First, hospitalization medical insurance benefits, basic medical expenses above Qifubiaozhun, pooling funds to pay according to the following proportion:
(1) Minors and students at school are paid according to the proportion of 85% in first-class medical institutions, 75% in second-class medical institutions and 65% in third-class medical institutions.
(2) Other urban and rural residents pay 85% in primary medical institutions, 70% in secondary medical institutions and 55% in tertiary medical institutions.
Two, outpatient treatment of chronic diseases, the insured in accordance with the provisions of the outpatient designated chronic disease outpatient specialist drug costs, the overall fund according to the proportion of primary medical institutions to pay 70%, other designated medical institutions to pay 50%. Co-ordinate the fund to pay the highest 50 yuan per person per disease month, and the excess will be paid by the insured.
Three, outpatient medical insurance benefits, the insured in accordance with the provisions of the general outpatient drug costs, paid by the overall fund in accordance with the following provisions:
(a) minors and students in the selected primary medical institutions for medical treatment according to the proportion of 80% payment; Within 30 days after referral from designated medical institutions at the grass-roots level, other designated medical institutions and designated specialized medical institutions pay 50% for medical treatment; Without referral from designated medical institutions at the grass-roots level, 40% will be paid directly to other designated medical institutions and designated specialized medical institutions for medical treatment.
(two) other residents in the selected primary medical institutions outpatient treatment according to the proportion of 60% payment.
(three) the insured in the implementation of the basic drug system approved by the health department, and the implementation of the zero-difference sales of basic drugs in designated medical institutions for medical treatment, the general medical expenses paid 70%.
(four) the overall fund to pay for the general outpatient medicine, minors and students per year does not exceed 65,438+0,000 yuan, other urban and rural residents per year does not exceed 600 yuan.
Loss reporting and replacement:
The insured shall properly keep the personal account card, and if it is damaged, it needs to be replaced with a new card, and the expenses shall be borne by the individual. If the personal account card is lost, it should be reported to the medical insurance agency or designated unit with relevant documents in time, and the medical insurance agency should immediately seal the account. If you can't find it within 30 days, you should apply for a new card at your own expense. The medical expenses incurred during the loss reporting period shall be paid in cash by the employee's personal account. If the personal account card is fraudulently used before reporting the loss, the insured shall bear the loss.
When the insured person purchases medicine for medical treatment and uses a card to settle medical expenses, the designated medical institutions and pharmaceutical service personnel should carefully verify, and those who find forged or fraudulently use the loss reporting card should be detained immediately, and the social medical insurance agency should be notified. Designated medical institutions and pharmacies shall not refuse the funds in the card or exchange cash for the cardholder.
Legal basis:
Article 28 of People's Republic of China (PRC) Social Insurance Law: Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.