Poor households and destitute dependents in the county. Fully subsidize the insured for the poor; Poor households are given a fixed subsidy according to the standard of per person 140 yuan. Persons with multiple identity attributes shall be given subsidies according to the principle of "priority", and the total amount of subsidies shall not exceed that of 280 yuan.
Second, the conditions for enjoying treatment
Non-poor households who have not paid during the centralized collection period can be insured by sporadic payment, and pay insurance premiums according to the sum of individual payment standards and government subsidy standards in the current year, and begin to enjoy medical insurance benefits for urban and rural residents 60 days after the date of payment.
(a) dynamic newborn insurance, by the guardian within 90 days after birth for insurance registration and payment, according to the current personal payment standard, since the date of birth to enjoy medical insurance benefits for urban and rural residents; Those who pay for more than 90 days will begin to enjoy medical insurance benefits for urban and rural residents 60 days after the payment date.
(two) the new staff of poor households to implement dynamic insurance, not limited by the number of years of centralized collection, enjoy the insurance subsidy policy. Individuals only pay 140 yuan and financial subsidies at all levels 140 yuan.
(3) In the year when active servicemen retired from active service, the urban and rural residents' medical insurance bank participated in the insurance dynamically throughout the year, and the payment standard was the individual payment standard of urban and rural residents in that year, and they enjoyed the medical insurance benefits for urban and rural residents from the date of payment.
(4) Those who participate in the basic medical insurance for employees may participate in the medical insurance for urban and rural residents within 90 days after the payment of the basic medical insurance for employees is suspended. The payment standard is the individual payment standard of urban and rural residents in that year, and they can enjoy medical insurance benefits for urban and rural residents from the date of payment; More than 90 days, 60 days from the date of payment to enjoy medical insurance benefits for urban and rural residents.
Third, the medical insurance treatment policy
(1) outpatient treatment
The level of medical institutions is based on the approval letter of practice registration issued by the health administrative department or the hospital-level approval document. There is no clear grade standard of medical institutions, with reference to the first-class medical institutions approved by the health administrative department at the county level; Medical institutions approved by the municipal public health administrative department shall be implemented with reference to secondary medical institutions; Medical institutions approved by the provincial health administrative department shall be implemented with reference to tertiary medical institutions.
2. Outpatient treatment of chronic diseases:
① For the insured with hypertension (high risk and extremely high risk among 1 grade hypertension, grade 2 hypertension and grade 3 hypertension) and without target organ damage and diabetes (1 type, type 2 diabetes), the compensation standard shall be in accordance with the Implementation Opinions on Improving the Medication Guarantee Mechanism for Hypertension and Diabetes Outpatients in Urban and Rural Residents (Guizhou Medical Insurance Development [20 19]).
② Rheumatoid arthritis (rheumatoid arthritis), arthropathy (hip and knee), psychosis, cerebrovascular disease and its sequelae (with severe dysfunction), diabetes (with chronic diseases of heart, brain, kidney and nervous system), hypertension (with damage of heart, brain and kidney), chronic obstructive emphysema, pulmonary heart disease, active tuberculosis, rheumatic heart disease, senile dementia, cardiomyopathy and chronic bronchitis. For the medical expenses of liver cirrhosis, chronic active hepatitis, pneumoconiosis, heart disease complicated with cardiac insufficiency, coronary heart disease, hypothyroidism, Parkinson's disease and myasthenia gravis within the policy scope, the payment ratio is 60%, and there is no deductible line, and the annual capping line is 4,000 yuan. Handling process of chronic disease certificate: it is necessary to provide the township (street) health center (community health service center) where the household registration is located with the disease certificate of public medical institutions, the corresponding auxiliary inspection report, the hospitalization medical record and the copy of ID card (household registration book), and the hospital (community health service center) will submit it to the county medical insurance bureau for examination and approval.
3. Outpatient treatment of special diseases: For all kinds of special diseases such as malignant tumors, leukemia (except the standardized drug treatment of chronic myeloid leukemia), aplastic anemia, systemic lupus erythematosus, organ transplant anti-rejection treatment, rare diseases, etc., the proportion of medical expenses paid within the outpatient treatment policy of public medical institutions above the second level is 75%, and there is no deductible. In a natural year, the fund paid a total of 60,000 yuan.
(two) the basic medical insurance hospitalization benefits
1. The expenses incurred by the insured during hospitalization in the designated medical institution at the place of medical treatment shall be reimbursed according to the following policies.
The level of medical institutions is based on the approval letter of practice registration issued by the health administrative department or the hospital-level approval document. There is no clear grade standard of medical institutions, with reference to the first-class medical institutions approved by the health administrative department at the county level; Medical institutions approved by the municipal public health administrative department shall be implemented with reference to secondary medical institutions; Medical institutions approved by the provincial health administrative department shall be implemented with reference to tertiary medical institutions.
2. Top line: the annual cumulative reimbursement top line is 250,000 yuan (excluding critical illness insurance).
3. Off-site medical treatment, referral and referral for the record:
(1) When the insured is hospitalized outside the city, it is necessary to go to the district (county) medical insurance agency or the hospital led by the medical * * * institution for systematic referral registration.
(2) critically ill patients to the insured medical insurance agencies to implement telephone filing. Due to accidental injury hospitalization, according to the provisions of the commercial insurance institutions as referral for the record.
③ If the insured person lives outside the overall planning area for a long time, he shall apply for medical registration in different places and follow the referral policy. Did not apply for medical registration in different places, according to the implementation of regional policy without reference.
(4) Patients suffering from the same disease in the same medical institution who need to be hospitalized for many times only need to go through the referral procedure once a year.
(III) Treatment of 25 major diseases If 25 major diseases are treated in designated medical institutions recognized by the original provincial level, they will be reimbursed according to the standards of the original major diseases before integration.
(4) Accident insurance benefits
1. Accidental injuries caused by the insured without third-party liability shall be hospitalized in designated medical institutions and designated medical institutions with the ability to treat them. If the hospitalization expenses meet the requirements of the three catalogues, they shall be reimbursed according to the hospitalization policy of basic medical insurance. The medical expenses incurred in hospitalization in township hospitals and community health service centers due to accidental injuries are not included in the accidental injury insurance fund, and are paid by the basic medical insurance fund for urban and rural residents. Follow-up treatment of trauma (such as taking steel plate implants, etc.). ) according to the general hospitalization into the basic medical payment.
2. Non-payment scope:
(1) shall be paid from the industrial injury insurance fund;
(2) The expenses that should be borne by the third-party responsible person and their subsequent treatment;
(3) It should be borne by public health;
3. If the insured person is hospitalized in this city due to accidental injury, the hospital shall report the case to the commercial insurance institution within 48 hours of admission; In case of hospitalization outside the city, the insured person or his family members shall report to the commercial insurance company of the insured place within 5 working days after admission. If the case is reported beyond the specified time, the reimbursement ratio will be reduced by 30 percentage points, and some of the reduced expenses will no longer be included in the scope of serious illness insurance and medical assistance. The undertaking commercial insurance institution shall feed back the investigation report to the hospital, the insured or their families within 3 days after receiving the report, and the special circumstances may be appropriately extended.
(5) After the basic medical reimbursement of the treatment policy of serious illness insurance, if the annual accumulated out-of-pocket expenses of individuals within the policy range exceed 9,000 yuan, they can enter the compensation of serious illness insurance, and 60% will be reimbursed within 9,000 yuan to 30,000 yuan (including 30,000 yuan); The annual cumulative out-of-pocket expenses exceeding 30,000 yuan to 50,000 yuan (including 50,000 yuan) shall be reimbursed by 65%; 70% of the annual cumulative out-of-pocket expenses exceed 50,000 yuan. The capping line is300,000. The deductible line of serious illness insurance for poor households is reduced by 50% on the basis of the general population, and the compensation ratio of each file is increased by 5 percentage points. That is, after the reimbursement of basic medical care, the accumulated annual out-of-pocket expenses of individuals within the policy scope exceed 4,500 yuan, and within 30,000 yuan (including 30,000 yuan), they will be reimbursed by 65%; The annual cumulative out-of-pocket expenses exceed 70% of 30,000 yuan to 50,000 yuan (including 50,000 yuan); 75% of the annual cumulative out-of-pocket expenses exceed 50,000 yuan. There is no capping line for serious illness insurance for poor households.
(VI) Medical Assistance Policy: After the poor households are referred for hospitalization and reimbursed by basic medical insurance and serious illness insurance, the out-of-pocket proportion of hospitalization medical expenses within the annual assistance limit is 70%, and the annual assistance limit is 50,000 yuan. The reduced proportion is not included in the scope of medical assistance reimbursement.
Four, hospitalization reimbursement process
(1) One-stop instant settlement. The medical insurance poverty alleviation object is hospitalized in the designated medical institutions in the city, and the three guarantees of basic medical insurance, serious illness insurance and medical assistance are "one-stop" instant settlement, and patients only need to pay their share when they leave the hospital. Those with double or multiple special attributes shall not be reimbursed repeatedly.
(2) Non-one-stop instant settlement. When the medical insurance poverty alleviation object is hospitalized in a non-networked medical institution, it is necessary to provide a copy of the ID card or household registration book, the original hospitalization invoice, the discharge summary, the list of hospitalization expenses and the copy of the bank passbook (card) to the township (street) comprehensive outpatient station. If it is an accidental injury, submit it to window 28 of the county government affairs center (life insurance company). The medical insurance agency will complete the review of basic medical insurance, serious illness insurance and medical assistance reimbursement within 25 working days, and directly transfer the reimbursement expenses to the patient's designated bank account to realize the "one card" for fund payment. Except for special medical records and suspicious medical records.
Legal basis:
"Interim Measures for Social Assistance" Article 2 The social assistance system adheres to the bottom line, is difficult to help, is sustainable, and is connected with other social security systems, and the level of social assistance is compatible with the level of economic and social development.
Social assistance should follow the principles of openness, fairness, impartiality and timeliness.
Article 3 The civil affairs department of the State Council shall co-ordinate the construction of the national social assistance system. The State Council civil affairs, emergency management, health, education, housing and urban construction, human resources and social security, medical security and other departments are responsible for the corresponding social assistance management according to their respective responsibilities.
The departments of civil affairs, emergency management, health, education, housing and urban construction, human resources and social security, medical security and other departments of the local people's governments at or above the county level shall be responsible for the corresponding social assistance management within their respective administrative areas.
The administrative departments listed in the preceding two paragraphs are collectively referred to as social assistance management departments.
Fourth Township People's governments and sub-district offices are responsible for the acceptance, investigation and review of social assistance applications, and the specific work shall be undertaken by social assistance institutions or managers.
Villagers' committees and residents' committees shall assist in the relevant social assistance work.