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I. The basic medical insurance individual account shall pay for the following provisions
1. the medical expenses of outpatient and emergency treatment;
2. the expenses of purchasing medicines in designated retail pharmacies;
3. the medical expenses below the starting standard of the basic medical insurance fund;
4. the medical expenses exceeding the starting standard of the basic medical insurance fund, which shall be borne by the individual in accordance with the proportion of the medical expenses to be borne by the individual. medical expenses that should be borne by individuals.
The part of medical expenses not covered by the individual account shall be paid by the individual himself/herself.
The medical insurance fund shall pay for the medical expenses of hospitalization;
2. the medical expenses within 7 days before hospitalization for those who are hospitalized for emergency treatment;
3. the outpatient medical expenses for radiotherapy and chemotherapy of malignant tumors, renal dialysis, and the outpatient medical expenses for taking the antirejection medicines after renal transplantation.
Third, the basic medical insurance fund to pay the starting standard, the maximum ceiling line
The basic medical insurance fund to pay the starting standard is determined by the previous year's average wage of the city's employees about 10%. For medical expenses incurred by individuals hospitalized for the second and subsequent times in a year, the starting standard for payment by the basic medical insurance co-ordination fund is set at about 5% of the average wage of the city's employees in the previous year (RMB 1,300 and RMB 650 in 2001).
The starting standard for payment by the Basic Medical Insurance Coordination Fund for the insured who are entitled to the Minimum Subsistence Guarantee for Urban Residents in the city is determined at 50% of the starting standard stipulated in Article 32 of the Regulations (Decree No. 68, hereinafter referred to as the same).
The starting standard for payment by the Basic Medical Insurance Coordination Fund for medical expenses incurred by insured persons treated in the family hospital beds of designated community health service centers (stations) shall be determined at 50% of the starting standard stipulated in Article 32 of the Provisions, and for those who are transferred to inpatient hospitalization, the starting standard for payment by the Basic Medical Insurance Coordination Fund shall be in accordance with the starting standard stipulated in Article 32 of the Provisions.
The cumulative maximum payment limit of the basic medical insurance co-ordination fund for medical expenses paid to employees and retirees in a single year is determined at about four times the average salary of the city's employees in the previous year (in 2001, it was 50,000 yuan).
Fourth, the basic medical insurance co-ordination fund to pay medical expenses set settlement period
1. Participants hospitalization treatment does not exceed 90 days, each hospitalization is a settlement period; more than 90 days, incurred medical expenses for every 90 days as a settlement period, settlement is considered as the second hospitalization, more than 180 days is considered as the third hospitalization, more than 270 days is considered as the fourth hospitalization.
2. Medical expenses for outpatient radiation therapy and chemotherapy for patients with malignant swelling and pain are subject to a settlement period of every 360 days.
3. Patients who need long-term kidney dialysis treatment, patients who need to take anti-rejection drugs for a long period of time after kidney transplantation and patients who need to be hospitalized for a long period of time due to mental illnesses are entitled to a settlement period of 360 days for the medical expenses incurred.
(Calculation of dialysis fee: dialysis fee includes start-up fee, heparin, saline, dialysis fluid, dialysis tubing, disposable materials and so on. Other medicines cannot be included in the calculation of the dialysis fee, for example, the cost of EPO rocalcitonin, etc. is paid from the large mutual fund according to the outpatient medical fee payment regulations, and cannot be put in the basic medical insurance coordinating fund for payment. In case of hemodialysis in the following seven hospitals: Beijing Tiantan Hospital, Beijing Anzhen Hospital, Peking University Third Hospital, Beijing University of Traditional Chinese Medicine Dongzhimen Hospital, Beijing University of Traditional Chinese Medicine Dongfang Hospital, Post and Telecommunication General Hospital, and Beijing Electricity General Hospital, it will still be implemented according to the document No. 143 of the Beijing Laoshaifa [2000], i.e., the cost per person per session up to RMB 410 includes dialysis solution, puncture needle, saline, (hemodialysis treatment fee, syringes, dialysis tubing, infusion sets, ordinary heparin.)
V. Payment by the Basic Medical Insurance Coordination Fund and Individuals in accordance with the following provisions
Medical expenses incurred by employees and retirees during a settlement period shall be calculated in segments and paid cumulatively according to the level of the hospital and the amount of the expenses, and shall be shared by the Basic Medical Insurance Coordination Fund and individuals in accordance with the following proportions (the proportion of payment for retirees shall be 60% of that of the active employees):
(a) The proportion of payment for retirees is 60% of the proportion of payment for active employees.
(1) Medical expenses incurred in tertiary hospitals:
1. 80% of the portion from the starting standard to 10,000 yuan shall be paid by the integrated fund and 20% by the employee;
2. 85% of the portion exceeding 10,000 yuan to 30,000 yuan shall be paid by the integrated fund and 15% by the employee;
3. 90% of the portion exceeding 30,000 yuan to 40,000 yuan shall be paid by the integrated fund and 10% by the employee; and 90 percent and the employee pays 10 percent;
4. For the portion exceeding 40,000 yuan, the integrated fund pays 95 percent and the employee pays 5 percent.
(2) Medical expenses incurred in secondary hospitals:
1. For the portion of the starting payment standard up to 10,000 yuan, the co-ordination fund pays 82%, and the employee pays 18%;
2. For the portion of the payment standard exceeding 10,000 yuan up to 30,000 yuan, the co-ordination fund pays 87%, and the employee pays 13%;
3. For the portion of the payment standard exceeding 30,000 yuan up to 40,000 yuan, the co-ordination fund pays 92%, and the employee pays 8%;
4. 92 percent and the employee pays 8 percent;
4. For the portion exceeding 40,000 yuan, 97 percent is paid by the integrated fund and 3 percent by the employee.
(3) Medical expenses incurred in first-class hospitals and home hospital beds:
1. For the portion of the starting payment standard up to 10,000 yuan, the centralized fund pays 85%, and the employee pays 15%;
2. For the portion of the payment standard exceeding 10,000 yuan up to 30,000 yuan, the centralized fund pays 90%, and the employee pays 10%;
3. For the portion of the payment standard exceeding 30,000 yuan up to 40,000 yuan, the centralized fund pays 95%, and the employee pays 10%;
4.
4. The portion exceeding 40,000 yuan shall be paid 97% by the integrated fund and 3% by the employee.
6. Mutual aid funds for large medical expenses shall be paid according to the following provisions
1. For the portion of outpatient and emergency medical expenses exceeding 2,000 yuan in a year, the mutual aid funds for large medical expenses shall pay 50%, and the individual shall pay 50%.
2. For retirees whose outpatient and emergency medical expenses exceed 1,500 yuan in a year, 60% of the outpatient and emergency medical expenses will be paid by the mutual aid fund and 40% by the individual for those who are less than 70 years old, and 70% of the outpatient and emergency medical expenses will be paid by the mutual aid fund and 30% by the individual for those who are 70 years old or older.
3. The maximum amount of outpatient and emergency medical expenses that can be paid by the mutual funds for large medical expenses is 20,000 yuan for employees and retirees in a year.
4. The mutual aid fund for large medical expenses pays 70% of the hospitalization medical expenses exceeding the maximum payment limit of the Basic Medical Insurance Coordination Fund (excluding the portion below the minimum payment standard and the portion borne by the individual), and the outpatient medical expenses for radiation therapy and chemotherapy for malignant tumors, renal dialysis, and antirejection medication after renal transplantation within an annual period, and 30% of the expenses are paid by the individual. However, the maximum cumulative amount paid by the mutual funds for large medical expenses in a year is 100,000 yuan.
VII. Medical Expenses Not Payable by the Basic Medical Insurance Coordination Fund
Part I is expressly stipulated in Municipal Government Decree No. 68 and related documents
1. medical treatment at a medical institution other than one's own designated medical institution, except for emergencies (which must be treated at a designated medical institution in close proximity to one's own home);
2. purchase of medicines from a retail pharmacy other than one's designated pharmacy;
3. outpatient medical expenses due to traffic accidents or medical malpractice; and 3. Injuries caused by traffic accidents, medical malpractice or other accidents;
4. Injuries caused by drug abuse, fights or other illegal acts;
5. Treatment for suicide, self-injury, alcoholism, etc.
6. Treatment abroad or in Hong Kong or Macao Special Administrative Regions or Taiwan;
7. In accordance with national and municipal regulations should be paid by the individual.
Medicare is not like workers' compensation insurance, is to be more than the starting line part can be reimbursed, you certainly can not go to the medical insurance, since it is caused by the work, then the declaration of injury, even if you can not identify the level of reimbursement of medical expenses, and now there is no work-related injury, the cost of your rightful unit to pay for the units to find units reimbursement, do not lose out on their own, I hope that you will soon get well!
Your case should not involve the starting line, I only know that the starting line of Beijing's active employees is 1,800 yuan, you can ask the unit personnel on it