? 1, insured object
All urban and rural residents who have not participated in the basic medical insurance for urban workers in this city can participate in the medical insurance for urban and rural residents on a household basis (students who have participated in the medical insurance for urban and rural residents at school do not need to participate in the insurance again), including migrant workers and their families.
? 2. Insurance procedures
Urban and rural residents with household registration book, ID card to the administrative village (community) where the household registration is located to pay the insurance premium in one lump sum, and go through the insurance registration procedures; Migrant workers pay insurance premiums in the administrative village (community) where they live with their ID cards and work certificates.
? 3. Financing criteria
Medical security for urban and rural residents consists of three types: basic security, large-sum security and student security. Urban and rural residents can voluntarily choose a way of participation on a household basis.
Basic guarantee type: 800 yuan/year/person (including individual 260 yuan/year/person)
Large guarantee type: 1 100 yuan/year/person (including individual 560 yuan/year/person).
Student security type: 760 yuan/year/person (including personal 220 yuan/year/person, including 30 yuan/year/person accident insurance).
Finance at all levels shall implement special subsidies according to the standard of 540 yuan per insured person per year (urban and rural low-income households, severely disabled persons, orphans, five-guarantee households, urban three-no-persons and key entitled groups specified in Document No.84 of Lanzheng Office [20xx], and the municipal finance shall pay some special subsidies according to the basic guarantee standard. )。
? 4. Time of payment
Urban and rural residents who participate in the basic security type (large-sum security type) should pay off their personal expenses in one lump sum before 20xx65438+February 65438+May, and will not go through the formalities of paying back or refunding fees halfway.
? 5. Midway insurance
Newborns born within (1) years are allowed to apply for insurance at the township (street) medical insurance office where their household registration is located with the household registration book after birth. Babies born before June 30th (inclusive) pay the annual personal expenses, and babies born after July 1 (inclusive) pay the half-year personal expenses. If the newborn is insured halfway within 30 days after birth and pays the medical insurance premium for urban and rural residents, it will enjoy the medical insurance benefits for urban and rural residents from the date of birth; Newborns who are insured for more than 30 days after birth and pay medical insurance premiums for urban and rural residents will enjoy medical insurance benefits for urban and rural residents from the date of payment.
Newborns born after June 65438+1 October1(inclusive) every year must go through the Hong Sen insurance procedures for the next year within 3 months after birth, and will not be reissued after the deadline. Insured newborns enjoy the medical security policy for urban and rural residents from the date of insurance.
Financial subsidies by the municipal finance according to the number of newborn insurance summary, at the end of a one-time payment.
(2) Persons newly registered in this city during the year, college graduates returning to this city after graduation, retired urban workers, persons whose basic medical insurance has been interrupted for less than three months, and released prisoners shall show the original and photocopy of their household registration books, among which: college graduates returning to this city shall also provide the original and photocopy of graduation certificates and other materials; If the retired urban workers in different places and the medical insurance are interrupted for less than three months, it is also necessary to provide the' interruption certificate, interruption certificate' and other materials issued by the social insurance business agency where the original insurance is located; The released prisoners must also provide the original and photocopy of the release certificate. The above-mentioned qualified personnel shall go through the insurance formalities at the medical insurance office for urban and rural residents in the street where the household registration is located, go through the insurance formalities in the middle of spring, and pay the annual premium (including personal and financial subsidies) in full, and enjoy the medical insurance policy for urban and rural residents after 30 days of payment.
All registered family members of the above-mentioned midway insured must have participated in medical insurance for urban and rural residents (including medical insurance for urban and rural students) or basic medical insurance for urban workers.
? 6. Time to enjoy reimbursement treatment
Basic security type/large security type: outpatient and inpatient medical expenses from 20 17 1 to 20 17 12 3 1.
On-campus student security type: outpatient and inpatient medical expenses and students' accidental injury insurance compensation expenses incurred during September 1 to August 3 1 of 20xx.
Transferring insurance halfway: On the premise of paying the medical insurance premium for urban and rural residents, those who participate in the basic medical insurance for urban workers halfway (including those who interrupt the follow-up insurance) will enjoy the medical security benefits for urban and rural residents for the medical expenses incurred during the exemption period of the basic medical insurance for urban workers.
? 7, hospitalization and special disease outpatient reimbursement period
① Basic security type/large security type: the deadline for reimbursement of out-of-town hospitalization medical expenses and special disease outpatient medical expenses (including newborns in the city) in the year of basic medical security for urban and rural residents is March 31of the following year; 1 to February 3 1 of the following year, the effective medical expenses that meet the policy scope shall be paid by the individual first 10%, and then reimbursed according to the basic medical security policy for urban and rural residents; No reimbursement will be made after 65438+February 3 1 in the following year.
(2) Student-guaranteed type: the reimbursement deadline for medical expenses incurred in different places and special disease outpatient clinics during the enrollment year is11.30 in the next enrollment year; For those who are reimbursed during the period of 65438+February 1 to August 3 1 in the next enrollment year, individuals who meet the policy scope will pay 10% of the effective medical expenses first, and then be reimbursed according to the basic medical security policy for urban and rural residents; No reimbursement will be made after August 3 1 of the next insurance year. Students who leave school due to graduation or other reasons will not continue to participate in the medical insurance for urban and rural residents (including student accident insurance) organized by the school. During the period from September 1 to February 1 of that year, urban and rural residents still enjoyed medical insurance reimbursement, and they no longer enjoyed student medical insurance and accidental injury insurance.
8, outpatient reimbursement designated hospitals and reimbursement standards
(1) community health service centers (stations) in various towns (streets) of Lanxi City: 50% of the effective expenses of general outpatient service will be reimbursed;
(2) Lanxi Ganxi Kangfu Hospital, Lanxi Shengkang Hospital, Lanxi Kang Min Hospital, Lanxi Zhan's Orthopedic Hospital of Traditional Chinese Medicine, Lanxi Kangyuan Hospital, Lanxi Dengsheng Gukang Hospital, Lanxi Huili Hospital, Lanxi Airong Chinese Medicine Hospital, Lanxi Huasheng Hospital and Lanxi Second Hospital: 25% of the effective expenses of general outpatient service will be reimbursed;
(3) 70% of the effective expenses of Chinese herbal medicines are reimbursed by all designated medical institutions in the city;
(4) Outpatient reimbursement capping line 500 yuan/person-year.
Outpatient reimbursement must be reported on the spot, and those who are not reported on the spot cannot be reported (refer to Chinese herbal medicine clinic).
? 9, the city's designated medical institutions
Municipal People's Hospital, Chinese Medicine Hospital, Second Hospital, Maternal and Child Health Hospital, Lanxi Kangrui Hospital, Geriatric Hospital, Chengxi Hospital, Qiu Yong Hospital, Lanxi Ganxi Kangfu Hospital, Lanxi Shengkang Hospital, Lanxi Zhan's Orthopedic Hospital, Lanxi Kangyuan Hospital, Lanxi Dengsheng Gukang Hospital, Lanxi Huili Hospital, Lanxi Chinese Medicine Hospital, Lanxi Airong Chinese Medicine Hospital, Lanxi Huasheng Hospital, and towns ().
Medical expenses incurred in designated medical institutions in the city shall be reported immediately at the reimbursement window of medical institutions with my medical insurance card and ID card (18 years old with residence booklet or household registration certificate). If they are not reported on the spot, the Municipal Social Insurance Administration will not reimburse them.
? 10, designated hospital outside the city
Designated medical institutions in Jinhua and surrounding counties and cities: Central Hospital, People's Hospital, Chinese Medicine Hospital, Guangfu Hospital, Second Hospital, Jinhua Eye Hospital, Zhejiang Quhua Hospital (Cancer Treatment Center), Pujiang County People's Hospital, Pujiang County Chinese Medicine Hospital, Longyou County People's Hospital, Longyou County Chinese Medicine Hospital, jiande city People's Hospital and jiande city Chinese Medicine Hospital.
Provincial designated medical institutions in Zhejiang Province: Zhejiang Provincial People's Hospital, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Zhejiang Cancer Hospital, Zhejiang Hospital, First Affiliated Hospital of Zhejiang University School of Medicine, Second Affiliated Hospital, Children's Hospital, Shaw Hospital, Zhejiang Tongde Hospital and Hangzhou Armed Police Hospital.
Designated medical institutions with special needs for hospitalization: Huashan Hospital (General Hospital) affiliated to Fudan University, Zhongshan Hospital (General Hospital) affiliated to Shanghai Jiaotong University School of Medicine, Ruijin Hospital (General Hospital) affiliated to Renji Hospital (General Hospital), Xinhua Hospital affiliated to Shanghai Children's Medical Center, Shuguang Hospital affiliated to Shanghai University of Traditional Chinese Medicine (General Hospital).
? When you are reimbursed for hospitalization in a hospital outside the city, you need to bring the following information:
(1) Copy of my medical insurance card or social security card;
(2) ID card (/kloc-carrying household registration book or household registration certificate under 0/8 years old);
(3) Medical certificate (hospitalization invoice, expense list, medical record or discharge summary). If it is a trauma patient, it is also necessary to provide the first outpatient record (original) and a copy of the first course record (stamped with the official seal of the hospital); For patients who use albumin, plasma protein examination report shall be provided within 5 days, and routine blood test sheet shall be provided for malignant tumor radiotherapy and chemotherapy.
(4) A copy of my personal settlement passbook opened in Lanxi Rural Cooperative Bank.
To the township (street) urban and rural residents' medical insurance office where the account is located, after the full-time agent goes through the reimbursement procedures at the Municipal Social Insurance Administration, the Municipal Social Insurance Administration will distribute the reimbursement to the personal settlement passbook account provided by the insured patients through the bank.
? 1 1, hospitalization reimbursement standard
Inpatient deductible line
Proportion of hospitalization reimbursement
Municipal People's Hospital, Municipal Hospital of Traditional Chinese Medicine
Eight hundred
75%
Other hospitals in the city
celebrity
75%
Neicheng town (street) community health service center
celebrity
85%
Designated hospital outside the city
1200
50%
Non-designated hospital outside the city
1200
25%
? Maximum reimbursement per person during the year
? Basic guarantee type10.5 million yuan, large guarantee type 200 thousand yuan.
● For traumatic diseases within the scope of urban and rural residents' medical insurance policy, cancel the 20% personal prepayment policy and include its reportable expenses in the payment scope of urban and rural residents' medical insurance fund.
● The drug list is implemented with reference to the drug list of basic medical insurance, industrial injury insurance and maternity insurance in Zhejiang Province. The use of Class A drugs is fully included in the reimbursement, and the personal responsibility of Class B drugs is included in the reimbursement after 15%.
? Remarks:
(1) The reimbursement standard for students who have participated in the medical insurance for urban and rural residents at school shall be implemented according to the document Lan Zhengban [20xx] 126, that is, 0-300 yuan will be reimbursed 30%; 300 yuan above-20,000 yuan will be reimbursed 80%; More than 20 thousand yuan will be reimbursed 85%. The reimbursement rate of students in hospitals outside the city is implemented according to the hospitalization standard in the city; In the city's town (street) community health service centers, the proportion of hospitalization medical expenses subsidies rose by 5%. The highest limit of hospitalization reimbursement during the year is 6.5438+0.5 million yuan.
(2) Tuberculosis patients who are hospitalized outside the city must go through the examination and approval procedures.
(3) If an individual is hospitalized many times during the year, he shall be paid in installments. Ten kinds of patients with special diseases are hospitalized for many times because of the same disease, and the medical expenses can be calculated cumulatively.
? 12, scope of special diseases and reimbursement treatment
(1) special disease clinic: the maximum payment limit for malignant tumor is 7000 yuan/person. In, the maximum payment limit for cerebrovascular accident, ascites due to liver cirrhosis, hypertension II (one of the complications of heart, brain and kidney), diabetes (one of the complications of heart, kidney and eye), tuberculosis, psychosis (schizophrenia), systemic lupus erythematosus (one of the complications of heart, lung, kidney, liver and nervous system), myasthenia gravis and AIDS was 65438+. Year;
(2) Chemotherapy and radiotherapy for malignant tumors in special disease clinics; Peritoneal dialysis for chronic renal failure (uremia); Three types of treatment, such as organ transplantation and anti-rejection treatment, were regarded as hospitalization expenses in the outpatient department of special diseases in that year, and the hospitals for these three types of treatment must be hospitals above dimethyl.
(3) The examination and approval time for the identification of special diseases is at the end of each quarter. Except for the special disease clinics of malignant tumors (leukemia and hematological diseases) and uremia, they will be enjoyed from the date of acceptance, and other special disease clinics will be enjoyed after examination and approval.
? 13, Application for Special Diseases
Individual application, the city hospital expert group identification. Among them, tuberculosis patients were identified by experts from the municipal tuberculosis prevention and control institutions, and mental illness (schizophrenia) was identified by experts from Jinhua Second Hospital. Eligible, submitted to the office of the Municipal Urban and Rural Residents' Medical Security Management Committee for approval, and the Municipal Social Insurance Administration issued the "Lanxi Urban and Rural Residents' Medical Security Special Disease Medical Record Card".
? 14, medical insurance related treatment regulations for childhood leukemia and congenital heart disease
Children aged 0- 14 (including 14) who have participated in the medical insurance for urban and rural residents in our city suffer from acute leukemia and congenital heart disease, and the medical expenses incurred in their hospitalization shall be implemented according to the medical insurance reimbursement policy for urban and rural residents in Lanxi city. In addition, the medical expenses incurred by the insured children due to leukemia and congenital heart disease can also apply to the local civil affairs department for medical assistance.
? 15, reimbursement treatment of commercial supplementary insurance for critical illness
In an annual basic medical insurance for urban and rural residents, the expenses incurred in hospitalization within the coverage of basic medical insurance (excluding the hospitalization deductible line of basic medical insurance for urban and rural residents) and the special drug expenses included in the payment range of serious illness insurance according to the regulations of Zhejiang Provincial Department of Human Resources and Social Security, and the part where the individual pays more than 20,000 yuan deductible line, shall be subsidized by the residents' serious illness insurance. The actual payment ratio is: 50% of basic insurance, and the maximum reimbursement limit is 654.38+ 10,000 yuan; 60% for students and large-sum insurance, and the maximum reimbursement limit is 6,543,800 yuan+0.5 million yuan.
? 16, Use, Storage and Handling of Medical Insurance Cards for Urban and Rural Residents
When a patient is hospitalized or out-patient in a designated medical institution in the city, he/she will be hospitalized by swiping his/her ID card and medical insurance card.
One social security card for each person, and keep it properly to avoid scratching and damaging the bar code. If it is damaged or lost, you can apply for a replacement card at the head office of the issuing bank. Do not lend the card to others, or you will be disqualified for reimbursement in the current year.
? 17, not covered by reimbursement.
(1) has participated in the medical insurance for urban workers and the medical expenses of medical security personnel for urban and rural residents within the year;
(2) medical expenses incurred by all family members (excluding insured students) who did not participate in the medical insurance for urban and rural residents;
(3) Medical expenses incurred due to fraudulent acts such as impersonation;
(4) all kinds of disputes, fights, drug abuse, suicide, alcoholism, sexually transmitted diseases, intentional self-injury;
(5) Family sickbed, plastic surgery, non-functional orthopedic surgery and instruments, four operations of family planning, treatment fees for male and female infertility (except those caused by reproductive system diseases or other systemic diseases), in vitro fertilization, artificial insemination fees, contraceptive drugs and instruments fees;
(6) Medical expenses, expert consultation fees, ambulance fees, escort fees, bed fixing fees, air conditioning fees, meals, nursing fees, non-medical personal services and other items, Chinese medicine decoction fees, and miscellaneous expenses during hospitalization;
(seven) the cost of assembling artificial eyes, wigs, artificial limbs, dentures, hearing AIDS, massagers, magnetic therapy supplies and other health care auxiliary treatment costs;
(8) all kinds of medical consultation fees, health prediction fees, smoking cessation, drug rehabilitation, diet therapy outpatient and hospitalization fees, all kinds of medical accident appraisal, judicial appraisal, labor appraisal and other expenses;
(9) Medical expenses payable for medical accidents, traffic accidents, work-related injuries and other compensation liabilities;
(10) Various preventive and health care items (such as vaccines, vaccinations, disease investigation, follow-up, etc.). );
(1 1) Medical expenses incurred during going abroad or arriving in Hong Kong, Macao and Taiwan;
(12) The excess hospital beds shall be settled according to the daily 40 yuan standard;
(13) Self-purchased drugs and other medical expenses that are not allowed to be reimbursed according to regulations.
? 18, part of the expenses of medical security payment project for urban and rural residents in Lanxi city.
(1) The catalogue of diagnosis and treatment items is implemented with reference to the catalogue of medical service items of basic medical insurance in Zhejiang Province. The expenses incurred in using Class A articles shall be fully reimbursed, and the expenses incurred in using some Class B articles shall be reimbursed after the individual takes care of himself. (two) the use of medical materials that meet the requirements of the "applicable items" and "remarks" columns of the medical service catalogue shall be included in the scope of medical insurance reimbursement for urban and rural residents.
(1) The single cumulative maximum of CQ medical material expenses is 30,000 yuan, and that of CG medical material expenses is 20,000 yuan. If the above materials are imported (joint venture), the individual shall take care of 40% first, and then submit an expense account according to the regulations; In China, it will be paid by the individual first 10%, and then reimbursed according to the regulations.
② If the unit price of CL medical materials is above 200 yuan, the imported (joint venture) materials will be reimbursed 40% first, and the domestic materials will be reimbursed 65,438+00% first, and then reimbursed according to regulations. The cumulative maximum amount of materials included in reimbursement is 40,000 yuan.
③ The expenses of blood and plasma in CX medical materials shall be reimbursed as Class B drugs.
If the above-mentioned medical materials are not marked as imported (joint venture) or domestic, they shall be treated as imported (joint venture) medical materials.
? 19. If a person who participates in medical insurance for urban and rural residents commits one of the following acts, he will be suspended from enjoying medical insurance reimbursement for urban and rural residents for 3-6 months, and his illegal income will be recovered. If the circumstances are serious and refuse to correct them, their accounts will be frozen indefinitely until their eligibility for future insurance will be cancelled; Violation of the law, shall be investigated for legal responsibility according to law:
1. Lend the medical insurance card for urban and rural residents to others for medical treatment and reimbursement.
2, resort to deceit, defrauding urban and rural residents medical security fund reimbursement.
3, meet the discharge conditions, medical institutions issued a discharge notice still refused to leave the hospital.
4, urban and rural residents' medical insurance card loss is not reported in time or due to improper storage, resulting in the loss of urban and rural residents' medical insurance fund.
? 20, student accident insurance
Insurance contents and standards:
① Accidental injury outpatient medical insurance. The maximum compensation amount is 6000 yuan, 90% of the compensation amount.
② Insurance against illness and death. The compensation amount is 50,000 yuan.
③ Accidental injury death insurance. The compensation amount is 100000 yuan.
④ Accidental injury and disability insurance. Pay according to the disability proportion listed in the Table of Disability Degree and Insurance Payment Proportion of Life Insurance issued by the People's Bank of China, and the maximum compensation amount is 50,000 yuan.
? Reimbursement procedures: after an accident, students should submit their medical records, invoices for outpatient medical expenses and other valid documents to the insured commercial insurance company for reimbursement after being signed by their school.