How to reimburse the proportion of social security medical care in Xiamen

Reimbursement benefits include not only hospitalization benefits, but also outpatient benefits. According to reports, the reimbursement rate of outpatient medical expenses is 1000 yuan, and 35% is reimbursed; 1000 yuan to 5000 yuan, 45% reimbursement; 5000 yuan to 10000 yuan, 55% reimbursement; 10000 yuan, reimbursed 65%. The reimbursement ratio is the same as that of Xiamen minor medical insurance.

It should be noted that the reimbursable medical expenses refer to the medical expenses that meet the basic medical insurance requirements in designated medical institutions, and July of that year to June 30th of the following year is a medical insurance year.

It should be noted that if the amount of outpatient bills is less than 1 ,000 yuan (including 1 ,000 yuan), or the amount of hospitalization bills is less than 4,000 yuan (including 4,000 yuan), it will be reimbursed at the social security centers in each district; If a single bill exceeds the above amount, it must be reimbursed to the Municipal Social Security Center. In addition, the medical expenses incurred in that year must be settled within 6 months after the start of the next medical insurance year (that is, 65438+February 3 1). 1. If the insured person transfers to a foreign hospital for medical treatment, he shall go through the examination and approval procedures for "transferring to a foreign hospital for medical treatment" in advance in accordance with the Interim Measures for the Administration of Transferring Basic Medical Insurance in Xiamen (in case of emergency, he shall go through the examination and approval procedures within 7 days after transferring to a foreign hospital). After the end of medical treatment, submit the materials listed in the attached table to the social security agency for review and settlement; If it is really necessary to postpone hospitalization due to illness at the same time, it shall, within 7 days from the date of expiration, carry the certificate of recent illness treatment issued by the hospital and go through the extension formalities at the municipal social insurance management center. 2. If the insured person resettles, lives or works in different places, the examination and approval procedures for "filing in different places" shall be handled in advance in accordance with the Notice on Implementing the Work and Life Declaration of Medical Insurance Insured Persons in Different Places; If the insured registered in different places need to be transferred for medical treatment, the registered tertiary hospital shall issue a referral proposal and affix its official seal. 3. The medical expenses incurred by the insured during business trip, visiting relatives and traveling abroad due to acute diseases shall be provided with the certificate issued by the unit or community and stamped with the official seal. 4. Need to check and treat in other hospitals other than the hospital, must be approved in writing by the department in the hospital and the hospital. This approval is one of the reimbursement vouchers. 5, off-site delivery must comply with the family planning policy and provide proof of maternity leave. 6. Individual insured persons such as flexible employment have lived in other places for a long time due to employment: if they have lived in other places for more than 6 months, they will be managed by employees in different places after applying for filing; Those who go out to work for less than 6 months are limited to reimbursement of emergency expenses and maintenance of medical care in chronic disease clinics. In addition to providing proof of work in the field, the latter also needs to provide medical outpatient medical records related to peacetime in Xiamen. 7. Medical expenses in different places without being transferred to hospital (reported in different places): (1) Chemotherapy, radiotherapy and regular review during the treatment of malignant tumor cases. When applying for reimbursement, in addition to the materials listed in the concise table, it is also necessary to provide the follow-up radiotherapy and chemotherapy treatment plan and course certificate issued by the original hospital transferred to medical treatment; (2) If there is no one to take care of during hospitalization in Xiamen, and it is really necessary to take refuge in immediate family members, and be hospitalized in local medical insurance designated medical institutions, in addition to the materials listed in the concise table, the proof of immediate family members issued by the local neighborhood Committee should also be provided when applying for reimbursement; (3) In addition to the materials listed in the concise table, the former should also provide the notice of study abroad, and the latter should also provide the medical outpatient records related to Xiamen at ordinary times when the employees go out to study and the retirees go out to reimburse the maintenance expenses of chronic diseases clinics; (4) The insured does not understand the policy, and the illness really needs to be transferred to hospital for medical treatment, and it is the first time that he has not gone through the formalities of transferring to hospital for medical treatment; (5) Although the procedures for going abroad for medical treatment have been completed, if the medical treatment period is exceeded and there is no delayed medical treatment certificate, in addition to the materials listed in the concise table, the delayed medical treatment certificate issued by the original hospital for going abroad for medical treatment should also be provided when applying for reimbursement; (6) For the first time, the insured person was transferred to other local designated medical institutions at the same level or higher level after being transferred to hospital for medical treatment because he did not understand the policy; In the above circumstances, the insured shall submit a written application report and related materials when applying for reimbursement. 8. The insured person belongs to the outpatient medical expenses incurred during the emergency rescue, social security card confirmation damage or loss reporting, and shall be reimbursed by medical records and expense list. The outpatient medical expenses incurred during the annual shutdown settlement of medical insurance and the failure of medical insurance computer system shall be certified and signed by the hospital. 9. The medical expenses paid by the insured due to traffic accidents shall be submitted to the social security agency for review and reimbursement with the proof of responsibility issued by the traffic police department and the materials listed in the concise table of "local outpatient service" and "local hospitalization" after the medical treatment is over. The proportion of medical insurance fund payment shall be subject to the proportion of the insured's responsibility. 10, the insured is injured by others or has a traffic accident without his own responsibility, but the perpetrator (or injured person) escapes, and the medical expenses for more than one year may not be investigated for responsibility. When applying for reimbursement, the injured insured person must write a "description of the situation", and must also submit the materials listed in the Concise Form of Local Hospitalization and the closing materials or certification materials of the public security organ, which will be audited by the agency. 1 1. The insured person goes to the outpatient department of the designated medical institution in this city for medical treatment. If the number of visits in a month exceeds 20, a complete outpatient medical record must be provided, and unified reimbursement will be made from the next month. 12. When the insured needs to go to other designated medical institutions in this city for examination, treatment and dispensing in medical insurance coverage during his hospitalization in this city, he must obtain the written consent of the medical institution where he lives, and the medical expenses incurred shall be paid in advance by the insured, and will be reimbursed by the inpatient medical institution at the time of discharge settlement, which will be included in the total medical expenses of this hospitalization.

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