Division of funds:
Hospital funding channels are divided into: basic medical funds, medical equipment and equipment purchases two parts (5 million yuan per year)
Medicare fund: personal account + co-ordination of the gold, each year, roughly 20 million personal account co-ordination of the gold 40 million.
Unified fund == enterprise 8% - (1% + 1.4% + 3.7%), personal account == personal 2% + (1% + 1.4% + 3.7%).
Individual account: mainly used to pay outpatient + pharmacy fees;
Coordinated payment: mainly used for hospitalization costs, chronic diseases and large-scale inspection and other into the integrated.
Two medical aid special fund:
1) at the end of the year according to the total number of registered employees and retirees per person 80 yuan of the standard composition of the extraction, divided into large medical aid (35,000 - 150,000) and difficult medical aid.
2) in a year, the health insurance co-ordination fund maximum payment limit of 35,000 yuan, large medical aid payment limit of 35,000 yuan to 150,000 yuan, more than 150,000 yuan part of the basic medical insurance no longer bear the burden of the leadership to decide.
3) Large medical aid: the insured workers incurred in the year in line with the provisions (35,000 to 150,000 yuan) of medical expenses. Payment ratio: 80% for the first year of participation; 85% for more than two years; retirees are treated 5 percentage points higher than active employees.
4) Difficulties in medical assistance: the insured employees in the year in the designated hospitals, in line with the provisions of the personal burden of the expenses exceeded more than 50% of their annual gross salary (half a year's salary). At the end of the year by each unit to report materials - medical insurance center review ---- reported by the group company's medical insurance leading group review and approval of ---- aid eligible employees in difficulty.
Three treatment cost mode:
1) outpatient: the main use of personal account, the integrated fund can pay for outpatient chronic diseases and large-scale inspection into the integrated proportion of the project.
2) Hospitalization:
a) Starting standard:
Second class A (and third class) hospitals: 400 for in-service, 300 for the second time and thereafter, and 200 after 300 for retirement. only the main hospital and the transfer, off-site hospitals Second class B (and first class) hospitals: 300 for in-service, 200 for the second time and thereafter, and 100 after 200 for retirement.
b) The part above the starting standard will be paid by the individual and the coordinated fund in proportion to the out-of-pocket expenses:
Above the starting standard from 0 to 10,000 yuan, the individual out-of-pocket expenses are 15% for the active employees and 7.5% for the retirees; above 10,000 yuan and up to the ceiling line (35,000 yuan), the individual out-of-pocket expenses are 10% for the active employees and 5% for the retirees.
3) Use of materials:
Participating employees enjoying basic medical treatment (0---35,000 yuan), use of domestic materials, 100% into the integrated reimbursement; joint venture materials individual out-of-pocket payment of 10%, the large amount of payment of 30%, the integrated proportional payment of 60%; imported materials individual out-of-pocket payment of 10%, the large amount of payment of 40%, the integrated proportional payment of 50%;
When enjoying large medical aid (35,000--150,000 yuan), the individual pays 10% for the use of imported and joint-venture materials, and the remaining 90% is paid by the large amount according to the prescribed proportion.
4) Drug management:
a) Use of Class A drugs 100% into the integrated reimbursement scope, paid in proportion.
b) Class B medicines: The insured employee pays 10% and 90% == Class A medicines
c) The use of Class B medicines ---- should first obtain the consent of the employee and sign an agreement ---- The cost of medicines without an agreement ---- The insured employee can refuse to pay the cost of the medicines ---- The medical insurance fund will not pay for them either.
d)The cost of Class B drugs used in hospitals shall not exceed 50% of the total cost of drugs for the current hospitalization; the cost of self-financed drugs shall not exceed 10% of the total cost of drugs for the current hospitalization, and the hospitals must ensure that more than 90% of the drugs are covered by the medical insurance policy
Four Interest on Individual Employee Medical Insurance Accounts
The specific method of calculating the interest accrued on the employee's individual medical insurance account is ---- tentatively calculated according to the interest rate on demand deposits announced by the bank in the current year. The interest rate is calculated according to the interest rate of demand deposits announced by the bank in the current year.
V Chronic Disease Management:
After the identification of the chronic disease employees recorded in the health insurance network, after the exhaustion of the individual account, the active employees will pay 400 yuan out-of-pocket, and the retirees will pay 300 yuan out-of-pocket, and they can enter into the integrated system. Each time the cost of ----- the insured workers pay 20% out of pocket after the proportion of the integrated fund. (The maximum payment limit of outpatient co-ordination fund for multiple chronic diseases at the same time is 500 yuan for each additional type, up to a maximum of 5,000 yuan. Outpatient chemotherapy and radiotherapy for malignant tumors, dialysis for patients with uremia, and anti-discharge treatment after organ transplantation are not subject to the outpatient maximum limit of the coordinated fund, and are not subject to the 20% threshold, and are paid by the coordinated fund on a pro rata basis. Chronic disease costs incurred on an outpatient basis are counted towards the maximum payment limit of the integrated fund (0 to 150,000).
Six family members medical management:
Company employees to support the immediate family (including only child) in the event of illness, you can enjoy on-the-job employee medical expenses 1/2.
Outpatient treatment: employees' family members can swipe the card in the outpatient clinic Pharmacy to purchase medicines, the current year's personal account will not be carried forward and inheritance. Employee family members hospitalization transfer in accordance with 1/2 of the reimbursement scope of active employees.
Seven referral and transfer of medical expenses settlement and process
1) Transfer to the designated hospitals: the Group has tentatively decided on four hospitals affiliated to Bengbu Medical College; the hospital affiliated to Anhui Medical University; the General Hospital of the Nanjing Military Command; and the Second Hospital of Xuzhou. When reimbursement is made, the individual first pays 10% of the amount that meets the requirements for medical insurance payment, and the other 90% is reimbursed according to the proportion. If the patient is transferred to a non-designated hospital, the individual pays 50% and the other 50% is reimbursed on a pro rata basis.
2) For those who are suffering from serious specialized diseases, which cannot be treated in general hospitals or for which there is no good treatment, and are recommended by the designated hospitals to be transferred to specialized non-designated hospitals for treatment, reimbursement can be made on the basis of the designated hospitals (90% of the reimbursement enters into the reimbursement).
3) Emergency medical treatment for business trip and legal family leave: If you are hospitalized in a non-scheduled hospital for emergency treatment, after the treatment is finished, you can go to the scheduled hospital for the relevant reimbursement procedures with the hospital's emergency medical record data, valid invoices, the list of medical expenses and the certificate of your own unit, as well as a copy of the round-trip ticket to and from the place where you went out, specifically, the individual pays 10% of the expenses in line with the regulations on the payment of the basic medical care fund, and the remaining part is The rest will be reimbursed according to the regulations.
VIII. Conditions for medical treatment in other places:
The conditions for medical treatment in other places:
1. retired workers, due to the need of life, the household registration is moved to other places and live in other places for a long period of time. 2. retired workers, due to the lack of children around them, go to their children's place of residence for more than one year in other places. 3. units are sent to other places and work in other places for a long period of time for more than one year. Reimbursement for medical treatment in a different place: the individual pays 10% out of pocket first, and the rest is reimbursed according to the proportion.
Nine birth control four surgery management:
Four birth control surgeries refer to ring implantation, ring removal, ligation, termination of pregnancy ----- The object is the whole company employees and their married immediate family members. ---- Procedures:Anyone who needs to implement the four surgeries, you need to hold a certificate of the birth control office of your unit and your medical insurance card ----- to the designated hospitals in this unit to implement the cost of booking processing.
Ten medical insurance cost settlement:
Medical insurance management department of the hospital costs incurred in accordance with the provisions of the audit, will be audited in accordance with the provisions of the payment of costs reported to the assets of the Department of Finance as the basis for disbursement. 90% of the unified fund will be used by the general hospital, and the other 10% will be honored by the medical insurance management department after the assessment (which will be carried out in January of the following year), and the individual account fund will be settled according to the facts.
Related contribution base Proportion:
Individual employees will use their 2005 average monthly salary income (including bonuses and allowances) as their contribution base for the year 2006, and the insured units will use the sum of the contribution base of all individual employees of the unit as their contribution base.
Pension insurance contribution rate: 18% for the unit, 8% for the individual
Unemployment insurance contribution rate: 2% for the unit, 1% for the individual
Medical insurance contribution rate: 8% for the unit, 2% for the individual
Worker's compensation insurance contribution rate: the unit is subject to the adjustment of worker's compensation insurance fee rate in 2006
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