According to Article 15 of the Xiangyang Municipal Measures for the Implementation of Municipal Integration of Work-Related Injury and Maternity Insurance, the budget of the fund for work-related injuries and maternity insurance consists of a budget for the income of the fund and a budget for the expenditure of the fund. The income of the fund mainly includes income from work injury and maternity insurance premiums, interest income, financial subsidy income, transfer income, subsidy income from higher levels, income from lower levels, and other income, etc.; the expenditure of the fund mainly includes expenditure on work injury and maternity insurance treatment, expenditure on labor capacity appraisal fee, expenditure on medical fee, transfer expenditure, expenditure on subsidy income, expenditure on transferring to lower levels, expenditure on transferring to higher levels, and other expenditures.
According to Chapter 3 of the Trial Measures for the Management of Basic Medical Insurance for Urban and Rural Residents of Xiangyang City, Chapter 3: Hospitalization Medical Insurance Treatment
Article 7: The settlement year of medical insurance expenses for urban and rural residents shall be from January 1 to December 31 of each year.
Article 8: The medical insurance treatment for urban and rural residents shall be implemented in accordance with the three catalogs of "Hubei Provincial Urban Workers' Basic Medical Insurance and Workmen's Compensation Insurance Drug Catalog", "Xiangfan Urban Workers' Basic Medical Insurance Diagnostic and Treatment Items Scope", and "Xiangfan Urban Workers' Basic Medical Insurance Medical Service Facilities Scope and Payment Standard", among which the medical insurance treatment for people over 18 years old who are insured under the Class I contribution standard shall be implemented in accordance with the Class A Drug Catalog. treatment is implemented in accordance with the Class A Drug Catalog.
Article 9 Urban and rural insured residents who are hospitalized due to illness can independently choose the designated medical institutions, and the hospitalization medical expenses incurred in accordance with the provisions of the basic medical insurance shall be settled directly at the designated medical institutions, and the expenses borne by individuals at the time of settlement shall be settled by the insured persons directly with the designated medical institutions, and the rest of the expenses shall be settled by the medical insurance agencies with the designated medical institutions.
Article 10: For urban and rural insured residents hospitalized for treatment, the starting standard for hospitalization in community health service institutions, first-class medical institutions and healthcare institutions for the benefit of the people shall be RMB 100 yuan; the starting standard for second-class designated medical institutions shall be RMB 300 yuan; the starting standard for third-class A-class comprehensive medical institutions shall be RMB 700 yuan, and the starting standard for other third-class medical institutions shall be RMB 550 yuan; and for hospitalization in designated medical institutions outside of the city upon referral, the starting standard shall be RMB 700 yuan. The starting standard is 700 yuan.
The minimum payment for hospitalization in township health centers is RMB 50 yuan for Class I residents.
The starting payment standard is halved for two or more hospitalizations of the same level within a billing year for Type II insured residents; there is no starting payment line for hospitalization of the "three have-nots" (those who are incapable of working, have no source of livelihood and have no designated breadwinner or support obligor) at the healthcare institutions of the people with benefits, and the starting payment standard for patients with acute and critical illnesses is RMB 700 yuan for outpatient treatment. Critically ill patients, who are transferred to hospitalization after being rescued on an outpatient basis, their outpatient and hospitalization expenses can be combined and settled.
Article XI of the first class of financing standards for insured residents hospitalized in designated hospitals, the integrated fund above the starting standard, the maximum payment limit below the prescribed medical expenses, township hospitals integrated fund to pay 75%, the individual out-of-pocket payment of 25%; community health service institutions, first-class medical institutions and medical institutions in favor of the people of the structure of the integrated fund to pay 60%, the individual out-of-pocket payment of 40%; the second-class medical institutions The coordinated fund pays 50% and the individual pays 50%; the coordinated fund of the tertiary medical institutions pays 40% and the individual pays 60%; and for those who seek medical treatment in a different place, the coordinated fund pays 40% of the hospitalized medical expenses that meet the reimbursement requirements and the individual pays 60%.
The second type of financing standards of the insured residents in the designated hospital hospitalization, the coordinated fund above the starting standard, the maximum payment limit below the stipulated medical expenses, township hospitals, community health service institutions, the first level of health care institutions and health care institutions of the people to pay 75% of the coordinated fund, the individual out-of-pocket 25%; second level of health care institutions, the coordinated fund pays 60%, the individual out-of-pocket 40%; third level of health care institutions, the coordinated fund pays 50%, the individual out-of-pocket 40%. The coordinated fund pays 50% and the individual pays 50%. In the case of foreign medical treatment, the coordinated fund pays 50% of the hospitalized medical expenses that meet the requirements for reimbursement.
Article 12: The maximum amount of inpatient and outpatient medical expenses paid by the integrated fund in a billing year shall be 40,000 yuan for the insured with the first-class contribution standard and 80,000 yuan for the insured with the second-class contribution standard.
Chapter 4 Outpatient Medical Insurance Treatment
Article 13: The outpatient family account model is implemented for the first category of insured persons. The outpatient treatment is transferred to the outpatient family account (bookkeeping mode) at the rate of 20 yuan per person per year, and the outpatient fixed-point management is carried out and utilized in a lump sum. Family account funds are restricted to use only when seeking medical treatment at the medical institution of one's choice. The maximum amount of general outpatient medical expenses reimbursed by each household in a billing year is the total amount of the household's outpatient family account, and any savings at the end of the year may be carried over for use in the following year. The annual balance shall not be offset against the individual contributions payable in the following year.
Article 14: The second category of insured persons shall have an outpatient co-ordination fund withdrawn from the basic medical insurance fund at the rate of 30 yuan per person per year for the purpose of settling the outpatient treatment of urban residents. Within a settlement year, outpatient medical expenses incurred by insured persons at selected hospitals that meet the scope of payment under the medical insurance regulations shall be reimbursed by the outpatient co-ordination fund at a rate of 40% of the cumulative amount of RMB 50 or more than RMB 400, while the individual shall pay for the cumulative amount of RMB less than RMB 50 and more than RMB 400 at his/her own expense.
Article 15 Participants in the basic medical insurance for urban and rural residents who suffer from malignant tumors, chronic renal failure (uremia stage), anti-rejection treatment after organ transplantation, aplastic anemia, hemophilia, and systemic lupus erythematosus shall be entitled to the outpatient medical treatment for major diseases. The declaration, standardization and management of outpatient medical treatment for major diseases are the same as those for urban workers' basic medical insurance. Within a settlement year, the integrated fund of the first category of participants pays 50% and the individual pays 50% of the expenses within the quota, while the integrated fund of the second category of participants pays 60% and the individual pays 40% of the expenses.
The monthly quotas for outpatient treatment of major diseases are: 300 yuan for malignant tumors; 3,650 yuan for hemodialysis of chronic renal failure (uremic stage) (including 500 yuan for treatment medication) and 5,000 yuan for peritoneal dialysis; 300 yuan for aplastic anemia; 200 yuan for hemophilia; 200 yuan for systemic lupus erythematosus; and anti-rejection treatment after organ transplantation is decided according to the condition of the patient. If two or more outpatient major diseases are handled at the same time, the monthly flat rate will be based on the flat rate of the disease with the higher flat rate, and the monthly flat rate will be increased by 100 RMB for each additional disease, up to a maximum of 500 RMB.