1, hospitalization reimbursement
Employees: medical expenses between 1300 yuan -30,000 yuan (including 30,000 yuan), the reimbursement rate of 85%; medical expenses between 30,000 yuan -40,000 yuan (including 40,000 yuan), the reimbursement rate of 90%; medical expenses between 40,000 yuan -100,000 yuan (including 100,000 yuan), the reimbursement rate of 95%; medical expenses between 100,000 yuan -300,000 yuan (including 300,000 yuan), the starting threshold for hospitalization reimbursement is 85%. The reimbursement rate is 95%; medical expenses between 100,000 yuan and 300,000 yuan (including 300,000 yuan), the reimbursement rate is 85%, and the starting line for hospitalization reimbursement is 1,300 yuan.
Retirees: the reimbursement rate is 91% for medical expenses between 1,300 yuan and 30,000 yuan (including 30,000 yuan); the reimbursement rate is 94% for medical expenses between 30,000 yuan and 40,000 yuan (including 40,000 yuan); the reimbursement rate is 97% for medical expenses between 40,000 yuan and 100,000 yuan (including 100,000 yuan); and the reimbursement rate is 97% for medical expenses between 100,000 yuan and 300,000 yuan (including 300,000 yuan), the reimbursement rate is 90%, and the starting line for hospitalization reimbursement is 1,300 yuan.
2. Outpatient Reimbursement
Active employees: 90% reimbursement for community outpatient services and 70% reimbursement for non-community outpatient services. The starting line for outpatient reimbursement is 1,800 yuan, and the maximum reimbursement limit is 20,000 yuan. Retirees: aged under 70, 90% reimbursement for community outpatient visits and 85% reimbursement for non-community outpatient visits; aged over 70, 90% reimbursement for community outpatient visits and 90% reimbursement for non-community outpatient visits, with a starting line of 1,300 yuan and a limit of 20,000 yuan for reimbursement.
The drugs reimbursed by the insurance are specific, only drugs within the health insurance catalog can be reimbursed, while for drugs outside the health insurance catalog can not be reimbursed.
Reimbursement scope
Medical expenses for outpatient and emergency treatment;
Expenses for purchasing medicines at designated retail pharmacies;
Medical expenses within 7 days of hospitalization before hospitalization for those who have been hospitalized for emergency rescue and stayed in hospital;
Medical expenses for outpatient treatment of malignant tumors for radiation therapy and chemotherapy, renal dialysis, and anti-rejection medicines after renal transplantation.
The following items are excluded from the reimbursement of urban workers' medical insurance:
(i) Service item category.
(1) registration fee, out-of-hospital consultation fee, medical record cost, etc.;
(2) special medical services such as consultation fee, expedited fee for examination and treatment, surcharge for named surgery, quality and premium fee, and self-invited special nurses.
(2) The category of non-disease treatment programs.
(1) all kinds of beauty, fitness and non-functional cosmetic and orthopedic surgery;
(2) all kinds of weight loss, weight gain, height increase program.
(3) Health checkups;
(4) Preventive and health care programs;
(5) Medical consultations and appraisals.
(3) Diagnostic and treatment equipment and medical materials
Employee production, outpatient and inpatient medical expenses reimbursement ratio is different, and they both have a starting standard, over which medical expenses can be reimbursed. Not all medical items are eligible for reimbursement, and health insurance will not reimburse expenses for items such as cosmetic items, physical examinations and medical appraisals.
Legal basis:
Notice of the Ministry of Labor and Social Security, the State Development Planning Commission and the State Economic and Trade Commission on the issuance of the Interim Measures for the Management of the Scope of Medicines Used in the Basic Medical Insurance for Urban Employees
Article 8: The expenses incurred by the basic medical insurance participants for the use of medicines listed in the Medicines Catalogue shall be paid in accordance with the principle of "under". Expenses incurred for the use of drugs in the "Class A Catalog" shall be paid in accordance with the provisions of the basic medical insurance. Expenses incurred for the use of drugs in the "Class B List" will be paid by the insured person at a certain percentage of his/her own expense, and then paid in accordance with the provisions of the basic medical insurance. The specific proportion of out-of-pocket payment by individuals shall be stipulated by the coordinating area and reported to the labor security administrative departments of provinces, autonomous regions and municipalities directly under the central government for the record. The costs incurred in the use of Chinese medicine tablets, except for the basic medical insurance fund does not pay for the drugs, are paid in accordance with the provisions of the basic medical insurance.
The Social Insurance Law of the People's Republic of China
Article 23: Employees shall participate in the basic medical insurance for employees, and the employer and the employee shall pay the basic medical insurance premiums in accordance with the provisions of the State **** the same.
Individual industrial and commercial households without employees, part-time employees who do not participate in the basic medical insurance for employees at their employing units, and other flexibly employed persons may participate in the basic medical insurance for employees, and individuals shall pay the basic medical insurance premiums in accordance with the state regulations.
Article 26: The standards of treatment for basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be carried out in accordance with the provisions of the State.
Article 27: Individuals who have participated in the basic medical insurance for employees, and whose accumulated contributions have reached the number of years stipulated by the state when they reach the legal retirement age, shall no longer pay the basic medical insurance premiums after retirement, and shall enjoy the basic medical insurance benefits in accordance with the state regulations; those who have not reached the number of years stipulated by the state may pay contributions up to the number of years stipulated by the state.
Article 28: Medical expenses in accordance with the basic medical insurance drug list, diagnostic and treatment items, medical service facility standards, as well as emergency and rescue, shall be paid from the basic medical insurance fund in accordance with state regulations.