I. Reimbursement proportion
Reimbursement proportion of medical expenses for urban workers:
Reimbursement proportion of hospitalization:
Qifubiaozhun:
First hospitalization: Grade I: 1 yuan; Secondary 3 yuan; Three-level 88 yuan.
Second hospitalization: Grade I: 3 yuan; Secondary 9 yuan; Three-level 264 yuan.
Third and above hospitalization: Grade I: yuan; Secondary yuan; Three-level yuan.
note: qifubiaozhun for people over 7 years old will be halved.
Out-of-pocket part:
1. Class B drugs, special inspection and special treatment: 3% for class B drugs, and 1% for special inspection and special treatment;
2. Disposable medical materials and artificial organs above 2 yuan: 1% made in China and 2% imported;
3. Out-of-range medication: 4%.
co-ordination self-payment part:
co-ordination self-payment part = [total hospitalization expenses-(Qifubiaozhun+first self-payment part+full self-payment part) ]× self-payment ratio.
On-the-job employees: 9% for Grade I, 12% for Grade II and 15% for Grade III;
retired employees: level 1 5%, level 2 8% and level 3 11%;
reimbursement rate for outpatient service:
1. General outpatient service
Full payment by individuals
2. Special examination and treatment for outpatient service
3% by individuals and 7% by basic medical care.
note: special examination and special treatment are required in the outpatient department of hospitals above Grade II.
3. Outpatient service for chronic diseases
Regardless of the hospital level in a natural year, the Qifubiaozhun is 55 yuan first. After exceeding the Qifubiaozhun, the overall fund pays 8% and the individual pays 2%;
note: the maximum payment limit of the overall fund in each natural year is 2, yuan (limited to drug expenses). If two or more "special chronic diseases" are identified after examination, the maximum payment limit will be raised to 3, yuan, and the drug expenses beyond the maximum payment limit will not be reimbursed.
4. Outpatients with special diseases
Patients with "special diseases" who have been examined and identified shall be reimbursed for outpatient expenses in a natural year according to hospitalization treatment.
proportion of reimbursement for medical expenses of urban and rural residents:
In terms of hospitalization medical expenses:
1. The threshold for medical institutions at or below the first level is 1 yuan, and the reimbursement ratio is 85%;
2. the qifubiaozhun of secondary medical institutions is 3 yuan, and the reimbursement rate is 75%;
3. the qifubiaozhun of tertiary hospitals is 6 yuan, and the reimbursement rate is 6%;
Treatment of outpatient medical expenses:
The outpatient medical expenses and medical expenses of the insured in the designated primary health service institutions are reimbursed by the overall fund by 5%, and the maximum payment limit is 4 yuan in a natural year;
II. Scope of reimbursement
Non-reimbursement under urban and rural medical insurance expenses:
(1) Defining the medical expenses paid by the industrial injury insurance fund;
(2) traffic accidents (except for the relevant certificates issued by the traffic administrative department of the public security), accidents, medical accidents, etc. which are clearly the responsibility of a third party;
(3) It should be borne by public health;
(4) seeking medical treatment abroad;
(5) Other expenses not paid as stipulated by laws and regulations.
III. Reimbursement conditions
Individuals begin to enjoy medical insurance benefits after six months of continuous payment for the first time
IV. Reimbursement materials
1. Outpatient medical records
2. Discharge summary
3. Disease certificate
4. Receipt (invoice) of hospitalization expenses
5. List of hospitalization expenses
6. For reimbursement of hospitalization expenses in different places, provide the original and photocopy of the certificate of the unit (community neighborhood committee/school) or the Registration Form of Kunming's Personnel Living in Different Places or Working Abroad Choosing Designated Medical Institutions in Different Places
8. If the card cannot be directly settled in a designated hospital for special reasons, provide relevant certificates and explanations of medical treatment
9. If someone entrusts others to act as an agent, the applicant's power of attorney and the original and photocopy of the agent's ID card (original inspection) must be provided