Measures of Foshan Municipality on the Administration of Cash Reimbursement of Social Medical Insurance for Urban Workers

1. There is no specific time limit for bill reimbursement, as long as it is timely.

2. Medical insurance needs hospitalization to be reimbursed, and part of the personal down payment (depending on the hospital level, we usually pay 600 yuan), and the rest is divided into several types of drugs. Some drugs can't be fully reimbursed, which is more complicated. If it is not a skin disease hospitalization, it cannot be reimbursed.

2. The reimbursement methods of social medical insurance vary from place to place.

In order to standardize the management of cash reimbursement of social medical insurance for urban workers in our city, according to the Measures of Shenzhen Municipality on Social Medical Insurance for Urban Workers (Order No.2004) and the municipal government 125, we have formulated the Measures for the Management of Cash Reimbursement of Social Medical Insurance for Urban Workers in Shenzhen, which are hereby printed and distributed to you, please follow them.

Measures of Shenzhen Municipality on the Administration of Cash Reimbursement of Social Medical Insurance for Urban Workers

Article 1 In order to standardize the cash reimbursement management of social medical insurance for urban workers in our city, these Measures are formulated in accordance with the Measures of Shenzhen Municipality on Social Medical Insurance for Urban Workers (OrderNo. 12 of 2004). Municipal government 125).

Article 2 These Measures shall apply to the medical expenses that the social medical insurance for employees in our city (hereinafter referred to as the insured) meets the requirements of basic medical insurance, local supplementary medical insurance or maternity medical insurance, and are paid in advance by the insured and their relatives in cash and need to be reimbursed.

Article 3 In any of the following circumstances, the insured person may go to the municipal social insurance management institution (hereinafter referred to as the municipal social insurance institution) to handle the reimbursement procedures within the scope stipulated in Article 2 of these Measures with relevant documents and materials:

(a) medical institutions designated for medical treatment due to the damage of employees' social insurance vouchers caused by computer failure or unable to keep accounts;

(two) due to acute and critical diseases in the city's non designated medical institutions for treatment;

(three) with the consent of the designated medical institutions or social insurance institutions in this Municipality, it is transferred to medical institutions outside the city for diagnosis and treatment;

(4) Suffering from acute diseases during business trip, visiting relatives, vacation and study (including the insured giving birth outside the city) and being treated in medical institutions outside the city;

(five) stationed outside the city for a long time or settled outside the city after retirement.

Article 4 In case of any of the circumstances specified in Article 3 of these Measures, the insured shall pay the medical expenses in cash and provide the following information to the municipal social insurance institution at the time of reimbursement:

(a) the original fee receipt;

(2) A detailed list of expenses;

(3) A copy of outpatient medical records or inpatient medical records (stamped with the official seal of the medical institution);

(4) disease diagnosis certificate;

(5) Social insurance certificate of my employee.

When applying for reimbursement of medical expenses incurred in long-term residence or settlement outside the city after retirement, in addition to submitting the information mentioned in the preceding paragraph, you should also go through the registration procedures for work (settlement) in different places at the municipal social insurance institution in advance.

Article 5 If the insured person agrees to be transferred outside the city for medical treatment by the designated medical institution or the municipal social insurance institution, when handling the reimbursement, in addition to providing the information specified in Article 4 to the municipal social insurance institution, he should also submit the Shenzhen Social Medical Insurance Outside the City Referral Review Application Form with approval opinions, and approve the reimbursement according to the following procedures:

(1) If the referral is approved by the municipal social insurance institution, the above information will be directly sent to the municipal social insurance institution for approval and reimbursement;

(two) by the municipal tertiary hospitals or municipal specialized hospitals for referral, the above information will be sent to medical institutions, after the audit, the reimbursement plan will be put forward, and then reported to the municipal social insurance institutions for audit, and the expenses will be reimbursed after the audit.

Those who are not approved to be transferred outside the city or invited to hospitals, buy medicines and go to for-profit medical institutions for treatment (except for emergency rescue) will not be reimbursed.

Article 6 If the insured pays the medical expenses in cash (except as stipulated in Article 9 of these Measures) and needs to apply for reimbursement, it shall submit the relevant materials to the municipal social insurance institution for reimbursement within 6 months from the date when the expenses occur (the hospital is the day of discharge, the same below), and fails to submit the reimbursement within the time limit.

Article 7 The basic medical expenses (excluding baby expenses) for outpatient prenatal examination, delivery hospitalization expenses, postpartum visit and family planning operation of the insured who participate in maternity medical insurance outside the city shall be paid by the maternity medical insurance fund. With the information, marriage certificate, unit certificate and birth certificate (second child) specified in the first paragraph of Article 4 of these Measures, the reimbursement of maternity hospitalization expenses shall be based on the birth certificate; Family planning surgery expenses reimbursement by birth control surgery certificate, by the municipal social insurance institutions in accordance with the provisions of the examination and approval of reimbursement.

Prenatal examination includes the following basic items:

The first examination: (13 weeks ago) the Manual of Maternal and Child Health Care in Shenzhen was established; Urine HCG, gynecological examination, blood routine (category 3), urine routine (category 10), electrocardiogram and B-ultrasound;

Secondary examination: (16— 18 weeks) obstetric examination (including fetal heart Doppler), blood type (ABO, Rh), blood routine, urine routine, renal function (3 items), liver function (5 items), hepatitis B and hepatitis C antibodies, syphilis serum antibodies and blood sugar;

The third examination: (20-24 weeks) obstetric examination, urine routine, color Doppler ultrasound;

The fourth examination: (24-28 weeks) obstetric examination and urine routine;

Fifth examination: (28-30 weeks) obstetric examination and urine routine;

The sixth examination: (30-32 weeks) obstetric examination, blood routine, urine routine, B-ultrasound;

Seventh examination: (32-34 weeks) obstetric examination and urine routine;

Eighth examination: (34-36 weeks) obstetric examination, fetal monitoring, urine routine;

Ninth examination: (37 weeks) obstetric examination and urine routine;

Tenth examination: (38 weeks) obstetric examination, fetal monitoring, urine routine;

Eleventh examination: (39 weeks) Obstetric examination, urine routine, B-ultrasound;

Twelfth examination: (40 weeks) Obstetric examination, fetal monitoring, urine routine.

Family planning surgery projects include:

(1) placing (taking out) the intrauterine device;

(two) artificial termination of pregnancy (abortion), including artificial abortion (negative pressure suction, curettage), mid-term induced labor, drug termination of pregnancy;

(3) placing and taking out the contraceptive implanted under the skin;

(4) tubal sterilization and vasectomy;

(5) Tubal recanalization and vas deferens recanalization.

Article 8 Emergency hospitalization expenses incurred during going abroad on business, going to Hong Kong, Macao and Taiwan or visiting relatives shall be reimbursed according to the reimbursement standards of municipal hospitals in this Municipality, and outpatient and drug purchase expenses shall not be reimbursed. When handling reimbursement, in addition to providing the information specified in the first paragraph of Article 4 of these Measures, it is also necessary to provide unit certificates, passports for going abroad or special passes for Hong Kong, Macao and Taiwan.

Ninth comprehensive medical insurance insured outpatient basic medical expenses and outpatient use of local supplementary medical insurance drug list, the cost of diagnosis and treatment items, paid by personal accounts.

Personal account is not enough to pay, social medical insurance annual excess outpatient basic medical expenses, in the last year, the average annual salary of urban workers 10% above, by the basic medical insurance fund to pay 70%, the individual pays 30%.

The insured person shall, in the next medical insurance year, report to the municipal social insurance institution for review and reimbursement with the information specified in the first paragraph of Article 4 of these Measures.

Article 10 When the insured person of local supplementary medical insurance exceeds the maximum amount of basic medical expenses paid by the basic medical insurance pooling fund and the expenses of drugs and diagnosis and treatment items using the local supplementary medical insurance drug list during hospitalization, after approval, the local supplementary medical insurance fund will pay 85% and the individual will pay 15%.

Eleventh due to illness blood transfusion (whole blood, blood component) costs, paid by individuals in cash, with the information provided in the first paragraph of Article 4 of these measures and proof of rescue blood, approved by the municipal social insurance institutions for reimbursement. 90% of the expenses are paid by the basic medical insurance pooling fund, and the individual pays 10%.

Twelfth approved by the municipal social insurance agencies, the use of disposable medical materials with a unit price exceeding 1 000 yuan in the basic medical insurance project, according to the domestic popular type (including domestic disposable medical materials), 90% will be paid by the basic medical insurance pooling fund. If there is no comparable domestic popular model, 50% will be paid according to the imported popular model.

Thirteenth basic medical expenses for organ transplant surgery shall be approved and reimbursed according to regulations. The cost of purchasing organs or tissue sources is self-care.

Organ transplantation includes kidney, heart valve, cornea, skin, blood vessels, bone and bone marrow transplantation.

Fourteenth artificial organ placement and replacement costs, should be in accordance with the provisions of the first paragraph of article fourth of these measures, submitted to the municipal social insurance institutions for approval and reimbursement.

Artificial organs include artificial pacemakers, artificial heart valves, artificial lenses and artificial joints. The cost of artificial organs is reimbursed at 90% of the domestic popular price; If there is no comparable domestic popular price, it will be reimbursed at 50% of the imported popular price. The highest reimbursement is: pacemaker 15000 yuan, artificial heart valve 8000 yuan, artificial joint 5000 yuan, artificial lens 1500 yuan.

Article 15 Special medical materials include cardiovascular catheter, cardiovascular stent and intracardiac balloon. Special medical materials are reimbursed at 90% of the domestic public price; If there is no comparable domestic popular price, it will be reimbursed at 50% of the imported popular price. The maximum reimbursement limit is 6500 yuan for cardiovascular catheter 1200 yuan, cardiovascular stent1kloc-0/500 yuan and cardiovascular balloon.

Article 16 The expenses of outpatient dialysis (hemodialysis, peritoneal dialysis), outpatient anti-rejection drugs, outpatient chemotherapy, interventional therapy, radiotherapy or radionuclide therapy for chronic renal failure of the insured shall be paid by the patient in cash first, and then reported to the municipal social insurance institution for approval and reimbursement according to the information specified in the first paragraph of Article 4 of these Measures. The basic medical insurance pooling fund shall pay 90%, and the individual shall pay 10%.

Seventeenth the measures shall be implemented as of the date of issuance.

3. The retirement procedure is very troublesome. The thing is this: the company needs to handle 1 to check whether the employee's personnel file has reached the retirement age and month, and it has indeed arrived. Female: 50 years old (worker) or 55 years old (manager). Male: 60 or 55 years old (special type of work, the formula takes one month). 2. Print the old-age insurance statement in the social security center of the district (reduced). 3. Calculate the pension according to the statement. 4. Report to the Insurance Department of the Labor and Social Security Bureau in your district, and then take the retirement approval form. 5. Go to the social security center for retirement, add retirement information and medical insurance procedures (submit the retirement approval form stamped with the official seal of medical insurance) and change it to. 6. The unit informs employees to retire, and the factory issues a retirement certificate. 7. Next month, around 10, the company will inform employees to go to the enterprise to collect the passbook of endowment insurance.

The part paid by the enterprise is determined by the unit according to the actual situation.

Note: Female management cadres can also retire at the age of 50 this year. Write an application and retire for more than 5 years.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.