Suzhou health insurance reimbursement ratio:
1. General outpatient medical expenses (excluding outpatient specific item medical expenses) that meet the provisions of the Suzhou health insurance insurance settlement will be paid from the individual account first. After the individual account is exhausted, within each settlement year (April to March of the following year), the local supplementary medical insurance co-ordination fund will settle the expenses proportionally within the limit of 2,500 yuan (excluding the above mentioned amount of deductibles), after the individual deductibles of 600 yuan for active employees (including flexibly-employed insured persons and "co-insured" persons) and 400 yuan for retired persons are paid. proportionate settlement. Among them: outpatient expenses incurred in urban B-level and above designated community health service stations (centers), outpatient clinics (clinics), unit health clinics and township hospitals using the Social Insurance Card are settled at 70% for active employees and 80% for retirees; outpatient expenses incurred in other B-level and above designated medical institutions and designated retail pharmacies in urban areas are settled at 60% for active employees and 70% for retirees. The standard settlement.
2. Each time a participant of the Suzhou Health Insurance is hospitalized, he/she will be responsible for the medical expenses up to the starting standard, and the balance of his/her personal account in previous years can be used to offset the expenses.
1) Suzhou health insurance participants in the settlement year (April to March) the first hospitalization starting standard according to different levels of hospitals were determined, municipal and municipal hospitals: active employees (including flexible employment participants, "co-insurance" personnel, the same below) 800 yuan, retirees 700 yuan; district (county) level hospitals, specialized hospitals, the hospitals, the hospitals, the hospitals, the hospitals, the hospitals, the hospitals, the hospitals and the hospitals. ) level hospitals, specialized hospitals: 600 yuan for active employees, 500 yuan for retirees; townships and other grass-roots hospitals: 400 yuan for both active employees and retirees.
(2) The starting standard for the second hospitalization in the current year is 50% of the initial starting standard; the starting standard for the third or more hospitalizations is unified at 200 yuan.
(3) In case of consecutive hospitalization exceeding 180 days, every 180 days will be billed as one hospitalization, and the portion exceeding 180 days will be treated as re-hospitalization.
(4) For insured persons who seek medical treatment at Guangji Hospital, Psychiatric Rehabilitation Hospital, Hi-tech Zone Ankang Hospital and Taicang Ankang Hospital in the city and are diagnosed with mental illness and hospitalized for treatment, the hospitalization expenses incurred in accordance with the provisions of the medical insurance settlement shall not be subject to any starting standard and shall be settled directly in accordance with the method of hospitalization sectional settlement.
(5) In case of consecutive inpatient hospitalization due to the need for intra-city transfer of medical conditions, the starting payment standard of the higher level hospitals can be combined and calculated at the Municipal Social Security Center with the settlement vouchers and invoices after discharge from the hospital.
Settlement Methods
Participants holding their own social security cards and medical records will only be required to pay for the expenses borne by the individual (including the individual's own portion and the individual's out-of-pocket expenses) when they seek outpatient treatment at a designated medical institution, and the rest of the expenses will be settled between the Municipal Social Security Center and the designated medical institution in accordance with the relevant regulations.
Precautions
1. When purchasing medicines on an outpatient basis, the insured person should take the initiative to present his social security card and medical records; the purchase and dispensing of prescription medicines should be accompanied by a prescription issued by a licensed physician at the designated unit. Because I can not be present, entrusted to another person to do, in addition to the commissioner's social security card, medical records, should also be issued at the same time the commissioner and the commissioner's valid identity documents.
2. The insured person's outpatient medical treatment in the designated outpatient medical institutions in Suzhou city (including community health service institutions, outpatient clinics, clinics, unit health centers) shall not be settled by real-time card more than three times a day (if more than three times, the medical insurance fund shall not be settled); and if the dispensing of medicines for a single prescription is more than RMB 200 yuan, the relevant information shall also be registered.
3. Participants suffering from severe mental illness (including schizophrenia, major depression, mania with psychotic symptoms, bipolar disorder, paranoid psychosis, schizoaffective psychosis, mental retardation with mental disorders, mental disorders caused by epilepsy), aplastic anemia, hemophilia, or need to carry out dialysis for uremia, chemotherapy and radiotherapy for malignant tumors, and anti-rejection drug treatment after organ transplantation. Those who need to undergo uremic dialysis, chemotherapy and radiotherapy for malignant tumors, anti-rejection drug treatment after organ transplantation, or intend to undergo ultrasonic emulsification and IOL implantation for simple senile cataract can enjoy the medical treatment for the corresponding outpatient specific items after completing the procedures of diagnostic recognition of the specific items and registration confirmation in accordance with the relevant laws and regulations.
4. For the insured persons who are eligible for real-time medical aid and whose medical aid declaration and registration procedures have been completed by the Federation of Trade Unions, the outpatient medical expenses incurred in the urban aid medical institutions shall be subsidized by the medical aid funds at the rate of 85% of the outpatient medical expenses incurred on the basis of the above medical insurance treatment and the out-of-pocket portion of the medical aid within the limit of 2,000 yuan for each billing year. On the basis of the medical insurance treatment of organ transplantation anti-rejection drug treatment, chemoradiotherapy of malignant tumors, uremia dialysis outpatient specific items of medical treatment of the insured, not subject to the limit of 2,000 yuan, and its outpatient medical costs of the out-of-pocket portion of the medical aid funds were subsidized at a rate of 85%, 90%, and 95%, respectively.
Legal basis:
The People's Republic of China *** and the State Social Insurance Law, Article 28 provides that: in line with the basic medical insurance drug directory, diagnostic and therapeutic items, medical service facilities standards, as well as emergency and rescue medical expenses, in accordance with state regulations from the basic medical insurance fund to pay.
Article 29 of the Social Insurance Law of the People's Republic of China stipulates that the portion of the medical expenses of insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.
Social insurance administrative departments and health administrative departments should set up a system for settling medical expenses for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.
Article 48 of the Measures for the Administration of Social and Basic Medical Insurance in Suzhou stipulates that the social and basic medical insurance fund shall settle the medical expenses of the insured persons in two ways, namely, immediate settlement and sporadic reimbursement.
Participants holding a social security card in the designated medical institutions to purchase medicines for immediate settlement of costs, social insurance agencies and designated medical institutions to settle directly with the basic social medical insurance fund to pay the part of the insured person to pay out-of-pocket expenses and out-of-pocket expenses.
If immediate settlement is not possible due to one of the following circumstances, the insured person, after advancing the relevant medical expenses, can go to the social insurance agency for piecemeal reimbursement with his/her social security card, records of medical records, detailed lists of expenses, and settlement documents and other materials:
(1) The insured person who has applied for long-term residence outside the city for medical treatment, and medical expenses incurred in the designated medical institutions during the period of residence; medical expenses incurred in the designated medical institutions due to (a) The medical expenses incurred at designated medical institutions during the period of stay abroad by the insured person who has applied for long-term overseas medical procedures; the hospitalization medical expenses incurred after being diagnosed by a hospital at or above the municipal level and going through the procedures of transferring to a tertiary hospital or a hospital where the national key specialties are located due to the fact that the insured person suffers from a difficult and serious disease which cannot be diagnosed and treated under the conditions of the medical technology and equipment in the city. The administrative measures for the transfer of insured persons to out-of-home medical treatment shall be separately formulated by the social insurance administrative department.
(2) Medical expenses incurred in non-specified medical institutions due to sudden acute, critical or serious illnesses; emergency and first-aid medical expenses incurred in overseas medical institutions due to sudden acute, critical or serious illnesses during the period of going out.
(3) Other cases stipulated by the social insurance administrative department.
Reimbursement procedures shall be handled within the settlement year in which the medical expenses were incurred, and if reimbursement needs to be made across years, it can be extended to the end of the next settlement year. The above medical expenses incurred by the insured person shall be included in the annual accumulation of the reimbursement and settlement procedures.