Interpretation of Hainan Medical Insurance Reimbursement Process and Reimbursement Ratio in 2023

Medical insurance refers to social medical insurance, which is a social insurance system established to provide basic medical needs for workers within the scope of protection. The basic medical insurance premiums paid by individual employees are all included in individual accounts; The basic medical insurance premium paid by the employer is divided into two parts, one part is included in the personal account, and the other part is used to establish the overall fund. In this paper, please introduce the related knowledge of medical insurance reimbursement in Hainan. It mainly includes Hainan medical insurance reimbursement process, Hainan medical insurance reimbursement ratio, Hainan medical insurance reimbursement policy and other information.

I. Hainan Medical Insurance Reimbursement Process and Material Conditions Required for Reimbursement (I) Employees enjoy the conditions of overall payment for medical insurance.

1. After participating in the basic medical insurance, the insured person can enjoy the payment treatment of the overall fund only after continuously paying 1 year. Continuous interruption of payment for 3 months or accumulated payment for 6 months, stop enjoying the basic medical insurance benefits. After the payment is resumed, if the payment is interrupted for 3 months in a row, you can enjoy the overall fund payment again after 6 months of continuous payment; If the payment has been suspended for 6 months, you can enjoy the payment treatment of the overall fund again after the continuous payment of 1 year.

2, retirees to participate in employee medical insurance, in accordance with the "Regulations" accumulated payment period (including deemed payment) to enjoy the corresponding medical treatment. If the accumulated payment period is not enough, it can also be paid in one lump sum in accordance with the relevant provisions of Article 27 of the Regulations.

3. Retirees who have never participated in the basic medical insurance can enjoy the corresponding basic medical insurance benefits after paying the basic medical insurance compensation fee in one lump sum 10 years.

4. During the period of receiving unemployment insurance benefits, the unemployed pay the basic medical insurance premium from the unemployment insurance fund and enjoy the basic medical insurance benefits for employees.

Reimbursement materials 1. Reimbursement of hospitalization medical expenses:

Computer list, course homepage, disease certificate, discharge summary;

Two. Reimbursement of other medical expenses:

Referral from different places:

1, designated medical institutions referral approval form;

2, hospitalization invoice, hospitalization computer list, discharge summary, disease certificate, ID card copy bank account number (bank and account number);

Living in different places, referral in different places:

Hospitalization invoice, hospitalization computer list, discharge summary, disease certificate, copy of ID card and bank account number (bank and account number);

3. Urban residents:

1). reimbursement of hospitalization medical expenses:

With ID card (household registration book) or valid social security card.

2). Outpatient medical expenses reimbursement:

1, general outpatient: resident medical insurance card

2, special clinic:

(1) Identification Form of Special Diseases in Outpatient Department of Basic Medical Insurance for Urban Residents in Hainan Province (in duplicate);

(2), I recently hospitalized disease diagnosis certificate;

(3), nearly six months discharge summary or inspection report;

(4), disease diagnosis certificate and other information;

3. Seek medical treatment in different places:

(1.), social security card;

(2), remote referral approval form;

(3), hospitalization invoices;

(4), hospitalization home page and discharge summary;

(5), medical expenses summary list;

(6) A copy of the reimbursement passbook (account number);

(7), hospital delivery also need to provide birth service certificate and birth medical certificate of the original and a copy of each and other related information.

Note: All materials provided by the hospital must be stamped with the hospital seal.

Reimbursement process (1) Urban employees:

1. Batch bill reimbursement

Referral from different places:

(1), providing the Approval Form for Referral of Designated Medical Institutions.

(2), social security agencies for approval.

(3), hospitalization invoice, hospitalization computer list, discharge summary, disease certificate, copy of ID card (bank and account number)

(4), social security supervision personnel audit

(5), the department leader for examination and approval of the settlement team settlement.

Living in a different place, traveling, vacationing or visiting relatives:

(1), hospitalization invoice, hospitalization computer list, discharge summary, disease certificate, copy of ID card and bank account number (bank and account number)

(2), social security supervision personnel audit

(3), department heads for examination and approval

(4), the settlement team settlement

2. Hospitalization reimbursement

(1), the insured shall go through the hospitalization formalities at the designated medical institutions in this city with his ID card.

(2) When discharged from the hospital, with relevant materials (computer list, course home page, disease certificate, discharge summary), directly handle the hospitalization reimbursement procedures in the hospital medical insurance office.

Seek medical treatment in different places

Referral from different places:

(1), referred by tertiary hospital;

(2), holding an ID card, referral approval form to the insured medical insurance agencies for approval;

(3), medical insurance agencies for approval and seal;

(4) to the designated medical institutions for hospitalization with the approval form;

(5)5. After discharge, return to the medical institution of the insured place with the settlement voucher and invoice for registration;

(6) medical unsealing.

Living in different places:

(1), retirees who have lived outside the insured place for more than 6 months and employees sent by the government for more than 3 months can apply for medical treatment in this different place;

(2) Retirees receive the Registration Form for Designated Hospitals of Medical Insurance for Urban Workers Living in Different Places in Haikou City;

(3) The seal of the designated hospital of foreign medical insurance and the seal of the administrative department of foreign medical insurance;

(4) Retirees will send the stamped form back to the Medical Department of Haikou Social Security Bureau for registration and filing;

(5) If the company has on-the-job personnel who need to be stationed in other places for a long time, the company needs to issue a certificate;

(6) The insured sends the reimbursement voucher back to Haikou Social Security Bureau for reimbursement.

(2) Urban residents:

1. hospitalization reimbursement

Residents' medical insurance insured personnel are reimbursed at designated medical institutions.

(1). When the insured person is diagnosed by a designated medical institution and needs hospitalization, he/she must go through the hospitalization formalities at the designated medical institution in this city with his/her ID card (household registration book) or valid social security card;

(two) designated medical institutions to check the personal identity, medical insurance payment and the use of the overall fund, according to the provisions of the medical insurance fund to pay, for hospitalization accounting procedures;

(3) At the time of discharge settlement, the medical expenses paid by the medical insurance pooling fund shall be settled by designated medical institutions and social security agencies, and the medical expenses paid by individuals shall be settled by insurers and designated medical institutions.

2. General outpatient reimbursement

(1), the insured person registers for medical treatment in the outpatient department of the designated medical institution.

(2) After the diagnosis and treatment, the insured person will directly settle the reimbursement at the hospital settlement office with the resident medical insurance card.

3. Special outpatient treatment

(1), when the insured applies for outpatient treatment of special diseases, the applicant needs to apply to the second-class or above medical institutions (specialized diseases only) in this city, fill in the Identification Form of Special Diseases in the Basic Medical Insurance for Urban Residents in Hainan Province (in duplicate), and at the same time, issue the disease diagnosis certificate of my recent hospitalization, discharge summary or inspection report in the last six months, disease diagnosis certificate and other materials;

(2), the insured can apply for two kinds of special outpatient diseases according to the needs of the disease at the same time, suffering from a variety of special outpatient diseases, should be reported in the order of the main diseases;

(3) The medical insurance office of the designated medical institution conducts the preliminary examination, and the applicant can enjoy the treatment only after the personnel of the medical supervision and audit team who meet the reporting conditions review the audit opinions, sign and affix the official seal, and enter them into the system;

(4), the insured can choose one of the designated medical institutions designated by the local social security agencies for outpatient treatment of special diseases, and within a certain period of one year, if it is necessary to change the designated medical institutions, it is necessary to go through the change procedures with the original approval form to the social security agencies;

(five) in the selected designated medical institutions for treatment or medicine, the medical expenses paid by the medical insurance fund shall be settled by the designated medical institutions and social security agencies, and the medical expenses paid by individuals shall be settled by the insured and the designated medical institutions.

4. reimbursement for medical treatment in different places

When the insured person goes to a medical institution in a different place for medical treatment, after paying all the hospitalization expenses, he/she shall submit the following materials to the residential insurance department of the Municipal Social Security Bureau or the social security offices in various districts for reimbursement as required: social security card, approval form for referral in different places, hospitalization invoice, hospitalization home page and discharge summary, detailed list of medical expenses summary, and a copy of the passbook (account number) of the reimbursement person. In the case of delivery in a hospital, one original and one copy of the birth medical certificate and other relevant information should also be provided. (All information provided by the hospital should be stamped with the seal of the hospital)

Second, Hainan medical insurance reimbursement ratio and related policy reimbursement ratio 1, basic medical insurance for employees.

The deductible line for hospitalization of the insured within one medical insurance year is: working in 800 yuan and retiring in 600 yuan; The reimbursement rate of tertiary medical institutions is 85%, that of secondary medical institutions is 88%, and that of primary or other medical institutions is 90%. ?

90% of retirees are paid by the overall fund, and the personal burden is 10%. However, the following conditions must be met: 1 Have received a monthly pension in Hainan Province; 2 Have participated in basic medical insurance at the time of employment, and the payment period (including deemed) has reached 30 years for men and 25 years for women. (If the payment period has not been reached, the basic medical insurance benefits enjoyed by them will be reduced by 3% every year).

2. Medical insurance for urban residents. The deductible line and reimbursement ratio of the insured in one medical insurance year are: 350 yuan, a tertiary medical institution, with the reimbursement ratio of 65%; 300 yuan, a secondary medical institution, has a reimbursement rate of 75%; First-class or other medical institutions 100 yuan, the reimbursement ratio is 90%. ?

3. New rural cooperative medical system. The deductible line and reimbursement ratio of the insured in one medical insurance year are: 800 yuan, a tertiary medical institution, with a reimbursement ratio of 60%; 600 yuan, a provincial-level secondary medical institution, has a reimbursement rate of 65%; 300 yuan, a secondary medical institution in cities and counties, with a reimbursement rate of 75%; Township-level medical institutions will be reimbursed by installments with zero payment, and ≤ 60% will be reimbursed by 200 yuan. > 200 yuan reimbursed 90%.