Description of medical insurance participation
1. What is basic medical insurance?
Basic medical insurance is a social insurance system established to compensate the insured for economic losses caused by disease risks. It is an important part of the social security system, and it is a kind of social insurance formulated by the government with the participation of employers and employees. It is universal, economical and compulsory. The basic medical insurance is the basis of the medical security system, and the combination of individual account and overall fund is implemented to ensure the basic medical needs of the insured in terms of basic drugs, basic services, basic technology and basic expenses.
2. What are the coverage of basic medical insurance?
All employers in cities and towns within the county, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises, etc.). ), organs, institutions, social organizations, private non-enterprise units and their employees must participate in the basic medical insurance. Township enterprises and their employees, urban individual economic organizations and their employees are gradually included in the coverage of basic medical insurance.
3. How to participate in basic medical insurance?
One is to apply for insurance, mainly fill in the roster and summary table of insured objects:
The second is insurance audit, which mainly means that the medical insurance agency reviews the registration form of the insured unit and inputs it into the computer for proofreading;
The third is to fill in the certification card. The employer shall submit two one-inch bareheaded photos to each person, fill in the medical insurance registration book and medical record book, and the medical insurance agency shall make a personal account IC card for each insured person;
The fourth is to pay the premium. After the employer fills in the "two certificates and one card" and checks the roster of insured persons, the medical insurance agency will print the payment schedule and payment bill to the insured unit, and the insured unit will pay the medical insurance premium according to the payment bill.
4. What is the payment standard of basic medical insurance premium?
The State Council [1998] No.44 "Decision on Establishing the Basic Medical Insurance System for Urban Employees" stipulates: "The basic medical insurance premium shall be borne by both employers and employees." The employer's payment base is 8% of the total wages of employees in the previous year, of which the unit pays 6% and the individual pays 2%. The part where the total annual average wage of employees of the employing unit exceeds 300% of the total annual average wage of employees in the overall planning area shall not be used as the payment base; If it is less than 60%, it will be paid at 60%. If the actual salary is lower than the file salary, it will be paid at the file salary. After the insured employees retire, the unit and I will no longer pay the basic medical insurance premium and continue to enjoy the medical insurance benefits.
5. What items constitute the total wages paid by the insured units and employees?
The National Bureau of Statistics 1 Order and 1994 37 documents stipulate that the total wages of employees in government organs, social organizations and institutions are composed of post wages, grade wages, basic wages, seniority wages, overtime wages, allowances, subsidies, bonuses and wages paid under special circumstances; The total wages of enterprise employees are composed of hourly wages, piecework wages, bonuses, post wages, skill wages, special wages, allowances, subsidies, overtime wages and wages paid under special circumstances.
6. What are the basic medical insurance funds? What are their uses?
The basic medical insurance fund is mainly composed of overall funds and individual accounts. All the basic medical insurance premiums paid by individual employees are credited to individual accounts, and the basic medical insurance premiums paid by employers are divided into two parts, one part is used to establish the overall fund, and the other part is credited to individual accounts. The proportion of individual accounts is generally about 30% of the employer's contribution.
Personal accounts cannot be taken out and used for other purposes, and can only be used for out-patient and in-patient medical expenses of the insured. The overall fund is mainly used to pay the hospitalization medical expenses of the insured.
7, the basic medical insurance personal account funds how to delimit?
First, the medical insurance premiums paid by employees according to 2% of their total wages in the previous year are all included in personal accounts.
Second, the basic medical insurance premium paid by the employer is transferred to the personal account according to a certain proportion of the employee's age. Under 45 years old (including 45 years old), 0.6% of my total salary in the previous year will be transferred to my personal account; Those who are over 46 years old and before retirement will be transferred to personal account according to 1. 1% of my total salary in the previous year; Retirees are credited to personal accounts according to 3.2% of the average salary of employees in the previous year of the payer. If my retirement fee is higher than the average salary of the employees in this unit, it will be credited to my personal account according to 3.2% of my retirement fee in the previous year. The age of on-the-job employees shall be determined according to the annual age of the current year 1.
8. How to manage and use the medical insurance IC card?
The medical insurance IC card is not only the identity certificate of the insured workers' outpatient and hospitalization, but also the settlement certificate of personal account funds to pay the outpatient medical expenses of designated hospitals and the drug purchase expenses of designated retail pharmacies. Therefore, insured employees must carry and show their IC cards when seeking medical treatment or purchasing medicines. The IC card is kept by the insured employee personally, and the password can be set in the designated hospital or pharmacy. Do not lend or falsely use another person's IC card for medical treatment. If the IC card is lost, you must take your ID card to the medical insurance office to report the loss in time, and you can reissue the IC card after 6 days.
9, what is the basic medical insurance Qifubiaozhun and the highest standard?
Qifubiaozhun, also known as Qifubiaozhun, is commonly known as pooling funds.
The "threshold" of payment is the amount of medical expenses that must be borne by the individual before the individual pays the medical expenses. The "Decision" stipulates that the minimum payment standard of the overall fund in that year is about 10% of the average salary of employees in the overall planning area in the previous year. The qifubiaozhun of our county in 2006 is still the first-class hospital 650 yuan, the second-class hospital 750 yuan and the third-class hospital 900 yuan.
The maximum payment limit, also known as the capping line, refers to the maximum amount of basic medical expenses that can be paid by the overall fund for individuals in that year. The "Decision" stipulates that the maximum payment limit is about four times the average annual salary of employees in the overall planning area. Since April 1 day, 2006, the maximum payment limit in our county is 20,000 yuan.
10, how do insured employees go through hospitalization procedures and settle hospitalization medical expenses?
The insured holds the medical insurance manual, medical record book and IC card to the designated hospital for registration. If it is really necessary to be hospitalized due to illness, the doctor with prescription right in the hospital will issue a notice of hospitalization, and then go to the medical insurance office of the hospital where he is located to handle the medical insurance hospitalization procedures. If the employer pays the premium on time, the individual only needs to pay part of the fee in advance. Otherwise, I will pay all hospitalization expenses first, and then settle the medical expenses according to the medical insurance policy.
All insured employees hospitalized within Qifubiaozhun are paid by individuals. The basic medical insurance adopts the method of "subsection calculation and cumulative payment" for medical expenses above Qifubiaozhun and below the maximum payment limit. That is, the basic medical insurance pooling fund qifubiaozhun above to 3000 yuan, pooling fund burden 84%, personal burden16%; 3,000 yuan to 10000 yuan, 88% of the overall fund burden and12% of the individual burden; 10000 yuan to the maximum payment limit, the overall fund burden is 92%, and the individual burden is 8%. The individual retiree shall bear 75% according to the above proportion.
1 1. What is mutual medical assistance for serious illness? How to pay and enjoy the mutual medical assistance fee for serious illness?
Medical mutual aid for serious illness refers to a social medical mutual aid system established by urban workers on the basis of participating in basic medical insurance to solve the problem that the insured patients exceed the maximum payment limit of the basic medical insurance pooling fund and ensure the medical needs of employees for serious illness.
The employer shall pay the medical mutual aid fee for serious illness for 6 months at the time of enrollment, and pay it monthly from the seventh month. Insured employees enjoy mutual medical treatment for serious illness from the next month of insurance payment.
The medical mutual aid fee for serious illness shall be paid according to the standard of 8 yuan per person (including retirees) every month, and the employer and employees shall bear the 4 yuan.
For enjoying mutual assistance for serious illness, no matter what illness, all insured patients should start with basic medical insurance. During the year, the medical expenses reach the maximum limit of the basic medical insurance, and then they are calculated in stages, and then they enter mutual assistance for serious illness. Patients who need to enjoy mutual aid for serious illness shall first apply by themselves or their families, and the unit shall sign opinions and report them to the medical insurance agency for examination and approval. For patients who have entered mutual aid for serious illness, the standard and scope of payment for special care, referral, medication scope, bed fee and medical service facilities are all treated equally according to the conditions of basic medical insurance, but the total amount calculated by stages within one year can reach 6,543.8+0.2 million yuan, and the personal burden ratio calculated by stages is 8%.
12, what is the impact of not paying the basic medical insurance premium on time?
If the employer fails to pay the basic medical insurance premium within the specified time, in addition to paying the arrears, it will also charge a late fee of 2‰ on a daily basis from the date of default, and suspend the treatment paid by the basic medical pooling fund from the next month; During the suspension period, the personal account funds will be suspended. At the same time, the insured will stop medical insurance benefits, and all medical expenses will be paid by individuals.
13. What are the provisions on the termination and renewal, change and renewal, interruption and treatment of basic medical insurance?
Where due to the adjustment of economic structure or irresistible objective factors, the units that have lost the insurance conditions and the individuals who need to stop insurance when going abroad (on business) should report in writing to the local medical insurance agency before stopping insurance, go through the confirmation procedures for stopping insurance, and stop paying medical expenses from the next month; Units and individuals who stop insurance shall report to the medical insurance agency in writing when reinsuring, pay the medical insurance premium from the date of stopping insurance to the date of reinsuring, and enjoy basic medical insurance and mutual medical treatment for serious illness from the next month; For units and individuals that stop insurance for no reason, in addition to going through the renewal procedures according to the renewal requirements, they will also be charged a late fee of 2‰ on a daily basis from the date of suspension to the date of renewal. You can enjoy basic medical insurance and mutual assistance for serious illness after 60 days of self-payment. No matter whether the unit or individual stops the insurance normally or for no reason, the medical expenses incurred during the period of stopping the insurance will not be paid by the pooling fund, and the pooling fund will not be included in the personal account. The cumulative payment period of the insured person is interrupted by full 1 year (including insufficient 1 year), and the individual self-payment ratio of medical insurance is increased by 5 percentage points on the basis of the prescribed self-payment ratio. If the medical treatment of the insured is affected by the unit, it shall be borne by the unit.
14. How do the insured workers go through the referral procedures?
Insured employees are hospitalized in county people's hospital, county traditional Chinese medicine hospital, county second people's hospital and county third people's hospital. If it is really necessary to be transferred to a higher-level hospital for treatment due to illness, the above-mentioned hospital shall put forward opinions, fill in the application form for referral and transfer, and then go to the county medical insurance office for examination and settlement (telephone number: 0736-66 12790) for approval and filing. All the patients diagnosed as malignant tumor by the superior hospital, with the discharge diagnosis certificate and discharge doctor's advice from the superior hospital, go directly to the county medical insurance office to review the settlement unit for referral and transfer procedures. Insured persons who meet the conditions for resettlement in different places must go through resettlement procedures. If you need to be hospitalized due to illness, you must report to the county medical insurance department for examination and settlement unit for the record before hospitalization, and the emergency department must report to the county medical insurance department for examination and settlement unit within 5 days after hospitalization (holidays are postponed). With the approval of the county medical insurance office, the hospitalization expenses of personnel transferred to other places outside the city and outside the city shall be paid in advance by individuals or units. After discharge, submit the reimbursement to the county medical insurance office with the referral approval form, discharge diagnosis certificate, cash invoice of hospitalization expenses, daily report of expenses approved by the county medical insurance office and other materials with complete procedures. The total medical expenses shall be paid in advance 10%, and then reimbursed according to relevant policies. Anyone who fails to go through the formalities as required shall be borne by the patient. If the referral procedures are re-submitted or the report is not made on time, the reimbursement expenses shall be calculated from the date of re-submitting or reporting.
15. What are the medical expenses not covered by the basic medical insurance?
The insured person belongs to one of the following circumstances, and the basic medical pooling fund will not pay the fee. (1) Transferred without approval; ② Medical expenses due to medical accidents and traffic accidents; (three) medical expenses incurred by illegal crime, suicide, self-mutilation, alcoholism, drug abuse and carelessness; (four) medical expenses for work-related injuries, maternity, occupational diseases, schistosomiasis and manic psychosis; The basic medical insurance diagnosis and treatment items and the items in the drug list that should not be paid by the overall fund.
16. What are the items that the basic medical insurance pays for (special examination and treatment)?
X-ray computed tomography (CT), gamma knife, X knife, cardiac angiography (including digital subtraction), magnetic resonance (MRI), single photon emission computerized scanning (SPECT), color Doppler ultrasound, dynamic electrocardiogram, brain topographic map, linear accelerator; Extracorporeal shock wave lithotripsy, hyperbaric oxygen, radio frequency therapy, video laparoscopic surgery.
Hemodialysis, peritoneal dialysis, kidney and heart bypass surgery, cardiac catheter balloon dilatation; Heart valve, cornea, skin, blood vessels, bone marrow transplantation, heart laser drilling, anti-tumor cell immunotherapy, fast neutron therapy project.
Various artificial organs and implant materials (such as pacemakers, artificial heart valves, artificial joints, intraocular lenses, artificial larynx, artificial femoral heads, vascular stents, etc.). ) are priced at domestic prices.
For the above-mentioned special examination and treatment items, retirees and on-the-job personnel during hospitalization pay a certain proportion (10-30%) according to the relevant provincial policies, and then enter the general hospitalization for reimbursement of medical expenses in proportion; If special examination and special treatment are needed due to illness, the doctor shall apply, and the hospital medical insurance office and county medical insurance office shall have the same examination and approval. If the examination results are abnormal and hospitalization is really necessary, the examination expenses will be included in the reimbursement scope of hospitalization expenses, and the overall fund will no longer pay for special outpatient examination and special treatment expenses. Replacement of artificial organs, whether on-the-job or retired, will be reimbursed according to the domestic price limit of 50%.
17. What drugs are not covered by basic medical insurance?
Drugs that are not paid by the overall fund are: (1) drugs that mainly play a nourishing role; (2) Some animals, animal organs and dried fruits that can be used as medicine; (3) Various wine preparations brewed with Chinese herbal medicines and Chinese herbal pieces; (4) Mushroom fruiting agents and oral effervescent agents in various medicines; (5) Blood products and protein products (except for special indications and first aid and rescue); (six) other drugs that are not included in the drug list formulated by the provincial labor and social security department and will not be paid.
18. What are the medical treatment items that are not paid by the basic medical insurance?
The diagnosis and treatment projects that are not paid by the overall fund mainly refer to the diagnosis and treatment projects that are not necessary for clinical diagnosis and treatment, and the diagnosis and treatment projects that belong to special medical services. Including: registration fee, out-of-hospital consultation fee, medical record fee, home visit fee, surgical examination nursing fee and special ward fee; All kinds of beauty, bodybuilding and orthopedic surgery fees; All kinds of weight loss, weight gain, higher cost; All kinds of health check-ups, premarital check-ups, swimming, exit check-ups, and medical and drug expenses incurred during going abroad to work, visit relatives, study and give lectures; All kinds of preventive health care diagnosis and treatment projects; Various medical appraisal and consultation fees; Equipped with glasses, artificial limbs, hearing AIDS and self-use health care, massage, examination and treatment equipment; Various infertility examination, identification, treatment costs, etc. ; The organ source or tissue source of various organ or tissue transplants; Clinical verification projects of various scientific research drugs and instruments.
19. What medical service facilities are not covered by the basic medical insurance?
The expenses of medical service facilities that are not paid by the overall fund include: medical transportation expenses, ambulance expenses, stretcher expenses, heating expenses, air-conditioning expenses, TV telephone expenses, electric stove expenses, electric fan expenses, coal fire expenses, public property compensation expenses, escort expenses, bed occupancy expenses, nursing expenses and sanitary tools expenses. Washing expenses, decocting expenses, meals expenses, secretarial expenses, entertainment expenses and other special life service expenses.
20, under what circumstances can handle special disease outpatient service?
The special diseases stipulated in Hunan Province include chronic active hepatitis, infiltrative tuberculosis, high coronary heart disease, diabetes, aplastic anemia, ascites due to liver cirrhosis, renal failure, postoperative rehabilitation of cancer and total paralysis.
These diseases can apply for special outpatient treatment after being identified by designated hospitals, and the management of "cost limit, proportional sharing, designated prescription, standardized drug use and regular reimbursement" is implemented.
2 1. How to reimburse the hospitalization expenses of resettlement and floating personnel?
For retired employees who work abroad for more than 1 year due to work, their hospitalization medical expenses will be reimbursed according to the reimbursement standard of hospitals at the same level in this county after the patient pays 15% of the total expenses. The unit where such personnel work should report to the medical insurance department for the record in advance, and those who fail to report for registration will not be recognized.
22. What is the maximum daily reimbursement standard for hospital bed fees?
Level III Hospital 15 yuan, Level II Hospital 13 yuan, Level I Hospital 10 yuan. When patients are admitted to the hospital, they must ask the nurses about the prices of various beds and choose ordinary beds for hospitalization.
Special personnel: level III hospital daily 20 yuan, level II hospital daily 18 yuan, level I hospital daily 16 yuan.
23. What are the provisions for reimbursement of medical expenses for special personnel?
Special personnel (retired cadres, disabled soldiers above Grade B) are ill, so they must choose designated hospitals (pharmacies) to see doctors and buy medicines. Each prescription of traditional Chinese medicine does not exceed that of 80 yuan, and that of western medicine does not exceed 150 yuan. All drugs outside the drug list are at their own expense, and 30% of materials for special examination and treatment, blood transfusion and internal placement are at their own expense. Disabled soldiers, second-class B or above, only pays the personal conceit after being approved by the county medical insurance department; Third-class disabled soldiers hospitalization medical expenses shall be implemented according to the basic medical insurance policy, and the Qifubiaozhun shall be reimbursed to the county civil affairs bureau after being audited by the county medical insurance bureau. If the work-related injury recurs, the medical expenses shall be reimbursed to the work-related injury insurance office according to the relevant policies and regulations with the work-related injury disability certificate.
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