People who are not covered by the basic medical insurance for employees within the administrative area of our city participate in the medical insurance for urban and rural residents. Include the following personnel:
Rural residents;
Urban non-employed residents;
Full-time undergraduates, full-time postgraduates and students from vocational high schools, technical secondary schools and technical schools who receive general higher education in various full-time colleges and research institutes;
Other personnel specified by the state and our province.
In 2022, the individual payment standard of medical insurance for urban and rural residents will be 320 yuan, and the time of insurance payment will be 20210 to 202 1 15.
Two. Basic medical insurance benefits for urban and rural residents
The treatment that can be enjoyed by participating in medical insurance for urban and rural residents: In 2022, the maximum payment limit of basic medical insurance for urban and rural residents is 6,543,800 yuan+0.5 million yuan.
1. Hospitalization: The deductible standard and reimbursement ratio of insured residents in 2022 are as follows:
kind
Medical scope
Qifubiaozhun
Reimbursement ratio
Town level
health clinics in towns and townships
150
90%
County level
Secondary hospitals or hospitals below a certain scale.
celebrity
80%
Municipal level
Secondary hospitals or hospitals below a certain scale.
600
80%
Tertiary hospital
1200
1200-4000 yuan 53%
More than 4000 yuan 72%
Provincial level
Secondary hospitals or hospitals below a certain scale.
600
600-4000 yuan 53%
More than 4000 yuan 72%
Tertiary hospital
2000
2000-7000 yuan 50%
More than 7000 yuan 68%
outside the province
2000
2000-7000 yuan 50%
More than 7000 yuan 68%
/kloc-Qifubiaozhun for insured residents under 0/4 years old will be halved. Other insured residents are hospitalized in hospitals at or above the county level for the second time and later in the year, and the Qifubiaozhun is halved.
2. Maternity medical treatment for insured residents: pregnant women who participate in medical insurance for urban and rural residents give birth in hospital, and the hospitalization medical expenses are paid in a fixed amount. The quota standards are: natural delivery in 600 yuan, cesarean section 1600 yuan. The actual hospitalization expenses are settled according to the facts below the quota standard, and those exceeding the quota standard are paid according to the quota standard.
3. Diseases and treatment of serious and chronic diseases in residents' medical insurance outpatient service: there are 35 kinds of chronic diseases in outpatient service, with no minimum payment standard, 80% reimbursement rate, fixed-point treatment and monthly quota capping management.
4. Major diseases of residents' medical insurance:
serial number
Type of disease
Monthly ceiling
1
Chronic heart failure
290 yuan/month
2
Decompensated stage of liver cirrhosis
420 yuan/month
three
tuberculosis
160 yuan/month
four
epilepsy
100 yuan/month
five
schizophrenia
230 yuan/month
six
Sun god
250 yuan/month
seven
ankylosing spondylitis
250 yuan/month
eight
lupus erythematosus
400 yuan/month
nine
Diabetes with complications
290 yuan/month
10
Sequela of acute cerebrovascular disease
230 yuan/month
1 1
Malignant tumor
560 yuan/month
12
Non-dialysis
1500 yuan/month
13
pulmonary heart disease
100 yuan/month
14
Chronic obstructive emphysema
200 yuan/month
15
Anti-rejection therapy after organ transplantation
0- 1 year 4900 yuan/month
1-3 years 4000 yuan/month
3 years and above 3,300 yuan/month
16
Treatment after coronary stent implantation
290/ month
17
rheumatic cardiopathy
100 yuan/month
18
chronic atrophic gastritis
100 yuan/month
19
Chronic viral hepatitis
2 10 yuan/month
20
Secondary and above hypertension
250 yuan/month
2 1
Parkinson's disease
250 yuan/month
22
coronary heart disease
500 yuan/month
23
Edema nephritis
1300 yuan/month
24
myasthenia gravis
300 yuan/month
25
hypothyroidism
300 yuan/month
26
hepatolenticular degeneration
300 yuan/month
27
pulmonary interstitial fibrosis
300 yuan/month
28
sicca syndrome
600 yuan/month
29
Myelodysplastic syndrome
500 yuan _ month
30
After heart valve replacement and coronary artery bypass surgery
350 yuan _ month
3 1
Schizophrenia
230 yuan/month
32
Persistent paranoia
230 yuan/month
33
bipolar disorder
230 yuan/month
34
Mental disorder caused by epilepsy
230 yuan/month
35
Mental retardation with mental disorder
230 yuan/month
There are 34 kinds of serious diseases in hospital, They are: childhood acute lymphoblastic leukemia, childhood acute promyelocytic leukemia, childhood congenital atrial septal defect, childhood congenital ventricular septal defect, childhood congenital patent ductus arteriosus, childhood congenital pulmonary valve stenosis, complete endocardial cushion defect, partial endocardial cushion defect, coarctation of aorta, tetralogy of Fallot, atrial septal defect with ventricular septal defect, ventricular septal defect with right ventricular outflow tract stenosis, ventricular septal defect with patent ductus arteriosus, Ventricular septal defect, patent ductus arteriosus with pulmonary valve stenosis, atrial ventricular septal defect with patent ductus arteriosus, cleft lip, cleft palate, breast cancer, cervical cancer, lung cancer, esophageal cancer, gastric cancer, colon cancer, rectal cancer, acute myocardial infarction, chronic myeloid leukemia, severe psychosis, multidrug-resistant tuberculosis, bilateral severe sensorineural deafness, hypospadias and congenital hypertrophic pyloric stenosis. Fill in the application form, register for the record, and see a doctor at a designated place in the province. There is no Qifubiaozhun, and reimbursement will be made in proportion, 80% at the county level, 70% at the municipal level and 65% at the provincial level.
There are 35 kinds of serious diseases in outpatient service, namely: end-stage renal disease, hemophilia, chronic myeloid leukemia, type I diabetes, hyperthyroidism, multidrug resistance, aplastic anemia, phenylketonuria, non-small cell lung cancer, gastrointestinal stromal tumor, HER2-positive breast cancer, advanced gastric cancer, stage III/IV nasopharyngeal carcinoma, peripheral T-cell lymphoma, renal angiomyolipoma, prostate cancer and multiple sclerosis. Primary immunoglobulin deficiency, idiopathic pulmonary fibrosis, thyroid cancer, acute promyelocytic leukemia, colon cancer, rectal cancer, melanoma, mantle cell lymphoma, small lymphocytic lymphoma, chronic lymphocytic leukemia, gastrointestinal pancreatic endocrine tumor, acromegaly, renal cancer, liver cancer, pancreatic neuroendocrine tumor, multiple myeloma. Fill in the application form, register for the record, and go to the designated hospital in the province for medical treatment. There is no qifubiaozhun, and it will be reimbursed in proportion. The proportion of outpatient peritoneal dialysis is 85%, the other outpatient diseases are 80%, and the reimbursement rate of rural poor people is 85%.
5. Medical care for newborns. In the year when the newborn is born, parents who participate in the basic medical insurance automatically obtain the insurance qualification and enjoy the medical insurance benefits for urban and rural residents. If a newborn mother or father participates in the local medical insurance for urban and rural residents, he can enjoy the medical insurance benefits for urban and rural residents in the year of birth as a mother or father with the identity certificate of the mother or father and the medical certificate of birth of the newborn. Parents did not participate in the local medical insurance for urban and rural residents, according to the provisions of the medical insurance agencies for insurance procedures, newborns from the date of birth to enjoy medical insurance benefits for urban and rural residents.
6. "Two diseases" and outpatient treatment as a whole. It is mainly used to pay the general outpatient medical expenses incurred by insured residents in designated medical institutions at the grassroots level. There is no Qifubiaozhun for "two diseases" and outpatient co-ordination, and the reimbursement ratio is 60%. "Two diseases" and outpatient co-ordination annual cumulative reimbursement amount combined calculation, reimbursement amount for 400 yuan. The former family account can be used for outpatient medical expenses and hospitalization medical expenses of insured residents.
7. Increase the reimbursement rate of hospitalization medical expenses for the elderly over 80 years old. The object of protection is those who have participated in the basic medical insurance for urban and rural residents in our province and have reached the age of 80 at the time of discharge. For the medical expenses incurred by the insured elderly within the policy scope of designated medical institutions at all levels, the reimbursement ratio of basic medical insurance will be increased by 5 percentage points on the basis of the current policy, with the maximum not exceeding 95%.
Graded diagnosis and treatment
Insured residents should first seek medical treatment in designated medical institutions at the grassroots level. If they need to be referred or transferred to medical institutions above the municipal level in the insured area, they should go through the procedures of referral and transfer and enjoy medical insurance benefits in accordance with the regulations; Failing to go through the referral procedures as required, the reimbursement rate at the corresponding medical institution level will be reduced by 20 percentage points.
Accidental injury hospitalization record
Insured residents who are hospitalized due to accidental injuries need to fill out the Notice of Accidental Injury Hospitalization in Basic Medical Insurance for Urban and Rural Residents in triplicate, and provide the first page of outpatient or inpatient medical records and injury history. After being signed and sealed by the medical department and the hospital medical insurance office, they shall go to the medical insurance service center for urban and rural residents for the record within three working days.
Seek medical treatment in different places
Long-term residents living in different places and long-term migrant workers can apply to the medical insurance agency in the insured place for off-site filing through on-site telephone and official WeChat account. After filing, the medical expenses incurred in hospitalization in designated medical institutions in different places of residence can be directly settled through networking.
Referral and referral personnel from different places, according to the regulations, after issuing referral and referral procedures in designated medical institutions with referral and referral qualifications in this city, go to the medical insurance agency of the insured place for filing and handle electronic referral, and realize direct settlement through networking of designated medical institutions in different places.
Outpatient chronic disease identification
1. Declaration conditions
All insured residents who participate in the basic medical insurance for urban and rural residents in Xinxiang and pay the fees on time can declare that they have one of the chronic diseases of the basic medical insurance for urban and rural residents in Xinxiang. If you have two or more diseases that meet the requirements of the disease at the same time, you should choose one of the main treatment diseases to declare.
2. Time of declaration
In principle, chronic diseases in outpatient clinics of basic medical insurance for urban and rural residents are reported once every quarter, and the reporting time is 1 to 25/in the last month of each quarter.
For the rural poor who have set up their cards, they can apply with them, identify them at any time, and handle them at any time.
3. Declaration procedure
Insured residents who meet the scope of outpatient chronic diseases should apply to the medical insurance agency for urban and rural residents in the insured area, receive and fill out the Application Form for Outpatient Chronic Diseases of Basic Medical Insurance for Urban and Rural Residents in Xinxiang City, and provide the diagnosis certificate, various inspection reports issued by the deputy chief physician of a medical institution above level 3, copies of hospitalization medical records related to the declared diseases for more than three months and less than two years, and copies of the first and second pages of my medical insurance card or social security card and ID card.
In view of the urgent need for treatment of some special diseases after operation, and the high medical expenses and heavy personal burden, the following diseases can be declared at any time, and experts will regularly review and identify them according to the application materials. They are: anti-rejection therapy after organ transplantation; Treatment within one year after coronary stent implantation; Malignant tumor; Tuberculosis; Schizophrenia; After heart valve replacement and coronary artery bypass surgery.
4. In the month following the application for appraisal, the appraisal results shall be publicized for one week.
III. Medical Insurance for Serious Illness of Urban and Rural Residents
Urban and rural residents who spend a lot on serious illness can enjoy the treatment of serious illness insurance for urban and rural residents. After the reimbursement of basic medical insurance, the part of the individual's accumulated compliance medical expenses exceeding 1. 1 10,000 yuan can be reimbursed according to the following standards:
1. 1 10,000 yuan-1 10,000 yuan is partially reimbursed by 60%;
65,438+70% for the part above 10,000 yuan;
You can reimburse up to 400,000 a year.
Serious illness insurance continued to give preferential policies to the rural poor, and the deductible line of serious illness insurance for the rural poor was reduced from 0.75 million yuan to 0.55 million yuan. The reimbursement rate of medical expenses within the policy scope of personal burden is: 0.55 million yuan-6.5438+10,000 yuan, with 85% reimbursement; The part exceeding 654.38+10,000 yuan shall be reimbursed according to the proportion of 95%. Cancel the annual reimbursement cap line of serious illness insurance for rural poor people.
The rural poor are determined according to the Implementation Opinions of the General Office of the People's Government of Henan Province on Further Improving the Medical Security Level of the Rural Poor, that is, the rural poor include the poverty-stricken people who have set up a file to establish a card, the rural low-income recipients, and the assistance and support recipients of the rural poor.
Four, urban and rural residents collect points
Urban residents:
Weibin District: Healthy Community Health Service Center, Tiexi Community Health Service Center, Shengli Community Health Service Center, Jiefang Community Health Service Center, Free Community Health Service Center, Nanqiao Community Health Service Center and Jingxi Hospital;
Hongqi District: Xiangyang Community Health Service Center, Jessie Community Health Service Center, Qudong Community Health Service Center, Dongjie Community Health Service Center, Wenhua Street Community Health Service Center, New District Community Health Service Center, Hongmen Town Health Center, Xinxiang Xinxing Hospital, Xiaodian Health Center and Disabled Persons' Federation Rehabilitation Hospital;
Muye district: North Trunk Road Community Health Service Center, East Trunk Road Community Health Service Center, Xinhui Community Health Service Center, Heshi Normal University Community Health Service Center, Weibei Community Health Service Center, Rongxiao Community Health Service Center, Garden Club Health Service Center, Diaoyutai Community Health Service Center, Heping Road Community Health Service Center,1kloc-0/6 Factory Workers Hospital, Xindong Community Health Service Center, Mudong Community Health Service Center.
Development Zone: Jinlong Community Health Service Center of Xinfei Avenue, Community Health Service Center of Development Zone, Vasculitis Hospital, Hongqi Community Health Service Center, High-tech Huatuo Chinese Medicine Hospital, Guandi Township Health Center and Yahua Hospital;
Fengquan District: Baoxi Community Health Service Center and Dongbao Community Health Service Center;
Xigong District: Xigong District Community Health Service Center.
Other residents: the administrative village where the household registration is located.
Note: Medical insurance reimbursement for urban and rural residents in Changyuan City is subject to local policies.