What is the reimbursement ratio of provincial medical insurance outpatient service?

1. reimbursement ratio of medical insurance outpatient service for employees: medical expenses of more than 2,000 yuan can only be reimbursed after the on-the-job employees see a doctor in the emergency department of the hospital, and the reimbursement ratio is 50%. For retirees under 70 years old, expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed. No matter what kind of people, the maximum payment limit for outpatient and emergency medical expenses is 20 thousand yuan. For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then this 500 yuan can be reimbursed 50%, that is, 250 yuan.

2. Proportion of reimbursement for residents' medical insurance outpatient service: outpatient settlement procedure: insured patients pay medical expenses incurred in the outpatient service of designated medical institutions directly at the settlement counter of residents' medical insurance with the special medical insurance office and social security card. In an insurance year, if the total outpatient expenses are below 50 yuan, the medical insurance fund will pay 40%, and the expenses above 50 yuan will be borne by individuals.

3. The reimbursement rate of rural medical insurance outpatient service: 60% of the village clinics and village center clinics seek medical treatment, and the prescription drug fee limit for each visit is 10 yuan, and the prescription drug fee limit for temporary rehydration of doctors in health centers is 50 yuan; 40% reimbursement for medical treatment in the town health center, the limit of each examination fee and operation fee is 50 yuan, and the limit of prescription drugs is 100 yuan; Second-level hospitals will be reimbursed 30% for medical treatment, with each examination fee and operation fee limited to 50 yuan and prescription drug fee limited to 200 yuan; Third-level hospitals will be reimbursed 20% for medical treatment. The examination fee and operation fee for each visit are limited to 50 yuan, and the prescription drug fee is limited to 200 yuan; Chinese medicine invoice with prescription, each paste limit 1 yuan; The annual compensation limit for rural cooperative medical clinics is 5000 yuan.

Outpatient reimbursement process:

Carry information:

1, original ID card or social security card;

2. Original disease diagnosis certificate issued by tertiary or secondary hospitals of designated medical institutions;

3, outpatient medical records, inspection, test results report and other original medical information;

4. Original receipt of outpatient charges of medical institutions with unified finance and taxation;

5. The detailed list of outpatient expenses printed by the hospital computer or the original payment of prescriptions issued by doctors;

6. Designated pharmacies: unified original invoices and computer-printed sales lists of taxable goods;

7. If acting as an agent, provide the original ID card of the agent.

Bring all the above information to the relevant departments of the local social security center. Upon examination, if the information is complete and meets the requirements, it will be handled immediately. When applying for reimbursement of outpatient medical expenses, the applicant should first deduct the amount allocated to the personal account of medical insurance in this social security year, and then verify the amount to be reimbursed.

Hospitalization reimbursement process:

1. When entering or leaving the hospital, you must go through the registration formalities with the medical insurance IC card at the medical insurance management window of each designated medical institution.

Personal hospitalization should pay 2000 yuan in advance for medical expenses, and make up for it more or less after discharge. The medical expenses incurred before the hospitalization registration formalities shall not be included in the payment scope of basic medical insurance. If the emergency hospitalization fails to go through the hospitalization registration formalities in time, it should go through the hospitalization formalities at the medical insurance management window with the emergency certificate on the day after admission (holidays will be postponed). If it exceeds the time limit, the medical expenses shall be borne by itself.

2, the insured after hospitalization as a whole fund deductible is divided into three files:

Level III Hospital 1000 Yuan, Level II Hospital 600 yuan, Level I Hospital 400 yuan. In a basic medical insurance settlement year, the medical expenses for multiple hospitalizations are calculated cumulatively.

3, the insured due to illness need referral (hospitalization), shall be approved by the designated medical institutions (three or more) deputy chief physician or chief physician diagnosis put forward referral (hospitalization) opinions, by the unit to fill in the application form, after the approval of the designated medical institutions medical insurance management department reported to the municipal (District) social security institutions for referral (hospitalization) procedures. The transfer is limited to provincial specialized hospitals, and the expenses are paid by me first. The reimbursement standard is 10% first, and then the reimbursable amount is calculated according to local regulations.

4. When the designated medical institutions are discharged from the hospital, the reimbursement amount and the amount payable by individuals shall be calculated by the designated medical institutions, and the reimbursement amount shall be settled by the designated medical institutions and urban social insurance agencies, and the amount payable by individuals shall be settled by the designated medical institutions and the insured.

legal ground

People's Republic of China (PRC) social insurance law

Article 25 The state establishes and improves the basic medical insurance system for urban residents.

The basic medical insurance for urban residents combines individual contributions with government subsidies.

People who enjoy the minimum living guarantee, disabled people who have lost their ability to work, elderly people and minors over 60 years old in low-income families, etc. , subsidized by the government.

Twenty-sixth basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.

Twenty-seventh individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, will no longer pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with state regulations; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state.

Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.

Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units.

The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.

Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:

(a) shall be paid by the industrial injury insurance fund;

(2) It shall be borne by a third party;

(three) shall be borne by public health;

(4) Go abroad for medical treatment.

Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.