(1) service items
1, registration fee, out-of-hospital consultation fee, medical record fee, etc.
2. Special medical services such as visiting fees, urgent fees for examination and treatment (except for emergency), surcharge for name calling operation, high quality and good price, and special care by oneself.
(2) Non-disease treatment projects
1, various beauty (life beauty, medical beauty) bodybuilding projects and disorderly non-functional plastic surgery, orthopedic surgery, etc. ;
2. Various weight loss, weight gain and height increase projects;
3. Various health checks;
4, all kinds of prevention and health care projects;
5. Registration fee, consultation fee outside the hospital, medical record fee, etc.
6. Special medical services such as visiting fees, urgent fees for examination and treatment (except for emergency), surcharge for name calling operation, high quality and good price, and special care by oneself.
(2) Non-disease treatment projects
1, various beauty (life beauty, medical beauty) bodybuilding projects and disorderly non-functional plastic surgery, orthopedic surgery, etc. ;
2. Various weight loss, weight gain and height increase projects;
3. Various health checks;
4, all kinds of prevention and health care projects;
5, tooth deformity, dental porcelain;
6, all kinds of medical consultation (excluding psychiatric consultation), medical appraisal.
(3) Diagnostic equipment and medical materials.
1, a project for examination and treatment with large medical equipment such as positron emission tomography, electron beam CT and ophthalmic excimer laser therapeutic apparatus;
2, glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation equipment;
3, all kinds of self-use health care, massage, rehabilitation and treatment equipment.
(4) Treatment items
1, the organ source or tissue source of various organ transplants or tissue transplants;
2. Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow;
3. Orthopedic surgery for myopia;
4, Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.
(5) Others
1, various infertility (pregnancy) and sexual dysfunction diagnosis and treatment projects;
2, all kinds of scientific research, clinical verification of diagnosis and treatment projects;
The medical expenses incurred by the insured under the following circumstances shall not be paid by the residents' basic medical insurance fund:
First, the damage caused by violation of relevant laws and regulations;
Second, suicide and self-harm (except mental illness) or drunkenness lead to casualties;
The third is plastic surgery and corrective treatment;
Fourth, it happened due to induced labor, abortion and family planning operation;
Fifth, it happened abroad;
Sixth, there is third party liability compensation;
Seventh, other payment ranges that do not meet the requirements of basic medical insurance for residents.
Proportion of medical insurance reimbursement in Jinan
See the table below for the reimbursement ratio of hospitalization expenses and deductible standard of medical insurance for employees in Jinan:
At the same time, there is also a reimbursement ratio for the second reimbursement: after the medical expenses of the prescribed diseases in the inpatient and outpatient departments in a medical year are paid by the employee basic medical insurance pooling fund and the large medical expenses relief fund according to regulations, the part of the individual's accumulated compliance medical expenses exceeding 6,543,800 yuan+0.2 million yuan will be paid by the pooling fund for the second time. Individuals who bear the compliance medical expenses of1.2000 yuan and less than 200000 yuan (including1.2000 yuan) will pay 60% and more than 200000 yuan (including 200000 yuan) from the overall fund.
, 400,000 yuan (including 400,000 yuan) part of the overall fund payment ratio is 70%; Personal compliance medical expenses 12000 yuan or less and more than 400,000 yuan will not be paid.
The insured person's medical expenses for diseases (including the part borne by individuals according to a certain proportion) that meet the payment scope of the residents' basic medical insurance fund within a medical year shall be subject to Qifubiaozhun and the maximum payment limit. Medical expenses below Qifubiaozhun and above the maximum payment limit shall be borne by individuals.
Qifubiaozhun: provincial (ministerial) tertiary medical institutions 1.200 yuan, other tertiary medical institutions 1.000 yuan, secondary medical institutions 700 yuan, primary medical institutions 400 yuan, and township hospitals 200 yuan.
Qifubiaozhun for college students: 700 yuan, a tertiary medical institution; 400 yuan, a secondary medical institution; 200 yuan, a primary medical institution (including community health service institutions and township hospitals).
Within a medical year, the Qifubiaozhun for the second hospitalization will be reduced by 20%, and the Qifubiaozhun will no longer be implemented from the third hospitalization. The outpatient service stipulates that the disease Qifubiaozhun is 200 yuan, and the insured person only undertakes it once in a medical year. The maximum payment limit for residents' medical insurance in a medical year is 200,000 yuan (including the individual pays part).
Reimbursement ratio: The medical expenses incurred by the insured in a medical year that meet the prescribed diseases of hospitalization or outpatient service within the payment scope of the residents' basic medical insurance fund shall be shared by the residents' basic medical insurance fund and individuals according to the following standards:
The proportion of reimbursement paid by children and adult residents according to the first-class standard (300 yuan) is stipulated in the following standards: for medical treatment in provincial (ministerial) tertiary medical institutions, the personal burden is 40%; In other tertiary medical institutions, 55% is paid by the residents' basic medical insurance fund, and the personal burden is 45%; Secondary medical institutions, residents' basic medical insurance fund to pay 65%, personal burden of 35%; In the first-class medical institutions and community health service institutions, 75% is paid by the residents' basic medical insurance fund, and the personal burden is 25%; For medical treatment in township hospitals, 80% is paid by the residents' basic medical insurance fund, and the personal burden is 20%.
According to the second standard (200 yuan), the proportion of reimbursement for adult residents is as follows: 35% for medical treatment in provincial (ministerial) tertiary medical institutions, and 65% for personal burden; In other tertiary medical institutions, 50% will be paid by the residents' basic medical insurance fund and 50% will be borne by individuals; Secondary medical institutions, residents' basic medical insurance fund to pay 65%, personal burden of 35%; In the first-class medical institutions and community health service institutions, 75% is paid by the residents' basic medical insurance fund, and the personal burden is 25%; For medical treatment in township hospitals, 80% is paid by the residents' basic medical insurance fund, and the personal burden is 20%.
The reimbursement rate of college students is stipulated according to the following standards: in tertiary medical institutions, 60% is paid by the residents' basic medical insurance fund, and the personal burden is 40%; For medical treatment in secondary medical institutions, 70% is paid by the residents' basic medical insurance fund, and 30% is borne by individuals; In the first-class medical institutions, township hospitals for medical treatment, the basic medical insurance fund for residents to pay 80%, personal burden of 20%.