Nanjing urban workers' medical insurance is divided into different types such as outpatient, outpatient chronic and outpatient unified.
The scope of reimbursement for each type is as follows:
(1) Outpatient chronic diseases
1. If a participant suffering from one of the 41 chronic diseases of the three major categories (see Table 1 for details) goes to the designated hospital of his/her own choice to consult a doctor for his/her chronic disease, or goes to the designated pharmacy of his/her own choice to purchase medicines with a dispensing prescription, the outpatient and chronic indications' medical expenses incurred shall be paid by the participant if they fall within the minimum starting point, and subsidized in accordance with a certain percentage and limit if they exceed the minimum starting point. If the medical expenses incurred for outpatient chronic indications are within the starting standard, the insured person will pay for them out of his/her own pocket, while those exceeding the starting standard will be subsidized in accordance with a certain percentage and limit. The part to be paid by the individual is settled by the patient directly with the charge counter of the hospital or pharmacy, and the part to be paid by the coordinated fund is settled by the health insurance administration organization with the designated hospital or pharmacy on a monthly basis. The treatment standards are shown in Table 2.
Table 1 List of Outpatient Chronic Diseases
Table 2 List of Outpatient Chronic Diseases Treatment Standards
2. The cost of interferon alpha (including ordinary and long-acting) for outpatient antiviral treatment for patients with chronic hepatitis C is subject to a quota of subsidies. There is no starting standard for the subsidy, and the basic medical insurance fund pays 70% of the cost, with a maximum monthly payment limit of 3,200 yuan, beyond which the patient pays out of his/her own pocket. The monthly limit fee is valid for the same month, and is not rolled over or accumulated. During the period of interferon α treatment, patients can enjoy the treatment of hepatitis C "outpatient slow" at the same time, and the costs of its auxiliary examination, treatment and medication can be included in the scope of hepatitis C "outpatient slow" limit subsidy. The patient is not hospitalized at the same time to enjoy this outpatient limit subsidies.
Hepatitis C outpatient interferon alpha treatment to formulate the designated medical institutions are: Nanjing Second Hospital, the Chinese People's Liberation Army Eighth Hospital.
3, hemophilia according to light, medium and severe typing, the fund to pay 85% of the in-service, 90% of the retired, the payment limit of 10,000, 50,000 and 100,000 respectively.
(2) Outpatient Specific Items
The medical expenses for outpatient specific items incurred by outpatient specialists for outpatient special illnesses when they go to the designated hospital of their own choice for consultation or purchase medicines at the designated pharmacy of their own choice with an outpatient prescription, which are in line with the provisions of the basic medical insurance, shall be settled directly with the charging front desk of the designated hospital or designated pharmacy; Category B medicines and Category B diagnostic and therapeutic items shall be paid out of pocket by the insured persons first in accordance with the prescribed proportion, and the remaining portion shall be paid out of the fund in accordance with the prescribed proportion. Class B drugs and Class B diagnostic and therapeutic items are first paid by the insured person in accordance with the prescribed proportion, and the rest is paid in accordance with the provisions of basic medical insurance.
Table 3 Outpatient dialysis treatment for chronic renal failure
Table 4 Outpatient anti-rejection treatment after human organ transplantation
Table 5 Outpatient anti-rejection treatment after hematopoietic stem cell (allogeneic) transplantation
Table 6 Outpatient malignant neoplasm treatment treatment
(3) Outpatient co-ordination
1. Within a natural year, outpatient medical expenses incurred by insured persons in accordance with the regulations (except for outpatient expenses that have been included in the settlement of "outpatient slow" and "outpatient special") shall be paid by the insured persons individually for the expenses below the starting standard; the expenses above the starting standard and below the payment limit shall be paid by the co-ordination center for outpatient treatment. Costs above the starting payment standard and below the maximum payment limit shall be shared by the coordinated fund and the individual***.
Table 7: Standardized Treatment Table for Outpatient Coordination
2. Outpatient coordination implements a system of first consultation and referral based on community health service institutions. Participants can have their first consultation at the designated community health service institutions or medical institutions that refer to the community management of the basic medical insurance for urban employees; specialized hospitals can be the first medical institution for all participants. If a participant needs to be referred to a medical institution, the first medical institution shall be responsible for the referral, and emergency treatment and rescue are not subject to this limitation.
Table 8 Outpatient Coordination Referral Medical Institutions
The above hospitals must be referred by the first hospital to enjoy the outpatient coordination treatment, and emergency and rescue are not subject to this limitation.
3. After the outpatient chronic disease subsidy limit is used up, the outpatient coordinated treatment standard will be settled directly from the next expense, and there is no need to refer to the original outpatient fixed-point medical treatment for chronic diseases. After the limit of outpatient subsidies for specific items has been used up, referrals must be made in accordance with the provisions of the outpatient coordinating system and general medical records must be used in order to enjoy the outpatient coordinating treatment. Purchase of medicines at pharmacies is not eligible for outpatient coordinated treatment.
(4) Mental illnesses
1. Psychiatric patients (suffering from schizophrenia, moderate to severe depression, mania, obsessive-compulsive disorder, mental retardation accompanied by mental retardation, epilepsy accompanied by mental retardation, and paranoid psychosis, hereinafter referred to as the same), when they go to the outpatient clinic of the fixed-point hospital of their own choice due to a psychiatric illness, they are required to present a social security card and register for the "Medical Insurance Psychiatry Specialty". Medical Insurance Psychiatry Specialist" number. The psychiatric consultation and treatment fees (including examination and medication fees) incurred within the scope of the basic medical insurance payment do not require personal payment, and will be settled by the Municipal Social Security Center with the hospital in accordance with the stipulated standards.
2. Mental patients who need to be hospitalized for treatment of mental diseases are exempted from paying the hospitalization starting standard, and one-third of the medical expenses incurred within the scope of basic medical insurance which are paid by individuals according to the regulations are paid by one-third of each of the fund for medical aid for the major diseases, the employing unit and the individual. Medical expenses incurred by psychiatric patients for physical diseases are implemented in accordance with the provisions of basic medical insurance. Long-term personnel stationed abroad, outpatient psychiatric outpatient use of 160 yuan per month standard flat-rate package, issued annually through the unit to the individual.
(E) family bed
1. bed conditions
Participants who are bedridden for a long period of time and meet one of the following conditions: recovery from stroke paralysis, malignant tumors in advanced stages, fracture traction bed treatment, eligible for hospitalization of elderly people aged 70 years or older, the person himself or his family nearby to the qualification of the family hospital bed services to apply to the designated medical institutions, the physician examination and confirmation of diagnosis can set up a family bed. After examination and confirmation of diagnosis, home hospital beds can be set up.
2. Standard of treatment
There is no starting standard for home hospital beds, and the expenses incurred by patients who have set up home hospital beds that are within the scope of medical insurance will be paid by the medical insurance fund at the limit of the proportion of payment. During the period of setting up the family hospital bed, the outpatient system, outpatient slow, outpatient special treatment is suspended, outpatient psychiatric, outpatient AIDS, hospitalization treatment is normal. The specific standards are shown in Table 9.
Table 9 Individual burden ratio table for family hospital beds
(F) Hospitalization
The hospitalization expenses incurred by the insured persons are subject to a maximum payment of 180,000 RMB by the Basic Medical Insurance Coordination Fund within a natural year. The starting standard and Class B drugs, diagnostic and therapeutic items, services and facilities for the individual's proportionate share of the costs and the costs outside the scope of basic medical insurance shall be paid by the individual first, and the rest of the costs shall be shared by the coordinated fund and the individual **** together.
Table 10: Standard hospitalization treatment
(7) Medical assistance for major illnesses
The Medical Assistance Fund for Major Illnesses is mainly used to solve the medical expenses incurred by insured persons who are suffering from major illnesses or serious illnesses that are above the maximum payment limit of the Basic Medical Insurance Co-ordination Fund within a natural year. The scope and standard of payment of the fund are in accordance with the provisions of the basic medical insurance. For medical expenses above the maximum payment limit of the basic medical insurance co-ordination fund that are in line with the scope of medical insurance, the proportion of payment from the medical aid fund for major illnesses is 95%.
(H) Major Disease Insurance
Participants in a natural year, incurred within the scope of basic medical insurance payment of inpatient and outpatient specific items of medical expenses, on the basis of enjoying the basic medical insurance treatment, individual out-of-pocket expenses exceeding the starting standard of major disease insurance, major disease insurance will be paid in accordance with the provisions of the insurance.
The starting standard for major disease insurance is set at about 50% of the annual per capita disposable income of urban residents in the previous year (currently set at 20,000 yuan). The expenses above the starting standard are "calculated in sections and paid cumulatively", and there is no maximum payment limit. Specific measures are as follows:
20,000 yuan (excluding 20,000 yuan, the same below) to 40,000 yuan (including 40,000 yuan, the same below) part of the payment of 60%; 40,000 yuan to 60,000 yuan part of the payment of 65%; 60,000 yuan part of the payment of 70% to 80,000 yuan part of the payment of 70%; 80,000 yuan part of the payment of 75% to 100,000 yuan part of the payment of 80% of the payment of 100,000 yuan part of the payment of more than 80%.
Participants who are eligible for medical assistance, after enjoying the benefits of major medical insurance, enjoy medical assistance. For eligible persons in difficulty, the starting standard for major disease insurance is 10,000 yuan, and the reimbursement rate for each cost section is increased by 5%.
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