Outpatient Reimbursement Ratio
(1)60% reimbursement for visits to village health centers and village central health centers, with a limit of 10 yuan for prescription drug fees per [1] visit and 50 yuan for prescription drug fees for temporary rehydration by health center doctors.
(2) Township health center visits are reimbursed 40%, with a limit of 50 yuan per visit for each examination and surgical procedure, and a limit of 100 yuan for prescription drugs.
(3) Secondary hospitals will be reimbursed 30% of the cost, with a limit of 50 yuan for each examination and operation and 200 yuan for prescription drugs.
(4) Tertiary hospitals will reimburse 20% of the cost, with a limit of RMB 50 for each examination and operation and RMB 200 for prescription drugs.
(5) Chinese medicine invoices with prescription attached are limited to $1 per sticker.
(6) The annual limit of outpatient compensation for township-level cooperative medical care is 5,000 yuan.
Hospitalization reimbursement rate
(1)Reimbursement scope:
A, medicine: auxiliary examination: EKG, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, CT, nuclear magnetic *** vibration and other examination fees limit of 200 yuan; surgical fees (with reference to the national standard, more than 1,000 yuan reimbursement at 1,000 yuan).
B, the elderly over 60 years of age hospitalized in Xingta Township Health Center, treatment and care costs are compensated 10 yuan per day, limit 200 yuan.
(2) Reimbursement rate:
Town health center reimbursement 60%; secondary hospital reimbursement 40%; tertiary hospital reimbursement 30%.
Reimbursement ratio for major illnesses
(1)Township risk fund reimbursement:
Any hospitalized patient who participates in cooperative medical care has a one-time or yearly cumulative reportable medical fee of more than 5,000 yuan or more reimbursed in segments, i.e., 5,001-10,000 yuan is reimbursed at 65%, and 10,001-18,000 yuan is reimbursed at 70%. Township-level cooperative medical inpatient and uremia outpatient hemodialysis, outpatient radiotherapy and chemotherapy oncology compensation annual limit of 11,000 yuan.
Not covered by the reimbursement scope
1, self-medical treatment (without designated hospitals for medical treatment or without referral orders), self-purchased medicines, medicines that cannot be reimbursed by the public medical care regulations, and medical expenses not in line with the family planning;
2, outpatient treatment expenses, consultation fees, hospitalization fees, meals, accompanying guests, nutritional costs, blood transfusion costs (except for those who have a family blood reserve, which is reimbursed in accordance with the relevant regulations ), heating and cooling costs, ambulance fees, special care costs and other expenses;
3, car accidents, fights, suicide, alcoholism, workplace accidents and medical malpractice medical expenses;
4, orthopedics, cosmetic surgery, dental implants, prosthetics, organ transplants, naming surgical fees, consultation fees, etc.;
5, reimbursement of the scope of the portion of the limit outside the scope of reimbursement.
In accordance with the residents
The starting standard and reimbursement rate of the basic medical insurance for urban residents are determined differently according to the categories of the insured.
First, students and children. For medical expenses under 180,000 RMB incurred within a billing year that are eligible for reimbursement,
the starting standard for tertiary hospitals is 500 RMB, and the reimbursement rate is 55%; for secondary hospitals, the starting standard is 300 RMB, and the reimbursement rate is 60%; and for primary hospitals, there is no starting standard and the reimbursement rate is 65%.
The second is the elderly aged 70 years or older. In a settlement year, incurred in line with the scope of reimbursement of medical expenses of less than 100,000 yuan, the starting standard for tertiary hospitals 500 yuan, reimbursement rate of 50%; secondary hospitals starting standard 300 yuan, reimbursement rate of 60%; first-class hospitals do not set a starting standard, reimbursement rate of 65%.
Third, other urban residents. In a settlement year, incurred in line with the scope of reimbursement of medical expenses of less than 100,000 yuan, the starting standard for third-level hospitals 500 yuan, reimbursement rate of 50%; second-level hospitals hospitalization starting standard 300 yuan, reimbursement rate of 55%; first-level hospitals do not set the starting standard, reimbursement rate of 60%.
Urban residents who are hospitalized for more than two times in one billing year will no longer be charged the starting standard fee from the second hospitalization. If they are transferred to another hospital or hospitalized for more than two times, the difference will be made up in accordance with the starting standard of the hospital to which they are transferred or re-admitted.
According to the employee
Generally speaking, the economic development of different regions varies, so the reimbursement rate also varies, the following on the situation of the proportion of Beijing employee health insurance coverage.
After getting medical insurance, if you are an active employee, you can only be reimbursed for medical expenses above 2,000 yuan after visiting outpatient and emergency clinics in hospitals, and the reimbursement rate is 50 percent. If you are a retiree under the age of 70, you can be reimbursed for expenses over 1,300 yuan, and the reimbursement rate is 70%. If the retiree is over 70 years old, the reimbursement rate is 80 percent for expenses over $1,300.
And regardless of the type of person, the maximum limit for expenses paid for outpatient and emergency major medical expenses is 20,000 yuan. For example, if you are an active employee and you spend $2,500 on an outpatient visit, you can be reimbursed 50 percent of the $500 portion, which is $250.
In the case of hospitalization expenses, the current starting amount is $1,300 for the first time you use basic medical insurance to pay in a year, whether you are an active employee or a retiree. And for the second and subsequent hospitalization medical expenses, the starting amount is determined at 50 percent, which is 650 yuan. And the maximum payment from the Basic Medical Insurance Co-ordination Fund (for hospitalization expenses) in a year is currently 70,000 yuan.
The standard of hospitalization reimbursement is related to the level of the hospital where the insured person lives, such as living in a tertiary hospital, from the starting standard to 30,000 yuan of expenses, the employee pays 15%, or 85% reimbursement; 30,000 yuan to 40,000 yuan, the employee pays 10%, reimbursement of 90%; more than 40,000 yuan to the highest limit of payment of the portion of the cost, then 95% can be reimbursed, the employee only has to pay 5%. And retirees personally pay 60 percent of the rate for active (that is, the aforementioned) employees, but anything below the threshold is paid by the individual.
The diagnostic and therapeutic items that are not paid for by the basic medical insurance for employees are mainly non-clinically necessary and uncertain diagnostic and therapeutic items as well as diagnostic and therapeutic items for special medical services, including services such as registration fees, non-disease treatments such as cosmetic treatments, therapeutic equipment and materials such as hearing aids, therapeutic items such as magnetic therapy, and other categories such as infertility treatments, etc. In accordance with the "National Basic Medical Insurance Diagnostic and Therapeutic Items", the basic medical insurance for employees is not paid for. In accordance with the "national basic medical insurance treatment program scope", as follows:
(a) service category. (1) registration fee, out-of-hospital consultation fee, medical record cost, etc.; (2) visit fee, examination and treatment of expedited fee, named surgery surcharge, quality premium fee, self-requested special nurses and other special medical services.
(2) non-disease treatment program category. (1) a variety of cosmetic, bodybuilding and non-functional cosmetic, orthopedic surgery; (2) a variety of weight loss, weight gain, height projects. (3) a variety of health checkups; (4) a variety of preventive, health care treatment programs; (5) a variety of medical consultation, medical appraisal.
(C) diagnostic equipment and medical materials. (1) the application of positron emission tomography device (PET), electron beam cT, ophthalmic excimer laser therapy and other large medical equipment for examination and treatment programs; (2) glasses, dentures, eye prostheses, prosthetics, hearing aids and other rehabilitative devices; (3) a variety of health care for their own use, massage, inspection and treatment equipment; (4) the provincial price departments can not be charged separately for disposable medical.
(D) treatment program category. (1) all types of organ or tissue transplantation of organ source or tissue source; (2) in addition to kidney, heart valve, cornea skin, blood vessels, bone, bone marrow transplantation; (3) myopic eye orthopedics; (4) qigong therapy, music therapy, health care nutritional therapy, magnetic therapy and other complementary therapeutic projects.
(5) Others. (1) a variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment program; (2) a variety of scientific research, clinical verification of the diagnosis and treatment program.
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