The reimbursement ratios of medical insurance for urban residents are as follows:
1. The starting line is 300 yuan/trip for one type of medical institution, 600 yuan/trip for two types of medical institutions, and 1,200 yuan/trip for three types of medical institutions;
2. The reimbursement ratios are 95% for one type of medical institution, 90% for two types of medical institutions, and 85% for three types of medical institutions, of which the fund pays 90% for malignant tumor The fund pays 90% for hospitalization for surgical treatment of malignant tumors, surgical treatment of heart and brain diseases, and surgical treatment of liver, kidney and bone marrow transplantation.
3. Reimbursement rate for specific outpatient diseases:
(1) The reimbursement rate is the same as that for hospitalization, with no starting line. 95% for first-class medical institutions, 90% for second-class medical institutions, and 85% for third-class medical institutions (of which 90% is paid for malignant tumor radiotherapy, chemotherapy, and thermotherapy, and outpatient dialysis treatment for uremia and other serious illnesses) are paid up to the limit standard;
(2) the annual limit is divided into three grades, with the low-grade limit of 4,500-5,500 yuan, the mid-grade limit of 40,000-45,000 yuan, and the high-grade limit of 100,000 yuan.
Medical insurance reimbursement rate process
1, medical insurance, whether urban workers' medical care or urban residents' medical care, the first need to be hospitalized according to the local health insurance agency approved by the local sentinel medical institutions;
2, if you need to go to other medical institutions for treatment, you need to go to the local community hospitals or community health service centers or fixed-point medical institutions to issue a referral certificate;
3. If you are hospitalized in a local health insurance designated medical institution, the hospital will automatically deduct the part of the medical insurance reimbursement when you are discharged from the hospital;
4. If you are not hospitalized in a local health insurance designated medical institution or if you are in the hospital for radiation therapy, chemotherapy or the like, and have not been reimbursed by the hospital, you can bring the official invoice, medical diagnosis, medication details, and the medical certificate from the hospital to the hospital. diagnosis, medication details, social security card or medical card to the local administrative service center health insurance window for reimbursement;
5, if the treatment is carried out in other medical institutions, there is a referral certificate, after discharge, or not discharged from the hospital must be in the annual December 31st all the treatment invoices, hospital diagnosis, hospitalization certificates, ID cards, social security cards, medication details, medical records and so on. The household (health insurance) location of the health insurance window for reimbursement;
6, if there is no proof of referral or direct medical treatment in a different place (sometimes the situation is urgent or the distance is too far from the timely issuance of proof of referral), in this case, you need to go to the community where you live to issue a certificate of residence, for example, whether it is a rented place, or live with their children, and so on. You can bring all the documents in step 5, plus the proof of residence, with you when you make a reimbursement.
When does the health insurance take effect after payment?
How long does it take for health insurance to take effect after you pay the premiums is determined on a case-by-case basis, as follows:
1. The effective date of the first enrollment in basic health insurance is the month following the month in which you enroll. The following month, the local tax department confirms that the participant has paid the basic medical insurance premiums, then the first day of the month to take effect. It should be reminded that before the basic medical insurance comes into effect, the insured person's medical insurance is the responsibility of the unit;
2. The effective time of the continuation of the basic medical insurance relationship. For the original unit for the basic medical insurance reduction procedures, the following month for the renewal procedures, and at the same time to the local tax department to pay the basic medical insurance premiums from the month of renewal, its basic medical insurance benefits will not be interrupted; interruption of the payment of premiums, the basic medical insurance benefits from the local tax department to the basic medical insurance premiums of the participants levied to the participants of the basic medical insurance premiums from the first of the month to take effect.
3. Special circumstances of basic medical insurance. If a participant fails to pay the medical expenses by credit card due to the delay in registration and collection of premiums, the participant shall pay the medical expenses with the payment voucher signed and stamped by the local tax department; and if there is a delay in the production of social security card, the participant shall pay the medical expenses with the payment voucher signed and stamped by the social security institution's card department and the proof of payment by the individual, and then the participant shall go to the corresponding social security organization to settle the medical expenses after the treatment takes effect according to the medical insurance regulations. expenses.
3, commercial medical insurance effective time. The effective time of commercial medical insurance is usually 30 days to 180 days, or 1 year.
(1) General hospitalization medical insurance: the effective time is 30 days to 90 days;
(2) Some long-term critical illness insurance: the effective time may reach 90 days, 180 days or even 1 year.
Legal basis: Article 23 of the Social Insurance Law of the People's Republic of China
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 state regulations*** together.
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 27
Individuals who have participated in the basic medical insurance for employees, and whose accumulated contributions have reached the state-provided number of years by the time 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 provisions; if the state-provided number of years has not been reached, the individual may pay the premiums up to the state-provided number of years.