The scope and proportion of medical insurance reimbursement for urban residents in Shenyang
First, the scope and proportion of outpatient reimbursement
(1) The disease scope specified by outpatient department: diabetes (with one complication), type I diabetes (students and minors only), hypertension complications, old myocardial infarction of coronary heart disease and anticoagulation treatment within one year after PCI(PTCA), dialysis treatment for uremia, anti-rejection treatment after organ transplantation, radiotherapy and chemotherapy for malignant tumor (bladder perfusion only), myasthenia gravis, polymyositis and dermatomyositis. Psoriasis (pustular psoriasis, arthropathy psoriasis, erythroderma psoriasis), myelodysplastic syndrome, polycythemia vera, Behcet's disease, aplastic anemia, hemophilia, chronic hepatitis B and its compensatory cirrhosis (antiviral therapy), chronic hepatitis C (antiviral therapy), antineoplastic drug therapy for malignant tumors, cor pulmonale (cardiac function grade 3) and rheumatic heart disease (cardiac function grade 3). Schizophrenia, anticoagulant therapy after other vascular stents, coronary artery bypass grafting, chronic renal insufficiency (decompensated period), pituitary prolactin's tumor, pituitary hypofunction, progressive supranuclear paralysis, epilepsy.
; (2) List of payment proportion of outpatient co-ordination fund.
(three) outpatient diseases and treatment standard table.
Table of prescribed diseases and treatment standards in outpatient department
Remarks on the number of diseases (yuan)
Employees (quota) and residents (quota)
Diabetes complications 360/ month (quota) 1000/ year
Type I diabetes 1000/ year is limited to minors such as students.
Hypertension complications (phase III) 360/ month (quota) 1000/ year
Old myocardial infarction of coronary heart disease 360/ month (quota) 1000/ year
Chronic renal insufficiency (decompensated period) is 350/ month 1000/ year.
Chronic hepatitis C (antiviral therapy) 3000/ month 10000/ year 12 months.
Chronic hepatitis B and its compensated cirrhosis (antiviral therapy) 350/ month 1000/ year.
Anticoagulation (PTCA) was 1 year after PCI and 12 months after PCI.
Uremic hemodialysis 5000+600/ month (special third-class quota) 10000/ year, the proportion of on-the-job self-payment in special third-class hospitals 15%, retirement10%; Other hospitals 13% are working and 8% are retired.
4700+600/ month (other hospital quota)
Uremic peritoneal dialysis 4500+600/ month (quota) 10000/ year.
After organ transplantation, the rejection rate decreased from 7560/ month (quota); From the 25th month, 3708/ month, 10000/ year.
According to the fact of bladder perfusion treatment in malignant tumor clinic/month 3000/ year
According to the number of radiotherapy patients per month and 5000/ year in outpatient department of malignant tumor.
The anticoagulation therapy after other vascular stents was 350/ month, 1000/ year, and 12 months after operation.
350 months after CABG 1000+02 months after CABG.
Anti-tumor drug therapy for malignant tumor is 350/ month 1000/ year
Myasthenia gravis 350/ month 1000/ year
Polymyositis and Dermatomyositis 350/ month 1000/ year
Systemic lupus erythematosus 350/ month 1000/ year
Psoriasis (pustular type, arthropathy type and erythroderma type) is 350/ month 1000/ year.
Myelodysplastic syndrome 350/ month 1000/ year
Polycythemia vera 350/ month 1000/ year
Behcet's disease 350/ month 1000/ year
Aplastic anemia 350/ month 1000/ year
Severe hemophilia: 4,200 yuan/month; Severity of hemophilia: 2 100 yuan/month.
Medium: 1700 yuan/month; Medium: 850 yuan/month.
Light: 850 yuan/Moonlight: 430 yuan/Moon
Pulmonary heart disease (heart function grade 3) 350/ month 1000/ year.
Rheumatic heart disease (heart function grade 3) 350/ month 1000/ year
Rheumatoid arthritis 350/ month 1000/ year
Schizophrenia 350/ month 1000/ year
Pituitary prolactin tumor 350/ month 1000/ year.
The function of anterior pituitary gland decreased by 350/ month 1000/ year.
Progressive supranuclear paralysis 350/ month 1000/ year
Epilepsy 350/ month 1000/ year
Endocrine therapy for breast cancer 1000/ month 5000/ year
Endocrine therapy for prostate cancer 1000/ month 5000/ year
Parkinson's disease 350/ month 1000/ year
Anti-tuberculosis drug therapy for tuberculosis 150/ 800/ year1February.
Ankylosing spondylitis 350/ month 1000/ year
Remarks: 1. Except dialysis, the reimbursement rate of employees is 75% in service and 85% in retirement; Residents account for 85% of the community; Level 1 80%; 70% of secondary schools; Level 3 60%; Santer 55%;
Second, the scope and proportion of hospitalization reimbursement
(1) range
1. Hospitalization in designated medical institutions;
2. Being hospitalized in non-designated medical institutions due to emergency rescue;
3. After examination and approval, transfer to other places for hospitalization;
4. Non-local registered students return to their places of residence during the winter and summer vacations and legal holidays, during their field practice, or are hospitalized due to illness during their field practice;
5. Hospitalization due to unexpected events during going out.
(2) Proportion
List of reimbursement ratio of hospitalization medical expenses of basic medical insurance for urban residents in Shenyang
(3) Precautions
1. The reimbursement ratio of the overall fund does not include the first-time out-of-pocket part of class B drugs, class B diagnosis and treatment projects and medical service facilities, and the out-of-pocket part of class C drugs, class C diagnosis and treatment projects and medical service facilities.
2. Qifubiaozhun refers to the amount of hospitalization expenses that must be paid by individuals before the start of the overall fund (excluding the expenses paid by individuals and the expenses for class B drugs and special examination and treatment). Mental illness, acute and chronic infectious hepatitis, infiltrative pulmonary tuberculosis and chronic fibrocavernous pulmonary tuberculosis do not have the minimum threshold for pooling funds. Patients with malignant tumors who have been hospitalized for many times in a natural year only need to pay the Qifubiaozhun for the first hospitalization every year.
Third, the proportion of reimbursement for family beds.
(1) conditions and scope
Insured persons suffering from family sickbed diseases can apply for family sickbeds if they meet the hospitalization conditions, can't take care of themselves completely, have difficulties in hospitalization in designated hospitals and need systematic treatment.
Scope of disease: cancer (advanced stage); Diabetic complications; Cardiovascular and cerebrovascular diseases and complications; Chronic pulmonary heart disease; Mental illness.
List of reimbursement ratio of medical expenses for family beds of urban residents in Shenyang
Fourth, the proportion of reimbursement for serious illness medical insurance.
(a) Protection of the population
Anyone who participates in the basic medical insurance for urban residents in Shenyang belongs to the range of people covered by the serious illness insurance for urban residents in our city.
(2) Funding criteria
The funding standard for serious illness insurance is 20 yuan per person per year, which is allocated by the basic medical insurance fund for urban residents, and individuals do not pay.
(iii) Scope of protection
In the natural year, the medical expenses incurred by insured residents due to outpatient (emergency) diagnosis and rescue (including observation and death), family sickbed, hospitalization (including transfer, long-term living away from home and going out for emergency) that meet the basic medical insurance policy and exceed the critical illness insurance deductible line of 6,543,800 yuan or more belong to the scope of urban residents' critical illness insurance treatment. There is no capping line for the compensation amount of serious illness insurance for urban residents.
(4) Compensation ratio
Critical illness insurance Compensation Proportion List
Note: Students and other minors suffering from six diseases, such as leukemia, congenital heart disease, aplastic anemia, hemophilia, cerebral palsy and congenital deafness, are entitled to basic medical insurance and critical illness insurance in turn according to relevant regulations. The compensation ratio of medical expenses for these six diseases stipulated in their critical illness policies will be settled manually by the commercial insurance company undertaking critical illness insurance in June of the following year at 5438+ 10, with the highest compensation ratio of 90.