Medicare reimbursement standard:
1, residents reimbursement ratio: town health center reimbursement of 60%; secondary hospital reimbursement of 40%; tertiary hospitals reimbursement of 30%;
2, urban residents, in a billing year, incurred in line with the scope of reimbursement of medical expenses up to 100,000 yuan, the starting standard of tertiary hospitals for 659 yuan, reimbursement ratio of 50% upper limit is 2,000 yuan; the starting standard for hospitalization in second-level hospitals is 300 yuan, with a reimbursement rate of 55%; first-level hospitals do not have a starting standard, with a reimbursement rate of 60%;
3. If the reimbursement is made in a different place, the reimbursement needs to go back to the place where you are insured in your hometown, with a reimbursement rate of 35-65%, and the rate varies according to the hospital level.
Chronic health insurance reimbursement standards:
1, Class A chronic disease patients incurred in accordance with the provisions of the outpatient medical costs, by the integrated fund at 85%. The outpatient hemodialysis cost, peritoneal dialysis cost and the cost of taking cyclosporine A after organ transplantation for patients with chronic renal failure in the stage of renal failure will be increased by ten percentage points on the basis of the above;
2. Starting line standard for chronic diseases of category B: 300 yuan. The outpatient medical expenses incurred by patients with Class B chronic diseases in accordance with the regulations shall be paid at 80% of the portion above the starting line standard, and the maximum payment limit for chronic diseases cannot be exceeded within one medical year (or validity period);
3. Participants can be recognized with two Class B chronic diseases at the same time and be managed according to the first recognized dual diseases, with the starting line calculated separately for each disease type. The management of the identification of chronic diseases and the maximum payment limit will be adjusted by the human resources and social security department in due course according to the income and expenditure situation of the integrated fund. The criteria, rules and procedures for the identification of chronic diseases will be formulated separately by the municipal human resources and social security administration.
Medical insurance reimbursement process:
1, confirm the scope of reimbursement: in the process of treatment, you need to confirm whether your treatment items belong to the scope of reimbursement of medical insurance;
2, collect reimbursement materials: collect the relevant records of treatment, drug receipts, list of medical expenses and other related materials;
3, to the social security department for reimbursement: submit the relevant materials to the local social security department to handle reimbursement.
4. Waiting for the audit: the social security department will carry out relevant audits and comparisons to confirm the reimbursement rate and reimbursement amount; receiving the reimbursement payment: after the audit is approved, you can receive the reimbursement payment of the medical insurance at the designated bank.
In summary, the reimbursement rate for Neijiang's foreign medical treatment is 60%. The reimbursement rate of Neijiang medical insurance is 95% for hospitalization, 90% for hospitals of the first category, 90% for hospitals of the second category and 85% for hospitals of the third category, while general outpatient reimbursement is 85% for hospitals of the first category, 80% for hospitals of the second category and 75% for hospitals of the third category, with an annual limit of 4,500 to 5,500 yuan. The reimbursement rate of each regional health insurance is different, urban and rural residents living in a different place for a long time, men aged 60 years old, women aged 55 years old, urban and rural residents and urban and rural residents working in a different place, students and children living with them, for the record of registration for medical treatment in a different place, in the registration for the record of the hospitalization of hospitalization in a place of 400 yuan for the first level of hospitals, the second level of 800 yuan, three levels of 2000 yuan, reimbursement rate of the implementation of the The reimbursement rate is the same as the reimbursement rate for designated hospitals within Baoji city.
Legal basis:
Article 28 of the Social Insurance Law of the People's Republic of China
Medical expenses that are in line with the basic medical insurance drug catalog, diagnostic and therapeutic items, standards of medical service facilities, as well as those for emergency and rescue, shall be paid from the basic medical insurance fund in accordance with state regulations.
Article 29
The portion of the medical expenses of insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.
The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.