9. What are the outpatient benefits for insured children and college students?
After children and college students participate in inpatient medical insurance, their outpatient services (outpatient services) that occur at the bound social health center or hospital (Including emergency medicine) expenses are handled according to the following regulations:
1. For Class A drugs and Class B drugs in the basic medical insurance drug catalog, the community outpatient coordinating fund will pay 80% and 60% respectively.
2. For diagnosis and treatment items or medical materials included in the basic medical insurance catalog, if the individual price is less than 120 yuan, 90% will be paid by the community outpatient coordinating fund; if the individual price is more than 120 yuan, the community outpatient clinic will pay 90% The overall fund payment is 120 yuan.
3. Outpatient medical expenses incurred by insured persons who need to be transferred to other designated medical institutions with the approval of the settlement hospital due to their illness, or emergency medical expenses incurred in non-settlement hospitals, shall be covered by the community outpatient coordinating fund in accordance with this article. Items 1 and 2 stipulate that 90% of the payment fee will be reimbursed.
The total amount of outpatient medical (including emergency) expenses paid by the community outpatient coordinating fund to each inpatient medical insurance insured person within a medical insurance year shall not exceed 800 yuan.
70% of the outpatient blood transfusion expenses incurred by insured children and college students due to their illness are included in the accounting scope of the basic medical insurance critical illness coordination fund.
10. What benefits can insured children and college students enjoy when they are hospitalized?
The basic hospitalization medical expenses and drug expenses incurred by insured children and college students fall within the scope of the basic medical insurance drug catalog The diagnosis and treatment items and general medical materials in the catalog will be included in the accounting scope of the basic medical insurance serious illness coordination fund at a ratio of 90%. When hospitalized, the hospitalization deductibles are also different according to the level of the hospital where the patient is staying. The portion below the deductible is paid by the individual and is not included in the scope of medical insurance payment. The fee is 100 yuan for first-level and lower hospitals in the city, 200 yuan for second-level hospitals in the city, 300 yuan for third-level hospitals in the city, and 400 yuan for hospitals outside the city. If the patient is transferred to a different hospital for hospitalization, the hospitalization deductible will be calculated separately.
11. Can parents’ personal accounts be used to pay for their children’s outpatient medical expenses?
Yes. After a child participates in inpatient medical insurance, if the personal account accumulation of one of his parents reaches one month's average monthly salary of city employees in the previous year and above, the excess can be used to pay for the outpatient medical expenses of the child who participates in inpatient medical insurance. When participating in insured children's outpatient medical treatment, parents must provide one parent's social security card, and the outpatient medical expenses incurred can be paid from the parent's medical insurance personal account, and will not occupy the child's own community outpatient overall fund payment limit.
12. What is the maximum payment limit of basic medical insurance? What is the maximum payment limit of local supplementary medical insurance?
The maximum payment limit of the basic medical insurance pooling fund for each medical insurance year is the same as The number of years the insured has continuously participated in basic medical insurance is linked to the period of continuous participation for less than half a year, for more than half a year but less than 1 year, for more than 1 year but less than 2 years, for more than 2 years but less than 3 years, and for more than 3 years but less than 6 years. , for more than 6 years, the maximum payment limits are 1 times, 2 times, 3 times, 4 times, 5 times, and 6 times the average annual salary of employees in the city in the previous year.
The maximum payment limit of the local supplementary medical insurance fund in each medical insurance year is linked to the time the insured has continuously participated in local supplementary medical insurance. For 2 years, for 2 years but less than 3 years, and for 3 years but less than 6 years, the maximum payment limits are 50,000 yuan, 100,000 yuan, 150,000 yuan, and 200,000 yuan respectively. If you have been insured for more than 6 consecutive years, there is no limit. Maximum payment limit.
13. How to enjoy the benefits of serious illness outpatient medical insurance?
Insured children and college students need outpatient dialysis for chronic renal failure due to outpatient serious illness, and outpatient anti-rejection drugs after organ transplantation. Outpatient chemotherapy, interventional therapy, radiotherapy or radionuclide therapy for malignant tumors, hemophilia, and aplastic anemia can enjoy outpatient medical insurance benefits for serious illnesses after approval by the municipal social insurance agency.
The specific treatment is that 90% of the basic medical expenses incurred are included in the accounting scope of the basic medical insurance serious illness pooling fund, and 80% of the local supplementary medical expenses are paid by the local supplementary medical insurance fund.
14. Under what circumstances can insured children and college students be referred to medical institutions outside the city? Can hospitalization in other places be reimbursed without going through the referral procedures?
Insured children and College students who have one of the following circumstances after being diagnosed and treated at designated medical institutions in this city can be transferred to medical institutions outside the city for treatment: 1. The disease is among the referral diseases announced by the city’s human resources and security department; 2. After being diagnosed by the city’s three medical institutions, Difficult diseases that cannot be diagnosed through examination and consultation in first-level hospitals or municipal specialized hospitals; 3. Critically ill patients who currently do not have the equipment or technology to diagnose and treat in the city's third-level hospitals or municipal specialized hospitals.
If the insured fails to go through the referral procedures as required, and the hospitalization medical expenses incurred by the designated medical institutions outside the city are within the payment range of the medical insurance fund, they can apply for reimbursement, but the reimbursement rate will be reduced by 20 percentage points; hospitalization medical expenses incurred at other non-designated medical institutions in China that meet the payment scope of the medical insurance fund can apply for reimbursement, but the reimbursement rate is reduced by 40 percentage points.
The medical institution receiving referral outside the city should be a non-profit medical institution at the same level or above as the medical institution being transferred out