Insurance Subsidy Policy
Poverty-free households and extremely poor people in the county. The extremely poor people will be fully subsidized to participate in the insurance; households lifted out of poverty will be given a fixed subsidy of 140 yuan per person. Personnel with multiple identities will be funded according to the principle of high priority, and repeated funding is not allowed. The total amount of funding shall not exceed 280 yuan.
2. Conditions for enjoying benefits
Urban and rural residents who have not been lifted out of poverty and have not paid within the centralized payment period can participate in insurance through sporadic payment. They will be insured according to the current year’s personal payment standards and government subsidies. After paying the insurance fee based on the standard sum, urban and rural residents will begin to enjoy medical insurance benefits 60 days from the date of payment.
(1) Newborns are subject to dynamic insurance. Guardians should register and pay for insurance within 90 days after their birth. They should pay according to the individual payment standards for that year and enjoy urban and rural residents' medical insurance from the date of birth. Benefits; If the payment exceeds 90 days, urban and rural residents will begin to enjoy the medical insurance benefits 60 days from the date of payment.
(2) New people in poverty-stricken households will be dynamically insured, and will not be restricted by the centralized payment period, and will enjoy the insurance subsidy policy. Individuals will only pay 140 yuan, and financial subsidies at all levels will be 140 yuan.
(3) In the year when military personnel retire from active service, the Urban and Rural Residents Medical Insurance Bank will dynamically participate in insurance throughout the year. The payment standard is the individual payment standard for urban and rural residents in that year, and urban and rural residents will enjoy the medical insurance benefits for urban and rural residents from the date of payment.
(4) Persons participating in the basic medical insurance for employees can participate in the medical insurance for urban and rural residents within 90 days after the payment of the basic medical insurance for employees is suspended. The payment standard is the individual payment standard for urban and rural residents for that year, and they can enjoy urban and rural residents from the date of payment. Resident medical insurance benefits; if the period exceeds 90 days, urban and rural residents will begin to enjoy urban and rural resident medical insurance benefits 60 days from the date of payment.
3. Medical insurance treatment policy
(1) Outpatient treatment
The level of medical institutions is based on the practice registration approval issued by the health administrative department or the hospital level review Identification document. For medical institutions without clear grade standards, medical institutions approved by the county-level health administrative department shall refer to the first-level medical institutions; medical institutions approved by the municipal health administrative department shall refer to the second-level medical institutions; medical institutions approved by the provincial health administrative department shall refer to the second-level medical institutions. Medical institutions shall refer to tertiary medical institutions for implementation.
2. Chronic disease outpatient treatment:
① Hypertension (high risk and very high risk in grade 1 hypertension, grade 2 hypertension, grade 3 hypertension) and no target organ development For insured persons with damage, diabetes (type 1, type 2) and no target organ damage, the payment standard shall be based on the "Implementation Opinions on Improving the Guarantee Mechanism for Outpatient Medication for Hypertension and Diabetes for Urban and Rural Residents" (Qian Medical Insurance Development [2019] No. 54 ) document shall be implemented.
②Rheumatic (rheumatoid) arthritis, joint disease (hip, knee), mental illness, cerebrovascular disease and its sequelae (with severe functional impairment), diabetes (combined with heart, brain, kidney and nerves) Systemic chronic diseases), hypertension (combined with heart, brain, and kidney damage), chronic obstructive pulmonary emphysema, pulmonary heart disease, active tuberculosis, rheumatic heart disease, Alzheimer's disease, cardiomyopathy, chronic bronchitis, asthma, and kidney disease Syndrome, chronic nephritis, ankylosing spondylitis, epilepsy, liver cirrhosis, chronic active hepatitis, pneumoconiosis, heart disease complicated by cardiac insufficiency, coronary heart disease, hypothyroidism, Parkinson's disease, myasthenia gravis are treated at designated points in the city For medical expenses within the scope of the policy incurred by outpatient institutions and public medical institutions outside the city, the payment ratio is 60%, there is no deductible, and the annual cap is 4,000 yuan. Procedures for applying for chronic disease certificates: Disease certificates from public medical institutions of secondary level and above, corresponding auxiliary examination reports, hospitalization medical records and copies of ID cards (household registration books) must be submitted to the township (street) health center (community health service center) where the household registration is located. , the health center (community health service center) will submit it to the county medical insurance bureau for review and approval after preliminary review.
3. Special disease outpatient treatment: various malignant tumors, leukemia (except standard drug treatment for chronic myelogenous leukemia), aplastic anemia, systemic lupus erythematosus and anti-rejection treatment for organ transplantation, rare diseases For special diseases such as medical expenses incurred in the outpatient service of secondary and above public medical institutions within the scope of the policy, the payment ratio is 75, and there is no minimum payment line. The cumulative payment cap of the fund in a natural year is 60,000 yuan.
(2) Basic Medical Insurance Hospitalization Benefits
1. Expenses incurred within the scope of the policy for hospitalization of insured persons in designated medical institutions at the place of treatment shall be reimbursed according to the following policy.
The level of a medical institution is based on the practice registration approval or hospital grade review and accreditation document issued by the health administrative department. For medical institutions without clear grade standards, medical institutions approved by the county-level health administrative department shall refer to the first-level medical institutions; medical institutions approved by the municipal health administrative department shall refer to the second-level medical institutions; medical institutions approved by the provincial health administrative department shall refer to the second-level medical institutions. Medical institutions shall refer to the implementation of tertiary medical institutions.
2. Cap line: The annual cumulative reimbursement cap line is 250,000 yuan (excluding critical illness insurance).
3. Filing for medical treatment in other places and referral to another hospital:
① If the insured person is hospitalized outside the city, he or she must go to the district (county) medical insurance agency or medical organization Lead the hospital to handle system referral registration.
② Emergency and critical patients should register by telephone with the medical insurance agency in the insured place. For hospitalization due to accidental injuries, reporting to the commercial insurance agency in accordance with regulations will be deemed as referral filing.
③If the insured persons live outside the coordinated area for a long time, they should register for medical treatment in other places and follow the referral policy. Those who have not registered for medical treatment in other places will be subject to the policy of not being referred outside the coordinating area.
④ If a patient suffers from the same disease and needs to be hospitalized multiple times in the same medical institution, he only needs to go through the referral procedure once a year.
(3) Benefits for 25 major diseases If 25 major diseases are treated in designated medical institutions designated by the original provincial level, they will be reimbursed according to the original fixed (limited) standards for major diseases before integration.
(4) Accidental injury insurance benefits
1. Accidental injuries caused by the insured without third-party liability are hospitalized in designated medical institutions and designated medical institutions with treatment capabilities. Hospitalization expenses that meet the requirements of the three catalogs will be reimbursed according to the basic medical insurance hospitalization policy. Medical expenses incurred for hospitalization in township hospitals and community health service centers due to accidental injuries are not included in the accident insurance fund and are paid by the urban and rural residents basic medical insurance fund. Follow-up treatment of trauma (such as removing steel plates and implants, etc.) is treated as ordinary hospitalization and is included in basic medical payments.
2. Scope of non-payment:
① Should be paid from the work-related injury insurance fund;
② Should be borne by the third party responsible party and its subsequent consequences Treatment costs;
③ Should be borne by the public health department;
3. If the insured person is hospitalized in the city due to an accidental injury, the treating hospital shall The case must be reported to the commercial insurance agency within 48 hours; if the patient is hospitalized outside the city, the insured person or his/her family member shall report the case to the commercial insurance company in the insured place within 5 working days of admission. If a case is reported beyond the prescribed time, the reimbursement rate will be reduced by 30 percentage points, and the reduced rate will no longer be included in the scope of critical illness insurance and medical assistance. The commercial insurance agency shall feedback the investigation report to the hospital, the insured person or their family members within 3 days after receiving the report. This may be extended appropriately under special circumstances.
(5) Critical illness insurance benefit policy: After the critical illness insurance policy for the general population has been reimbursed by basic medical treatment, an individual’s annual cumulative out-of-pocket expenses within the scope of the policy exceeds 9,000 yuan, and can be compensated by the critical illness insurance, ranging from 9,000 yuan to 30,000 yuan (inclusive) 60 will be reimbursed if the annual cumulative out-of-pocket expense exceeds 30,000 yuan and is within 50,000 yuan (including 50,000 yuan); 70 will be reimbursed if the annual cumulative out-of-pocket expense exceeds 50,000 yuan (including 50,000 yuan). The cap line is 300,000 yuan. The threshold for critical illness insurance for poor households will be lowered by 50% compared with that of the general population, and the compensation ratio for each level will be increased by 5 percentage points.
That is: after basic medical reimbursement, within the scope of the policy, the individual’s annual cumulative out-of-pocket expenses exceed 4,500 yuan and are reimbursed within 30,000 yuan (including 30,000 yuan)65; the annual cumulative out-of-pocket expenses exceed 30,000 yuan and are within 50,000 yuan (including 50,000 yuan). 70 will be reimbursed; 75 will be reimbursed if the annual cumulative out-of-pocket expenses exceed 50,000 yuan. There is no cap on critical illness insurance for households that have been lifted out of poverty.
(6) Medical Assistance Policy For households out of poverty who have been transferred to hospital and have been reimbursed by basic medical insurance and critical illness insurance, the proportion of personal out-of-pocket hospitalization medical expenses within the policy scope within the annual assistance limit is 70%, and the annual assistance limit is 50,000 yuan, and the reduced proportion will not be included in the scope of medical assistance reimbursement.
4. Hospitalization reimbursement process
(1) One-stop instant settlement. When medical insurance poverty alleviation targets are hospitalized in designated medical institutions in the city, "one-stop" instant settlement will be provided for the triple guarantees of basic medical insurance, critical illness insurance, and medical assistance. Patients only need to pay the burden when they are discharged. Those with dual or multiple special attributes shall not be reimbursed repeatedly.
(2) Non-one-stop instant settlement. If medical insurance poverty alleviation recipients are hospitalized in non-connected medical institutions for reimbursement, they must provide a copy of their ID card or household register, original hospitalization invoice, discharge summary, hospitalization expense list, and a copy of their bank book (card), etc. Submit the information to the township (street) general medical station. If you are injured accidentally, submit the information to window No. 28 of the County Government Affairs Center (life insurance company). The medical insurance agency completes the review of reimbursement for basic medical insurance, critical illness insurance, and medical assistance within 25 working days, and directly transfers the reimbursement fees to the patient's designated bank account to realize the "one card" payment of funds. Exceptions include special medical records, questionable medical records, etc.
Legal basis:
Article 2 of the "Interim Measures for Social Assistance" The social assistance system adheres to the bottom line, emergency relief, sustainability, and is connected with other social security systems. The level of social assistance Compatible with the level of economic and social development.
Social assistance work should follow the principles of openness, fairness, impartiality and timeliness.
Article 3 The civil affairs department of the State Council shall coordinate the construction of the national social assistance system. The civil affairs, emergency management, health, education, housing and urban-rural development, human resources and social security, medical security and other departments of the State Council are responsible for the corresponding social assistance management work in accordance with their respective responsibilities.
The civil affairs, emergency management, health, education, housing and urban-rural development, human resources and social security, medical security and other departments of the local people's governments at or above the county level are responsible for the corresponding social assistance management within their respective administrative regions in accordance with their respective responsibilities. Work.
The administrative departments listed in the first two paragraphs are collectively referred to as social assistance management departments.
Article 4 Township people’s governments and sub-district offices are responsible for accepting, investigating and reviewing applications for social assistance, and the specific work is undertaken by social assistance agencies or personnel.
Village committees and residents’ committees assist in relevant social assistance work.