1. Basic medical insurance
The basic medical insurance fund and individual account have their own scope of payment and are accounted for separately. Medical expenses eligible for payment by the basic medical insurance fund will be reimbursed in accordance with the basic medical insurance drug list, diagnosis and treatment item list, and the scope of service facilities and payment standards stipulated by the city.
The individual account pays for the following medical expenses: outpatient and emergency medical expenses; expenses for purchasing medicines at designated retail pharmacies; medical expenses below the starting standard of the basic medical insurance fund; medical expenses exceeding the starting standard of the basic medical insurance fund, which should be borne by the individual according to the proportion. The portion of medical expenses not covered by the individual account shall be paid by the individual himself/herself.
The basic medical insurance co-ordination fund pays for the following medical expenses: medical expenses for hospitalization; medical expenses within 7 days of hospitalization for those who are hospitalized after emergency rescue and hospitalization; and outpatient medical expenses for malignant tumor radiation therapy and chemotherapy, renal dialysis, and anti-rejection medicine after kidney transplantation.
The basic medical insurance fund shall not pay for the following medical expenses: medical treatment at a medical institution other than the designated medical institution, except for emergency treatment; purchase of medicines at a retail pharmacy other than the designated pharmacy; injuries caused by traffic accidents, medical malpractice or other accidents of responsibility; injuries caused by drug abuse, fights and brawls, or other illegal behaviors; treatments for suicide, self-inflicted injury or alcoholism; and medical treatment in a foreign country or in Hong Kong or Macao Special Administrative Region, as well as in a foreign country or in the Macao Special Administrative Region. Hong Kong, Macao Special Administrative Region and Taiwan for treatment; in accordance with national and municipal regulations should be paid by the individual.
Medical expenses incurred by an enterprise employee who is injured at work or suffers from an occupational disease shall be carried out in accordance with the relevant provisions of the Workers' Compensation Insurance. Medical expenses for the birth of a female employee shall be implemented in accordance with the relevant provisions of the State and the city.
The starting standard for payment by the Basic Medical Insurance Co-ordination Fund is set at about 10% of the average wage of the city's employees in the previous year. For medical expenses incurred by an individual for the second and subsequent hospitalizations within a year, the starting standard for payment by the basic medical insurance co-ordination fund shall be determined at about 5% of the average salary of the employees in the city in the previous year. The cumulative maximum payment limit of the basic medical insurance coordinating fund for the medical expenses of the employees and retirees in a year is determined at about 4 times the average salary of the employees in the city in the previous year.
In a settlement period (the settlement period is set according to the time of hospitalization of the employees and retirees, radiotherapy and chemotherapy for malignant tumors, kidney dialysis, and outpatient treatment with anti-rejection drugs after kidney transplantation). The medical expenses incurred by the employees and retirees within are calculated in segments and paid cumulatively according to the level of the hospital and the amount of the expenses, and are shared proportionally by the Basic Medical Insurance Co-ordination Fund and the individuals.
In order to alleviate the burden of kidney dialysis, kidney transplant, malignant tumor and psychiatric patients and to ensure their basic medical care, certain medicines will be paid by the Basic Medical Insurance Coordination Fund. Such as kidney dialysis patients in the outpatient clinic due to the need of the condition, the examination, treatment and the use of related drugs; kidney transplantation anti-rejection treatment patients, in the outpatient clinic due to the need of the condition, the examination, treatment and the use of related drugs; malignant tumors in the outpatient clinic during radiation therapy, chemotherapy, due to the need of the condition, the use of adjuvant treatment of traditional Chinese medicine costs are also included in the basic medical insurance co-ordination fund to pay the scope. In addition, psychiatric patients will receive more favorable treatment. In addition, psychiatric patients will be given more favorable conditions, psychiatric patients hospitalized in psychiatric hospitals and psychiatric wards of general hospitals, within a year, only once the starting standard fees of the integrated fund, and reduce the starting standard by 50%.
2. Scope of reimbursement of the coordinated medical expenses for major illnesses
The medical expenses for one-time hospitalization of employees and retirees for illnesses or injuries not caused by work, or the accumulated medical expenses over 2,000 yuan within 30 days, fall within the scope of the coordinated medical expenses for major illnesses.
But medical expenses incurred under one of the following circumstances are not covered by the medical expense coordination for major illnesses: unauthorized treatment in non-designated hospitals (except for emergency rescue); occupational diseases, work-related injuries, or recurrence of work-related injuries; injuries caused by traffic accidents; injuries caused by one's own violation of the law; food poisoning caused by liability accidents; and treatment for suicides (except for psychiatric episodes); Injuries caused by medical malpractice; medical expenses should be self-care according to national and municipal regulations.
The Medical Expenses Coordination Fund for Major Diseases pays for medical expenses, adopting the method of calculating by grades and paying cumulatively. The specific standards for the portion of medical expenses paid for more than 2,000 yuan are as follows: 90% for the portion of 2,000 yuan or more than 5,000 yuan or less; 85% for the portion of 5,000 yuan or more than 10,000 yuan or less; 80% for the portion of 10,000 yuan or more than 30,000 yuan or less; 85% for the portion of 30,000 yuan or more than 50,000 yuan or less; and 90% for the portion of more than 50,000 yuan or more.
The remaining portion of the medical expenses after they are paid by the coordinating fund for major medical expenses shall be borne by the enterprise and the individual employees and retirees*** together. The portion borne by the enterprise shall not be less than 70%. When employees and retirees are hospitalized for treatment of illness and need to pay a deposit in advance, the enterprise shall make a unified advance payment. If the enterprise has difficulties in making advance payment, it can apply to the district or county social insurance fund management organization to make a proportional advance payment in the integrated fund of medical expenses for major diseases.
The medical expense co-ordination for major illnesses implements a designated hospital and referral approval system.