Answer: All employers within the administrative area of the city, including government agencies, institutions, social organizations, enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises, etc.), ministries and provinces in Jingjing and their employees, retired (jobs), flexible employment without a fixed job, file custodians, and the owners of private and individual economic organizations and their employees.
Second, the basic medical insurance contribution rate? What is the percentage of contribution to the civil service subsidy or employee supplemental medical insurance?
Answer: Participating organizations pay 7% of the total wages of active employees in the previous month, and individuals pay 2% of their total wages in the previous month for basic medical insurance.
If a participant reaches retirement age and has paid premiums for less than 15 years, he or she is required to make up the full 15 years.
Organizations and institutions participating in the civil service medical subsidy pay 4.5% of the employee's monthly salary (including workers' compensation insurance). Units participating in the supplemental medical insurance for enterprise employees pay 4% of the employee's last month's salary for the employee.
Third, the individual medical account of the funds allocation ratio is how to stipulate?
Answer: 1.35 years of age or less, 2.6% of the total amount of my salary contributions;
2.36 years of age to 45 years of age, 3.2% of the total amount of my salary contributions;
3.46 years of age to the pre-retirement period, 4% of the total amount of my salary contributions;
4. Retirement (jobs) according to the amount of my previous year's pension 5% credited;
5. Organs and institutions have participated in the civil service subsidies or enterprises and institutions have participated in the employee's supplemental medical insurance, according to the above age groups, and then to the individual account were credited with 0.8%, 1.4%, 2%, 2.5% of the total amount of paid wages.
Four, how to deal with the balance of funds in the individual account of the insured employees in the year?
Answer: When the balance of the individual account funds of the insured employees in the current year, it will be transferred to the next year for further use and interest will be calculated in accordance with the state regulations.
Fifth, the insured workers transfer out of the city, terminate (terminate) labor relations, death for reasons, etc., how to deal with their personal accounts?
Answer: If an insured employee leaves the city, the employer should go to the municipal health insurance agency within one week with the transfer formalities of the personnel and labor departments to handle the medical insurance transfer formalities and the transfer of funds in the individual account. The death of the insured employee, the employer should bring the relevant information to the health insurance agency for the suspension of insurance procedures within one month, the balance of its personal account, confirmed by the Municipal Health Insurance Office to the legal successor's personal account, such as its legal successor is a non-participant, the legal successor inherited by the legal successor; no one inherited, the balance of its personal account into the basic medical insurance fund.
VI. What are the items for which the basic medical insurance fund will not pay?
A: The medical insurance fund will not pay for the following items:
1. Services
(1) social security card fees, registration fees, out-of-hospital consultation fees, and the cost of medical records.
(2) Fees for special medical services such as visit fees, expedited fees for examinations and treatments, surcharges for named surgeries, high quality premiums, and self-invited special nurses.
2. Non-disease treatment programs
(1) Various beauty and fitness programs as well as non-functional cosmetic and orthopedic surgeries.
(2) a variety of weight loss, fat gain, height increase program.
(3) Various health checkups.
(4) Various preventive and health care treatment programs.
(5) All kinds of medical consultation and medical appraisal.
3. Diagnostic and therapeutic equipment and medical materials
(1) the application of positron emission tomography device (pet), electron beam ct, stereotactic emission device (γ-knife, χ-knife), ophthalmology excimer laser treatment device and other large-scale medical equipment, inspection and treatment programs.
(2) eyeglasses, dentures, prosthetic eyes, prosthetic limbs, hearing aids and other rehabilitative devices.
(3) Various kinds of health care, massage, examination and treatment instruments for self-use.
(4) Provincial price department regulations can not be charged separately disposable medical materials.
4. Treatment program category
(1) all kinds of organ or tissue transplantation of organ source or tissue source.
(2) Other than kidney, heart valve, cornea, skin, blood vessel, bone, bone marrow transplantation of other organs or tissues.
(3) Orthopedic surgery for myopia.
(4) Complementary therapeutic programs such as qigong therapy, music therapy, nutrient therapy for health care, and magnetic therapy.
5. Other
(1) Various kinds of infertility (pregnancy), sexual dysfunction treatment program.
(2) A variety of scientific research, clinical verification of the treatment program.
(3) All expenses incurred due to disability caused by fighting, brawling, alcoholism, suicide, traffic accidents, medical liability accidents and so on.
(4) Medical expenses during the period of going abroad to visit relatives, further study or lecturing.
(5) Expenses for treatment of sexually transmitted diseases, drug or narcotic addiction.
(6) Expenses for treatment of work-related injuries, occupational diseases, collective food poisoning, and sequelae of family planning surgery.
Seven: How can insured workers seek medical treatment and purchase medicines?
Answer: 1. Outpatient consultation
Participating employees holding a social security card and a medical record of urban workers' medical insurance in Jingjiang City (hereinafter referred to as the "card"), "card"), go to the designated medical institutions in the city for medical treatment, and the hospital will transfer the expenses within the scope of the basic medical insurance directly from their individual accounts, and the part that is not enough to be paid by the individual account will be paid by the person himself/herself.
2. Emergency treatment
The insured workers due to sudden illness, can not go to the designated hospitals, can be the nearest medical treatment, but the next day to the medical insurance agency to report to the stabilization of the condition of the timely transfer to the designated medical institutions for medical treatment. The medical expenses can be handled in accordance with the relevant provisions on outpatient and hospitalization, depending on the specific circumstances. The insured employees or their families can take the "card", "certificate" and emergency medical records, prescriptions, valid medical receipts, etc., to the municipal health insurance agency for reimbursement procedures within ten days.
3. Hospitalization
An insured employee who needs to be hospitalized due to illness will go to the designated medical institution to go through hospitalization procedures with his/her "card" and "certificate", and settle with the hospital the part of medical expenses borne by himself/herself when he/she is discharged from the hospital.
4. Out-of-town transfer
(1) The insured employee with his/her "card", "certificate" and the certificate of transfer from the designated second-level hospital or the designated specialized hospital in the city to the municipal health insurance agency for registration and filing procedures, and upon approval, he/she can be transferred to other places for medical treatment. medical treatment.
(2) emergency, critical patients, really need to be immediately transferred to hospitals outside the city rescue, in the time does not allow the procedure to report to the municipal health insurance agencies for the record, should be signed by the hospital leadership (or the general duty) to deal with the opinion, but should be timely to the municipal health insurance agencies to make up for the referral formalities afterwards.
(3) In principle, out-of-town referrals should be made to designated hospitals confirmed by the municipal labor security department, and the referral procedure is valid once.
5. Self-purchase of medicines
Participating employees can purchase prescription medicines at designated retail pharmacies with the prescriptions of designated medical institutions and their social security cards, and non-prescription medicines within the scope of the medicines catalog of the medical insurance can be purchased by participating employees with their social security cards.
How are the starting standard and the maximum payment limit of the city's coordinated payment for the hospitalization medical expenses of the insured employees stipulated?
Answer: The starting standard of hospitalization medical expenses for insured employees in our city is:
1. 500 yuan for hospitalization in the first-level medical institutions in our city;
2. 650 yuan for hospitalization in the second-level medical institutions in our city;
3. 900 yuan for transferring to other places for medical treatment.
The maximum limit of the city's coordinated payment of hospitalization medical expenses for insured workers is four times the average salary of workers in the previous year in the city.
If an employee is hospitalized several times in the same year, and the interval between hospitalization in and out of the same level of medical institution is more than 15 days, from the second hospitalization onwards, the starting standard of hospitalization expenses will be reduced by 20% in turn, and the minimum shall not be less than 200 yuan.
9. What is the proportion of individual burden of hospitalization expenses after the payment of the starting standard?
Answer:
1. The segmented burden ratio of the active insured employees:
0-5000 yuan, 16% personal out-of-pocket;
5001-15000 yuan, 12% personal out-of-pocket;
15001-40000 yuan, 8% personal out-of-pocket;
2. The segmented burden ratio of the retirees is as follows.
0-5,000 yuan, personal out-of-pocket payment of 10%;
5,001-15,000 yuan, personal out-of-pocket payment of 8%;
15,001-40,000 yuan, personal out-of-pocket payment of 5%.
3. For hospitalization expenses incurred by civil servant medical assistance or supplementary medical insurance participants in a medical insurance settlement year that are in line with the scope of payment of basic medical insurance, the civil servant medical assistance or supplementary medical insurance fund shall bear 50% of the individual segmented out-of-pocket expenses after the individual out-of-pocket payment starting standard and up to the ceiling line.
X. How is the medical aid fund for major diseases raised? How to deal with the medical expenses of major diseases that exceed the maximum payment limit of the basic medical insurance hospitalization fund?
A: medical aid fund for major illnesses by the insured unit and the insured **** the same payment. The insured unit to pay 5 yuan per person per month, the insured person to pay 3 yuan per person per month, by the employer in July each year to withhold and pay the annual number of 96 yuan. Retiree medical aid fund unit to pay part of the annual contribution by the employer, the individual to pay part of the annual July deducted from the retiree's personal health insurance account.
Participants in a settlement year, the medical insurance coverage of inpatient medical expenses (including hospitalization settlement of outpatient costs of special diseases) over the basic medical insurance maximum payment limit of more than 40,000 yuan, 150,000 yuan or less, by the unit of the participant to apply for the municipal health insurance agencies to confirm the audit, 90% of the major illnesses by the Fund to pay the assistance fund, the unit and the individual to bear 10%.
Xi. How can insured workers who live abroad for a long time get medical treatment?
Answer: There are two kinds of cases for insured workers who live abroad for a long time:
1. Retired (professional) workers who are resettled in other places.
2. Those who work or study abroad for a long period of time on official business for a continuous period of more than 6 months (including 6 months).
The insured employees who live abroad for a long period of time are subject to fixed-point medical treatment. By the employee's unit or individual in the vicinity of their place of residence to choose 2-3 local medical insurance agency confirmed fixed-point medical institutions as a fixed-point hospital, and fill out the "Jingjiang City insured employees to seek medical treatment in a different place application form" submitted to the Municipal Health Insurance Office for the record.
Twelfth: How to reimburse the medical expenses of employees who live abroad?
Answer: If an employee resides outside of the city, the medical expenses will be paid by the individual first, and then the medical expenses will be reimbursed to the medical insurance agency in accordance with the relevant regulations of the city medical insurance with the "Application Form for Medical Treatment in a Different Place for Insured Employees of Jingjiang City" and the medical records provided by the hospitals, medical billing lists, and receipts of the medical expenses in conformity with the regulations (inpatient must show the summary of the hospital discharge and the detailed billing lists). In order to claim reimbursement of medical expenses incurred by an out-of-household employee who has been transferred to a hospital outside the co-ordination area of his/her place of residence, he/she is required to present the relevant referral authorization procedures before reimbursement can be made. For insured units with a large number of foreign workers, centralized reporting may be adopted by the insured units.
All medical expenses incurred by foreign workers must be settled within the current year.
Thirteen: What are the regulations on outpatient expenses for insured employees suffering from special diseases and long-term chronic diseases?
A: If an insured employee suffers from one of the following diseases and is confirmed in accordance with the prescribed procedures, his/her outpatient medical expenses can be paid by the coordinated fund according to the following ratios after examination and approval by the health insurance administration organization:
1. Manic psychosis and schizophrenia (excluding the simple type), and the outpatient (including inpatient) medical expenses that are in line with the scope of reimbursement of the health insurance will be settled by the coordinated fund in full.
2. For patients who need dialysis treatment for malignant tumor chemotherapy, radiotherapy, severe uremia and renal failure, the outpatient medical expenses shall be implemented in accordance with the settlement of inpatient expenses upon the recommendation of the attending physician of the hospital and the application of the employee himself or herself, and after the review and approval of the municipal health insurance agency.
3. Hospitalization expenses incurred by patients with malignant tumors in accordance with the scope of basic medical insurance will be taken care of, and their individual segmented out-of-pocket expenses will be reduced by half.
4. For patients who need to undergo hemodialysis, after going through the approval procedures, 5% of the hemodialysis fee shall be paid by the individual first, and the rest shall be paid by the basic medical insurance fund in accordance with the regulations.
5. Chronic viral hepatitis, diabetes mellitus with comorbidities, hypertension (stage II or above), chronic heart failure, renal failure, chronic obstructive pulmonary disease, systemic lupus erythematosus, aplastic anemia, retinitis macular degeneration and other chronic patients, outpatient medical expenses incurred in a medical insurance settlement year in line with the scope of the basic medical insurance, the out-of-pocket expenses of the incumbent exceeds 800 yuan in total, For retirees, 60% of the outpatient medical expenses incurred in one medical insurance settlement year that are covered by the basic medical insurance can be paid by the integrated fund with the medical records, examination and laboratory tests, and reported to the municipal medical insurance agency for examination and approval. For those who participate in the civil service subsidy or enterprise supplementary medical insurance, the supplementary medical insurance fund will pay another 20%.
Specified medical institutions with the above categories of disease treatment drugs should be separately prescribed accounting, payment.
Fourteenth: What are the regulations on general outpatient medical fees for civil servants' subsidies or enterprises' supplementary medical insurance?
Answer: The civil service subsidy or enterprise supplementary medical insurance can subsidize the general outpatient medical expenses within the scope of the basic medical insurance, and the personal out-of-pocket payment exceeds a certain amount. Specific subsidies for: insured employees in the year after the exhaustion of personal account, in line with the provisions of the basic medical insurance, out-of-pocket expenses exceeding 10% of the average salary of employees in the previous year to within 3,000 yuan of the costs, can be based on the medical records, the relevant tests, prescriptions and valid invoices, reported to the medical insurance agency for examination and approval of the supplemental medical insurance fund to pay 60% of the overall fund.
Fifteen, medical insurance expenses settlement year how to stipulate?
A: July 1 of the current year to June 30 of the next year for a medical insurance settlement year.
Sixteen: What are the responsibilities of the insured units in the social health insurance system?
Answer: The employer must pay the insurance premiums in full and on time, and withhold and pay on behalf of the individual's share of the contributions, and regularly publicize the payment of medical insurance premiums to the employees. The employer is responsible for any delay in the payment of insurance premiums, which prevents the insured employees from enjoying the normal medical insurance benefits and affects their post-retirement treatment by not being able to calculate the continuous insurance age. The unit shall assist the medical insurance agency in publicizing and managing the work of social medical insurance for the employees of the unit.
Seventeen, the employer does not pay the required medical insurance premiums, how to deal with?
Answer: Employers and their employees should pay the basic medical insurance premiums in full and on time in accordance with the State Council's "Provisional Regulations on the Collection and Payment of Social Insurance Premiums". Contributing units do not pay and withholding of basic medical insurance premiums, by the labor security administrative department ordered to pay the deadline, and at the same time to suspend the transfer of the unit's individual account funds and the overall fund payment and medical insurance transfer procedures; overdue payment is still not paid, in addition to make up for the amount of arrears of payment, from the date of arrears of payment of 2 ‰ of late fees per day. Contributing units refused to pay the basic medical insurance premiums, late fees, by the tax authorities or by the administrative department of labor security to apply for the people's court to enforce collection.
Eighteen, flexible employment how to participate in basic medical insurance?
A: Flexible employment needs to fill out the application form for medical insurance, confirmed by the village (or neighborhood), bring your ID card, a one-inch photo to the health insurance agency to apply for basic medical insurance enrollment procedures. After enrollment in July each year with the social insurance payment certificate to the medical insurance agency according to the contribution base (the province's average wage of the previous year) of 9% of the basic medical insurance premiums for the whole year, and pay the annual fee for major medical assistance. The waiting period for the newly insured flexibly employed persons to pay for the treatment of co-ordinated payment is six months, and the personal account of the social security card can be used in the following month after the payment of premiums, and from the seventh month onwards, they will be entitled to the payment of basic medical insurance co-ordinated fund (inpatient hospitalization), and in the case of suffering from the ten types of major diseases from the seventh month to the twelfth month of the insurance, the co-ordinated fund will reduce the payment by half.
Nineteen: how to use the medical insurance card (social security card)?
Answer: 1. Encryption After joining the medical insurance, the social security card of the insured person is equipped with an initial password, in order to ensure the security of the use of the funds of the social security card of the insured person, the cardholder in the first time of use, the initial password must be changed to a self-set password.
2. Purchase of medicines and settlement of expenses When participants go to designated hospitals and designated pharmacies to purchase medicines, they can use their social security cards to pay for medicines within the scope of medical insurance on the basis of their medical records; when they are hospitalized, they can use their social security cards and medical records to go to the hospitalization department of the designated hospitals for hospitalization registration and settlement of hospitalization expenses. When the insured person is discharged from the hospital and settles the bill, if the balance of the individual account can fully pay the starting standard of hospitalization, he can choose to use the individual account to pay.
3. Enquiry Cardholders can hold their social security cards and enquire about their individual account balances and personal medical information at the health insurance agencies, designated hospitals and designated pharmacies.
4. Lost and Replacement If the social security card is lost or damaged, the cardholder should go to the health insurance agency with his ID card and medical records to go through the procedures of losing and replacing the card, and pay the cost of social security card production. If the amount of personal account is stolen within three days from the date of loss, the cardholder will be responsible for it. A new card can be obtained seven days after the loss.
5. Maintenance The social security card in use should pay attention to keep the chip clean, in case of dirt can be gently wiped with a clean soft cloth, do not make the social security card scratches, folding, moisture, distortion, social security card should be placed away from cell phones, magnets, etc..