Qingdao Social Health Insurance Measures is implemented from January 1, 2015, the employee health insurance and resident health insurance participants from January 1, 2015 in accordance with the new policy to enjoy the health insurance related treatment. The approach applies to the six districts of Shinan, Shibei, Licang, Laoshan, Chengyang, Huangdao, and the four cities of Jimo, Jiaozhou, Pingdu, Laixi, all participants.
2, employee social health insurance and residents of the maximum annual coverage of social health insurance, respectively?
The annual maximum payment limit of basic medical insurance for employees and residents is 200,000 yuan and 180,000 yuan, respectively; after reimbursement by the basic medical insurance, the large costs borne by individuals within the scope of the integrated medical insurance will be reimbursed by the medical insurance for serious illnesses according to the regulations, with an annual maximum payment limit of 600,000 yuan; the large medical costs borne by individuals outside the scope of the integrated medical insurance and the costs of special medicines and special materials will be given For large medical expenses and special medicines and special materials outside the scope of coordination, medical aid for major diseases will be provided, with an annual maximum of 100,000 yuan or more. The three treatments combined, the maximum annual coverage of employee health insurance participants reached more than 900,000 yuan, an increase of 100,000 yuan over the current; resident health insurance participants reached more than 880,000 yuan, an increase of 100,000 yuan over the original urban residents' health insurance, 400,000 yuan over the original New Farmers' Cooperative.3, the city's social health insurance starting standard is how to stipulate?
3How is the starting standard of social health insurance for hospitalization and outpatient treatment of serious illnesses in first-, second-, and third-level hospitals is 200, 500, and 800 yuan, respectively. The first hospitalization is fully covered, the second is reduced by half, and the third and above are covered at 100 yuan. For outpatient treatment of serious illnesses, the insured person will pay one starting standard in one year.4, employee health insurance participants hospitalization treatment is how to provide?
Employee health insurance participants hospitalized in the first, second and third-level designated medical institutions, the starting standard above the coordinated payment of medical expenses within the scope of the annual total of less than 40,000 yuan, the annual total of less than 40,000 yuan, the proportion of payment of pre-retirement (job) were 90%, 88%, 86%, retirement (job), 95%, 94%, 93%; annual total of 40,000 yuan more than the portion of5, resident health insurance participants hospitalization treatment is how to provide?
Residents' health insurance participants hospitalized in the first, second and third level designated medical institutions, above the starting standard of medical expenses within the scope of the integrated payment, the proportion of the first class of adult residents to pay 85%, 80%, 70%; the second class of adult residents to pay 80%, 70%, 55%; students and children were 90%, 85%, 80%. Adult residents hospitalized in street and town health centers (community health service centers) implementing the basic drug system, the payment ratio increased by 5 percentage points.6, participate in the health insurance can be reimbursed for maternity medical expenses?
In view of the fact that there is no maternity insurance arrangement for flexibly employed persons and residents' health insurance participants, flexibly employed persons and residents' health insurance participants who participate in the employee's social health insurance will be paid by the basic health insurance fund for the hospitalized childbirth medical fees incurred in designated medical care and in line with the family planning policy, in accordance with the provisions of the basic health insurance fund.7, employee health insurance participants outpatient treatment of major diseases is how to provide?
Employee health insurance participants in the designated medical institutions in the outpatient medical expenses incurred above the starting standard within the scope of the integrated payment, in the first, second and third level of the designated medical institutions reimbursement rate of 90%, 88%, 86%, respectively, more than the limit of the standard of the part of the reimbursement of 50%; in the community designated medical institutions reimbursement of 92%, more than the limit of the standard of the part of the reimbursement of 70%. Partial reimbursement of 70%.8, residents of the medical insurance participants outpatient treatment of major diseases is how to provide?
Residents' health insurance participants in the designated medical institutions in the outpatient medical expenses incurred above the starting standard within the scope of integrated payment, in the first, second and third level of designated medical institutions, residents of the first tranche of reimbursement of 80%, 70%, 65%, residents of the second tranche of reimbursement of 75%, 65%, 55%, students and children were reimbursed 90%, 85%, 80%. The payment rates for community-based designated medical institutions are in accordance with those of first-class hospitals. The reimbursement rate for basic medicines for adult residents in community designated medical institutions is increased by 10 percentage points. The portion above the disease limit standard is not reimbursed. Compared with the original system, there are mainly the following changes: First, the scope of outpatient major illnesses and disease limit standards, rural residents expanded to 53 types of diseases, payment standards and limits are also correspondingly increased, the majority of rural residents generally benefit. Secondly, in order to encourage the use of basic medicines and reduce the burden on insured persons, the proportion of adult residents reimbursed for the use of basic medicines in community-based designated medical institutions has been increased by 10 percentage points, ensuring that the treatment of rural residents for outpatient major illnesses in township and village health centers is not reduced, while urban adult residents are also generally benefited.9, which medical expenses can be included in the scope of payment of medical insurance for major diseases?
Social health insurance participants in the designated medical institutions in the hospitalization, outpatient medical expenses incurred, the basic medical insurance fund in accordance with the provisions of the payment, the following costs borne by individuals into the scope of payment of major medical insurance funds: (a) in line with the coordinated scope of payment, more than the maximum payment limit of the basic medical insurance fund of medical expenses; (b) in line with the coordinated scope of payment, individuals in accordance with the minimum payment limit of the basic medical insurance fund of the payment of the following expenses Coordinate the scope of payment, the individual in accordance with the starting standard and the proportion of self-responsibility of medical expenses; (3) Category B drugs, medical services, medical services facilities into the scope of the coordinated payment of the individual in accordance with the proportion of self-responsibility of medical expenses.10, how is the treatment of major medical insurance?
Social health insurance participants in the designated medical institutions in the hospitalization and outpatient medical expenses incurred by the basic medical insurance payment, the overall scope of the personal burden of the costs can be included in the scope of payment of medical insurance for serious illnesses in accordance with the provisions of: (a) over the limit of the subsidy. Medical expenses exceeding the maximum payment limit of the basic medical insurance fund, employees are subsidized 90%; residents of the first class, students and children are subsidized 80%, and residents of the second class are subsidized 70%. A maximum subsidy of 400,000 yuan in a year. (ii) Large amount of subsidies. Accumulated in a year more than the starting standard of major medical insurance (specific standards are formulated and announced) above the part of the employee subsidies 75%; residents of the first class, students and children subsidies 60%; residents of the second class subsidies 50%. The starting standard for major medical insurance for uremia dialysis treatment and organ transplantation anti-rejection treatment is unified at 3,000 yuan, and for the portion above the starting standard, the employee subsidy is 75%; the subsidy for the first class of residents and students and children is 70%; and the subsidy for the second class of residents is 60%. The maximum payment is 200,000 yuan in one year.11, what medical expenses can be included in the scope of assistance for major medical aid?
Social health insurance participants in the enjoyment of basic health insurance and major medical insurance benefits at the same time, the following hospitalization, outpatient medical expenses incurred in designated medical institutions are included in the scope of payment of funds for major medical assistance: (a) eligible participants using special drugs and special materials incurred in the medical costs; (b) the basic medical insurance drug list, medical services and medical services facilities outside the catalog of treatment necessary for the treatment. Medical costs necessary for treatment outside the catalog of basic medical insurance drugs, medical service items and medical service facilities; (c) basic medical insurance drugs, medical service items and medical service facilities above the maximum cost limit of the catalog of medical costs necessary for treatment.12, social health insurance participants in the medical treatment of the sick how to stipulate?
The medical aid treatment for major illnesses is standardized for both employee health insurance participants and residents' health insurance participants. Participants in the designated medical institutions in the hospital, outpatient medical expenses, in the enjoyment of basic medical insurance treatment and treatment of major medical insurance on the basis of the overall scope of the personal burden of the costs can be included in the provisions of the funds to pay for medical assistance for major illnesses: (a) eligible participants in the use of special medicines and special materials incurred in the medical costs, 70% of the relief. (2) outside the scope of the coordinated treatment of necessary medical expenses, the annual total of more than 50,000 yuan part of the aid 60%. Pensioners and subsidized beneficiaries, low-income and low-income marginal family insured people do not set the starting standard for large-scale assistance. A maximum payment of 100,000 yuan of large-scale assistance within a year. (C) eligible low-income family participants, but also enjoy special medical assistance in accordance with the provisions of the Civil Affairs Department.13, the urban and rural areas after the integration, employees and residents to purchase medicine reimbursement catalog is the same?
After the urban-rural integration of health insurance, employees and residents unified implementation of medical insurance drugs, medical services, medical service facilities "and other three catalogs. The reimbursement scope for rural residents has been further expanded, and only the reimbursement of medication has been expanded from more than 900 to more than 2,400 types of medication.14, the only child of the medical insurance treatment has special provisions?
The family planning policy is China's basic state policy, in order to better implement the family planning policy, the only child's inpatient medical care, outpatient medical care, accidental injury outpatient medical expenses, the basic medical insurance fund in the student children on the basis of the prescribed percentage of payment by an increase of 5 percentage points.15, the employee social health insurance treatment waiting period is how to stipulate?
Employee social health insurance set the waiting period provisions, eligible to participate in employee social health insurance, should be within three months in time to participate in the premiums. Continuous renewal of less than six months, only enjoy the basic medical insurance individual account treatment; continuous payment of six months, in accordance with the provisions of the employee social health insurance treatment. Employees who have interrupted their enrollment for more than three months will have their waiting period recalculated when they re-enroll in the program.16What kind of people are exempted from the waiting period for employee health insurance treatment?
Full-time graduates of all types of schools who participated in employee social health insurance in the year of employment, military cadres and demobilized veterans who participated in employee social health insurance within one year of their transfer or demobilization, and other persons in line with the policy, are exempted from the waiting period, and are entitled to receive employee social health insurance benefits in accordance with the provisions of the law from the month following the month in which they paid their contributions.17How is the medical year of a social health insurance participant calculated?
The medical year for social health insurance participants is unified into a natural year, and each participant's medical year is the same, i.e., from January 1 to December 31 of each year.18, the basic medical insurance fund does not pay the medical expenses include what?
The basic medical insurance fund will not pay for the medical expenses including the following categories: (a) "three catalogs" outside the cost; (b) more than the maximum cost of basic medical insurance costs; (c) "three catalogs" within the cost; (d) "three catalogs" within the cost; (e) "three catalogs" within the cost; (f) "three catalogs" within the cost; (g) "three catalogs" within the cost; (h) "three catalogs" within the cost of basic medical insurance. Category B drugs and diagnostic and therapeutic items in the "Three Catalogs"; (d) costs borne by individuals in accordance with the starting standard; (e) costs borne by individuals in accordance with the graded ratio after entering the scope of payment of the coordinated fund; and (f) medical costs in accordance with the coordinated payment standard and exceeding the maximum payment limit of the basic medical insurance. Participants hospitalization and outpatient treatment of major diseases incurred in (a), (b) costs, in accordance with the provisions of the scope of medical assistance for major diseases; (c), (d), (e), (f) costs, in accordance with the provisions of the scope of medical insurance for major diseases.
19, what is the basic medical insurance "three catalog"?
After the insured person to participate in the insurance, not all of the medical expenses can be included in the integrated payment scope, but in the use of drugs, diagnosis and treatment, service facilities and so on, there is a basic specification, that is, the basic medical insurance "drug catalog", "diagnosis and treatment items catalog This is the basic medical insurance "drug list", "diagnosis and treatment items list", "medical service facilities scope", referred to as the "three catalogs" of medical insurance. Expenses incurred by the insured outside the scope of the "three catalogs" are not included in the overall reimbursement. Medicines and items included in the "three catalogs" are managed in two categories, A and B. Category A medicines and items can be directly included in the scope of payment, while Category B medicines and items must first be covered by a certain percentage of the individual's own expenses before they can be included in the scope of payment.20, the use of "drug list" of drugs incurred costs, can all be reimbursed?
No. The costs incurred for the use of "Class A drugs" in the "Drug List" will not be borne by the individual until they are reimbursed by the medical insurance; the costs incurred for the use of "Class B drugs" will be borne by the individual in accordance with the "self-supporting percentage". In accordance with the "self-responsibility ratio", "maximum cost limit" and other provisions of a certain amount of costs, and then reimbursed by the medical insurance in accordance with the provisions.21, "Drug List" in the "restricted use of the scope of" how to understand, how to choose to use drugs?
Some of the more expensive medicines in the Drug List are easier to abuse, and are only necessary for a few diseases with proven efficacy, while others can be used according to the condition, and there are alternatives of the same kind in the Drug List. Therefore, the scope of use of medicines is determined according to the condition, efficacy and other factors, and is limited to a certain disease or diseases, while the use of medicines for other diseases will be at the individual's expense or at a higher percentage of the individual's burden. These provisions in the "drug list" are clearly marked. For example: "Angong Niuhuang Pills" is limited to "high fever, fainting, rescue patients with", the treatment of other diseases will be at their own expense or to choose the "Drug List" in the other heat-expelling and enlightenment agents The company's products and services have been widely recognized by the public and the private sector.22, "Drug List" in the "maximum cost limit" how to understand, how to choose to use drugs? In order to reduce the tendency of abusing expensive drugs, a "maximum cost limit" has been set for the more expensive drugs, and the cost above the limit is to be borne by individuals. Clinicians and insured people can choose to use them according to their conditions and patients' affordability.
23, not included in the basic medical insurance drug list of the main drugs?
(a) the main role of nutritional tonic drugs; (b) part of the animal and animal organs can be used in medicine, dried (water) fruit; (c) with Chinese herbs and Chinese medicine tablets concocted all kinds of alcohol preparations; (d) all kinds of drugs in the fruit flavored preparations, oral effervescent; (e) blood products (except for special indications), protein products; (f) blood products (except for special indications), protein products;23, not included in the basic medical insurance drug list.
(vi) other medicines that are not paid by the basic medical insurance fund as stipulated by the human resources and social security departments.24, "diagnostic and treatment programs and medical service facilities" include what are the main content?
The scope of diagnostic and treatment programs and medical service facilities mainly include the name of the program, the program level, the deductible ratio, the fee, the pricing unit, the maximum cost limit, the scope of restricted use. Among them, the meaning of item level, deductible ratio, maximum cost limit, restricted use scope is consistent with the drug catalog. Charging standards, pricing units belong to the price charging policy, is the price of the price department to determine the standard of charges.25, not included in the basic medical insurance diagnostic and treatment items catalog of diagnostic and treatment items are mainly?
(a) service items: registration fees, out-of-hospital consultation fees, medical records, such as the cost of books; clinic fees, examination and treatment of expedited fees, surcharges on the name of the surgery, high-quality premiums, self-employed special nurses and other special medical services. (B) non-disease treatment programs: a variety of beauty, fitness programs and non-functional cosmetic, orthopedic surgery, etc.; a variety of weight loss, fertilization, height projects; a variety of health checkups; a variety of medical consultations, medical appraisal. (C) diagnostic and treatment equipment and medical materials: the application of positron emission tomography device (PET), electron beam CT, ophthalmic excimer laser therapy instrument and other large-scale medical equipment for examination and treatment projects; glasses, dentures, prosthetic eyes, prosthetics, hearing aids and other rehabilitative devices; a variety of health care for their own use, massage, inspection and treatment equipment; price departments can not be charged individually for a disposable Medical materials. (D) treatment projects: all kinds of organ or tissue transplantation of organ or tissue source; in addition to kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow transplantation of other organs or tissues; myopic orthopedics; qigong therapy, music therapy, health care of nutritional therapy, magnetic therapy and other complementary treatment projects. (E) other: a variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment program; a variety of scientific research, clinical verification of the diagnosis and treatment program.26What medical service facilities are not included in the basic medical insurance social co-payment?
According to the national regulations, the basic medical insurance does not pay for the cost of living services and services and facilities mainly include: consultation (referral) transportation fees, emergency ambulance fees; air-conditioning fees, television fees, telephone fees, baby warming box fees, food warming box fees, electric stoves, refrigerators, and compensation for damages to public property; escort fees, escort fees, cleaning fees, outpatient decoctions; meals; recreational activities, and other special needs of the cost. Recreational activities and other special living services.