How to reimburse hospitalization for chronic diseases under Huxian Employee Medical Insurance

The medical expenses of insured residents who are hospitalized in designated medical institutions (including home beds) are subject to a method of determining the minimum payment standard, paying the portion exceeding the minimum payment standard in proportion to the hospital level, and controlling the maximum payment limit.

The minimum payment standard is 250 yuan

The minimum payment standard is: 250 yuan for community health service institutions; 350 yuan for first-level hospitals; 500 yuan for second-level hospitals; 700 yuan for third-level hospitals .

Specified hospitalization medical expenses ranging from the minimum payment standard to the maximum payment limit have different payment ratios in designated medical institutions at different levels:

1. Urban non-employed residents

Community health service institutions: 70% is paid from the overall fund and 30% is borne by individuals; first-level hospitals: 60% is paid by the overall fund and 40% is borne by individuals; second-level hospitals: 50% is paid by the overall fund %, and the individual bears 50%; tertiary hospitals: the overall fund pays 40%, and the individual bears 60%.

2. The payment ratio of the overall fund for children and adolescents shall be increased by 5% according to the corresponding standards for urban non-employed residents.

Two types of outpatient serious illness expenses can be reimbursed

According to reports, outpatient serious illness includes: outpatient special diseases (outpatient radiotherapy and chemotherapy for malignant tumors, outpatient renal dialysis, anti-rejection medication after organ transplantation) medicine) and chronic diseases (hypertension, coronary heart disease, diabetes).

Outpatient treatment of special diseases: 50% is paid by the overall fund and 50% is paid by the individual; outpatient treatment of chronic diseases: if the cumulative medical expenses for outpatient treatment of chronic diseases in designated medical institutions in a year exceed 350 yuan, the amount exceeds 350 yuan. Part of the payment will be made from the overall pooling fund at a rate of 50%, and the maximum payment limit from the pooling fund is 2,000 yuan.

Seven situations cannot be reimbursed

1. Medical expenses incurred at non-designated medical institutions without approval; 2. Except for suicide and self-mutilation (mental illness); 3. Fighting, Fighting, alcoholism, drug abuse, and other injuries and illnesses caused by crimes or violations of the "Public Security Administration Punishment Law"; 4. Traffic accidents, accidental injuries, medical accidents, etc.; 5. Treatment for cosmetic, orthopedic, physiological defects, etc.; 6 .Belongs to the payment scope of work-related injury insurance (including occupational diseases) or maternity insurance; 7. Other non-payment situations stipulated in national, provincial and municipal medical insurance policies.

How to sign up for insurance?

Urban residents should go to the labor and social security workstation of the community where their household registration is located to go through the insurance enrollment procedures; students who belong to the urban collective household registration in Xi'an City are responsible for centralized registration by their school, and go to the medical insurance agency in their district to go through the insurance enrollment procedures.

Urban residents in Xi'an City need to bring the following materials: household registration book, ID card and copy, 2 recent 2-inch color photos with the same background and no hat (for preschool children, photos of mother and child or father and son with the same background) and household registration book Valid proof of other family members’ participation in medical insurance (subject to the participation certificate issued by the medical insurance department).

Newborns are required to provide original and photocopies of birth certificates and other relevant materials.

Urban residents receiving subsistence allowances and those with severe disabilities also need to provide relevant certification materials such as minimum living allowance receipt certificate and disability certificate respectively.

Children of migrant workers who have been studying and living with their parents in Xi'an for a long time need to provide relevant certification materials such as the temporary residence permit of one parent, the household register of origin, the certificate of migrant work, and the certificate of long-term labor relationship.

How to seek medical treatment?

Resident medical insurance is managed by designated medical institutions (including designated community health service institutions). If insured residents meet the regulations and need hospitalization, they can choose the nearest designated medical institution of Xi'an Urban Employee Medical Insurance for medical treatment; emergency and rescue patients Not subject to this restriction, but should go to the district medical insurance agency to go through the approval procedures within 3 working days.

If the disease suffered by the insured resident is diagnosed by the outpatient attending physician and indeed requires hospitalization and conforms to the catalog of inpatient diseases, the patient or his family member shall hold the patient's ID card, resident medical insurance special medical record, and hospitalization certificate issued by the outpatient physician. Certificate and other diagnostic evidence should be obtained at the medical insurance office of a designated medical institution.

How to reimburse?

Hospitalization is subject to open account settlement. Insured residents pay a certain fee in advance (including the minimum payment standard and a deposit required for personal out-of-pocket expenses) before being hospitalized. When discharged, the designated medical institution will calculate and determine the payment part of the overall pool fund and the individual. Payment part.

The emergency hospitalization medical expenses incurred by insured residents in other places due to visiting relatives, vacations, etc. will be included in the payment scope of the medical insurance fund.

When reimbursing, materials such as discharge summary, first page of medical records, copies of long-term and temporary medical orders, hospitalization expense breakdown sheet, hospitalization bills, disease diagnosis certificates and certificates of the hospital level where the patient is staying are required.

Startup area

Xincheng District, Beilin District, Lianhu District, Yanta District, Weiyang District, Baqiao District (including High-tech Zone, Economic Development Zone, Qujiang New District, Chanba District Ecological Zone) will be officially launched from now on; Chang'an District, Lintong District, and Yanliang District will be gradually launched before the end of June next year; Gaoling County, Zhouzhi County, Hu County, and Lantian will be gradually launched in 2009.

Insured objects

Resident medical insurance is applicable to the following people in Xi'an who are not included in the urban employee basic medical insurance: 1. Students in primary and secondary schools (including vocational high schools, technical secondary schools, technical schools students) and other children under the age of 18 (including children of migrant workers who have been studying and living in the city with their parents for a long time); 2. Urban non-employed residents who have urban household registration in this city and are over 18 years old.

Payment standards

Children and children: Fundraising is based on the standard of 100 yuan per person per year. The individual payment is 30 yuan, and the financial subsidy is 70 yuan.

Among them, children and adolescents who enjoy the minimum living security treatment for urban residents will pay an individual payment of 10 yuan and a financial subsidy of 90 yuan; those with severe disabilities (holders of Level 2 and above "Disabled Persons Certificate of the People's Republic of China and the People's Republic of China") 》), an individual payment of 10 yuan and a financial subsidy of 90 yuan (including a 50 yuan employment security subsidy for persons with disabilities).

Urban non-employed residents: raised at the standard of 250 yuan per person per year. The individual payment is 180 yuan and the financial subsidy is 70 yuan.

Among them, urban non-employed residents who enjoy the subsistence allowance and elderly people over 60 years old from low-income families pay an individual payment of 20 yuan and a financial subsidy of 230 yuan; severely disabled urban non-employed residents pay an individual payment of 20 yuan. , a financial subsidy of 230 yuan (including a 150 yuan employment security subsidy for persons with disabilities).

In addition, those who have participated in urban employee medical insurance can use the balance of their own medical insurance personal accounts to pay resident medical insurance premiums for their immediate family members.

Reimbursement amount

After participating in the insurance, the annual cumulative maximum payment limit for urban residents (total expenses for hospitalization and outpatient serious illness): 35,000 yuan for urban non-employed residents and 4 for teenagers and children Ten thousand yuan. If insured urban residents have paid contributions for 10 consecutive years, the maximum payment limit can be increased appropriately from the next year.

The co-ordination fund for medical expenses above the maximum payment limit of urban residents’ basic medical insurance and beyond the payment scope will no longer be borne, and can be solved by establishing large medical subsidies, commercial health insurance, etc.

Refund procedures

If insured urban residents have paid the medical insurance premium for the following year and die before December 31 of that year, their family members shall hold a death certificate issued by a medical institution or the public security department. To prove it, go to the municipal medical insurance agency to handle the refund procedures.

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