I. Reimbursement Procedures for Employee Medical Insurance
1. Participants must present their Citizen Cards for outpatient and hospitalization visits and swipe the cards for outpatient visits, and inform the hospitals of the types of visits (e.g., outpatient chronic diseases, outpatient specialties); the medical insurance fund will not pay for medical expenses incurred by the insured employees when they visit the hospitals if they do not present their cards or if they are not informed of the types of visits.
2, the insured person in the designated retail pharmacies to buy drugs, must present their own citizen card, informed of the type of consultation (such as outpatient chronic diseases, outpatient special), in accordance with the relevant policies of the card to purchase drugs, due to special circumstances by others to purchase drugs, must present the insured person and the identity card of the person who purchased drugs and the pharmacy registered for the record.
3. Outpatient coordination is based on the first consultation and referral system of community health service organizations. Participants in the basic medical insurance for urban workers designated community health service institutions or reference community management of medical institutions for the first visit; specialist hospitals can be the first visit to all participants medical institutions. If a participant needs to be referred, the first medical institution shall be responsible for the referral, and emergency treatment and rescue are not subject to this limitation.
After the outpatient chronic disease subsidy limit is used up, the outpatient treatment will be directly applied from the next payment, and no referral is needed for chronic diseases in the original outpatient fixed-point medical treatment. After the limit of outpatient subsidy for specific items has been used up, you must go through the referral procedures and use the general medical records according to the provisions of the outpatient coordination in order to enjoy the treatment of outpatient coordination. Purchasing medicines at pharmacies is not eligible for outpatient coordinated treatment.
Second, the employee health insurance reimbursement rate
First, the employee health insurance reimbursement rate in the tertiary hospitals are:
1. For the starting standard of 30,000 yuan of medical fees, the basic health insurance fund pays 85%, and the individual employee pays 15%;
2. For the part of the amount that is greater than 30,000 yuan to 40,000 yuan, the basic health insurance fund pays up to 90%, and the individual employee pays 15%. fund can pay up to 90%, and individual employees need to pay 10%;
3. For medical fees exceeding 40,000 yuan, the coordinating fund can pay 95%, and individual employees pay 5%.
Secondly, the reimbursement ratio of employee medical insurance incurred in secondary hospitals is as follows:
1. For the portion of the starting standard up to 30,000 yuan, the coordinated fund can pay up to 87 percent, and the individual employee pays up to 13 percent;
2. When the medical fee is greater than 30,000 yuan and up to 40,000 yuan, it will be paid by the coordinated fund at 92 percent, and the individual employee will pay 8 percent;
3. More than 40,000 yuan, the basic medical insurance fund can pay up to 97% of the high, individual employees pay only 3%.
Thirdly, the reimbursement rate for employees' medical insurance in first-class hospitals and home hospital beds is as follows:
1. For the portion of the starting standard up to 30,000 yuan, the basic medical insurance fund pays 90%, and the individual employee pays 10%;
2. For the portion of the amount that exceeds 30,000 yuan, or even 40,000 yuan, the fund pays up to a maximum of 95%, and the individual employee pays only 5 percent;
3.
3. For the part exceeding 40,000 yuan, the basic medical insurance fund pays 97 percent and the individual employee pays 3 percent.
Fourth, the individual payment rate for retirees is only a 60% share of the employee's payment rate.
If the first paragraph of the basic medical insurance fund payment ratio needs to be adjusted, it is necessary for the municipal labor security administrative department in conjunction with the municipal finance department to put forward an adjustment plan, reported to the municipal people's government for approval after the announcement of the implementation.
Expanded information:
Basic medical insurance is, in principle, co-ordinated in administrative regions above the prefecture level (including prefectures, cities, states, and leagues), or in counties (cities), with the three municipalities directly under the central government of Beijing, Tianjin, and Shanghai co-ordinating the insurance in principle on a city-wide basis (hereafter The three municipalities of Beijing, Tianjin and Shanghai are in principle coordinated on a city-wide basis (hereinafter referred to as coordinated areas).
All employers and their employees are required to participate in the basic medical insurance of the coordinated area in accordance with the principle of local management, and to carry out unified policies and the unified collection, use and management of the basic medical insurance fund. Railroad, electric power, ocean transportation and other cross-region, production mobility of enterprises and their employees, can be relatively centralized way to participate in the integrated region of the basic medical insurance.
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