What is the specific reimbursement ratio of medical insurance in Tianjin?

What is the specific reimbursement ratio of medical insurance in Tianjin? In Tianjin, social security medical insurance reimbursement is divided into two parts: outpatient reimbursement and hospitalization reimbursement.

I. Outpatient service fee (800 yuan threshold fee for outpatient service) x50%.

2. Hospitalization (hospitalization fee is in 800 yuan or threshold fee 1.300 yuan or 1.700 yuan) x (85% on-the-job or 90% retired) except for self-funded drugs.

Part of the outpatient medical expenses for serious illness are reimbursed;

(1) 80% of employees' medical treatment is paid by the overall fund and 20% by individuals;

(2) For retirees seeking medical treatment, the overall fund pays 85%, and the individual pays 15%.

Large medical insurance:

(1) 30,000 yuan to110,000 yuan (inclusive) for medical expenses, 94% for large medical insurance premiums, and 6% for individuals;

(2) For medical expenses ranging from 6,543,800 yuan to 200,000 yuan (inclusive), 96% of the large medical insurance premium is paid, and 4% is paid by the individual;

(3) For medical expenses of more than 200,000 yuan, 98% is paid for large medical insurance premiums, and 2% is paid for individuals.

Hospitalization medical insurance treatment standard:

The hospitalization medical expenses incurred by students and children within one year are less than 6.5438+0.8 million yuan, and the proportion of reimbursement in first-class hospitals (community health service centers) is 75%; The second-level hospital, starting from 400 yuan, has a reimbursement rate of 65%; A tertiary hospital, with a threshold of 500 yuan, has a reimbursement rate of 55%.

Among them, the first-level hospital Qifubiaozhun is 300 yuan, the second-level hospital Qifubiaozhun is 400 yuan, and the third-level hospital Qifubiaozhun is 500 yuan. If urban and rural residents are hospitalized for more than two times in a settlement year, starting from the second hospitalization, the Qifubiaozhun fee will no longer be charged. Transfer or hospitalization for more than two times, make up the difference of Qifubiaozhun in accordance with the provisions of transfer or hospitalization again.

Standard for reimbursement of large medical expenses in outpatient and emergency departments:

In a year, the threshold for outpatient and emergency medical expenses incurred by urban and rural residents in first-class hospitals and community medical institutions is 600 yuan, with the maximum payment limit of 3,000 yuan and the reimbursement ratio of 50%.

What is the proportion of medical insurance reimbursement in Tianjin? Social security medical reimbursement is divided into two parts.

I: outpatient service (outpatient service fee -800% threshold fee) *50%

2. Hospitalization fee (hospitalization fee -800 or threshold fee 65,438+0,300 or 65,438+0,700) * (85% employed or 90% retired)

Except for self-funded drugs.

Part of the outpatient medical expenses for serious illness are reimbursed;

(1) 80% of employees' medical treatment is paid by the overall fund and 20% by individuals;

(2) For retirees seeking medical treatment, the overall fund pays 85%, and the individual pays 15%.

Large medical insurance:

(! ) 30,000 yuan to 654.38+10,000 yuan (inclusive) for medical expenses, 94% for large medical insurance premiums, and 6% for individuals;

(2) For medical expenses ranging from 6,543,800 yuan to 200,000 yuan (inclusive), 96% of the large medical insurance premium is paid, and 4% is paid by the individual;

(3) For medical expenses of more than 200,000 yuan, 98% is paid for large medical insurance premiums, and 2% is paid for individuals.

Reference message: tj.bendibao./live/201381/37360.shtm.

What is the reimbursement rate of 20 17 medical insurance? Residents' medical insurance is divided into two grades, the proportion of hospitalization reimbursement in the first grade is between 50 and 60, and the second grade is above 70.

What is the reimbursement rate of social medical insurance? Outpatient service is the deductible line of 1800 yuan, and the excess will be reimbursed. Up to 20,000 yuan in one year, and the specific reimbursement ratio is divided according to the hospital level; The higher the general hospital level, the less reimbursement.

The hospitalization deductible line is10.3 million yuan, and the maximum one year is10.7 million yuan. You still have to pay a deposit for serious illness. The specific proportion is divided into hospital grades; The higher the general hospital level, the less reimbursement.

What is the reimbursement rate of community medical insurance? Qifubiaozhun and reimbursement ratio of basic medical insurance for urban residents are determined according to the categories of insured persons.

First, students and children.

In a settlement year, medical expenses below RMB 6,543,800+0,800 yuan that meet the scope of reimbursement occurred. The threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 55%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.

The second is the elderly over 70 years old.

In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.

Third, other urban residents.

In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The Qifubiaozhun for hospitalization in secondary hospitals is 300 yuan, and the reimbursement rate is 55%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 60%.

Urban residents hospitalized for more than two times in a settlement year, starting from the second hospitalization, no longer charge Qifubiaozhun fees. Transfer or hospitalization for more than two times, make up the difference of Qifubiaozhun in accordance with the provisions of transfer or hospitalization again.

What is the proportion of medical insurance reimbursement paid by the company?

(a) according to the first payment, in the implementation of the basic drug system, 80% of the hospitalization expenses are paid (90% of the basic drug payment), and 60% of the hospitalization expenses are paid in the implementation of the basic drug system; Secondary hospitals pay 58%; The tertiary hospital pays 45%.

(2) According to the second payment, the first-level hospital pays 85% (90% for essential drugs), the second-level hospital pays 70%, and the third-level hospital pays 60%.

(three) minor residents and special groups enjoy the medical insurance benefits of class II payment.

Qifubiaozhun for reimbursement of hospitalization medical expenses: 300 yuan, a first-class hospital, 500 yuan, a second-class hospital and 700 yuan, a third-class hospital. Malignant tumor patients who have been hospitalized for chemotherapy and radiotherapy for many times in a medical insurance year will only be deducted once.

Proportion of reimbursement for outpatient medical insurance for enterprise employees

Insured workers in designated community health service centers or township hospitals in accordance with the provisions of the outpatient medical expenses, paid by the general outpatient co-ordination fund according to the proportion of 50%. There is no deductible for the general outpatient expenses incurred by the insured workers in the basic medical institutions that implement the national basic drug system; In other primary medical institutions, the minimum payment standard was reduced from 40 yuan to 30 yuan. The reimbursement limit for the first-class general outpatient service was raised from 60 yuan to 80 yuan; The second payment was made in 200 yuan.

What is the reimbursement ratio of rural medical insurance 1, outpatient compensation:

(1) village clinics and village center clinics are reimbursed 60%, and the prescription drug fee limit for each visit 10 yuan, and the prescription drug fee limit for temporary rehydration for doctors in health centers is 50 yuan.

(2) 40% reimbursement for medical treatment in town health centers, the limit of medical examination fee and operation fee is 50 yuan, and the limit of prescription drug fee is 100 yuan.

(3) The reimbursement for medical treatment in secondary hospitals is 30%, and the medical examination fee and operation fee are limited to 50 yuan, and the prescription drug fee is limited to 200 yuan.

(4) 20% reimbursement for treatment in tertiary hospitals, with examination fees and operation fees limited to 50 yuan and prescription drug fees limited to 200 yuan.

(5) The prescription attached to the invoice of traditional Chinese medicine is limited to 1 yuan.

(6) The annual compensation limit for rural cooperative medical clinics is 5,000 yuan.

2, hospitalization compensation:

(1) Reimbursement scope:

A. Drug expenses: auxiliary examination: the examination expenses of electrocardiogram, X-ray fluoroscopy, radiography, laboratory tests, physiotherapy, acupuncture, CT and nuclear magnetic resonance are limited to 200 yuan; Surgical expenses (refer to the national standard, reimbursement exceeding 1000 yuan 1000 yuan).

B, the elderly over 60 years old are hospitalized in Xingta Town Health Center, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan. (2) Reimbursement ratio: town hospitals reimburse 60%; 40% reimbursement for secondary hospitals; Third-level hospitals are reimbursed 30%.

3, serious illness compensation:

(1) town risk fund compensation: where the medical expenses of inpatients participating in rural cooperative medical insurance exceed 5,000 yuan at one time or throughout the year, they should be compensated by stages, that is, 5001-kloc-0/0000 yuan will be compensated by 65%,10001-.

(2) The annual compensation limit for hemodialysis, radiotherapy and chemotherapy in the town-level cooperative medical system inpatient and uremia clinic is1.65,438+0.000 yuan.

What is the reimbursement rate of rural medical insurance in Tianjin? The reimbursement rate of local designated hospitals is about 5% to 60%. Up to 40% in different places.

What is the reimbursement rate of Neijiang medical insurance? Social medical insurance reimbursement is reimbursed after discharge or transfer.

Settlement procedures for inpatient and outpatient treatment of special diseases:

Designated medical institutions should report the expense list, hospitalization list and related materials of patients discharged from hospital last month to the medical insurance agency before 10 every month, which will be used as the basis for monthly pre-allocation and year-end final accounts after being audited by the medical insurance agency;

The medical insurance agency pre-allocated the hospitalization and outpatient co-ordination expenses for special diseases last month;

Insured persons who have been identified as suffering from special diseases shall go to the designated medical institutions designated by the labor and social security departments for medical treatment and medicine purchase, and the medical expenses incurred shall be directly recorded and settled immediately.

What is the proportion of medical insurance reimbursement in five insurances and one gold?

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Outpatient service

Reimbursement for medical treatment in village clinics and village center clinics is 60%, and the prescription drug fee limit for each visit is 10 yuan, and the prescription drug fee limit for temporary rehydration for 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 limit of outpatient compensation for town-level cooperative medical care is 5000 yuan [2].

be hospitalized

Reimbursement scope: medical expenses: auxiliary examination: ECG, X-ray fluoroscopy, radiography, laboratory test, physiotherapy, acupuncture, CT, nuclear magnetic resonance and other examination expenses 200 yuan; Surgical expenses (refer to the national standard, reimbursement exceeding 1000 yuan 1000 yuan). The elderly over 60 years old are hospitalized in health centers, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan.

Reimbursement ratio: town health centers reimburse 60%; 40% reimbursement for secondary hospitals; Third-level hospitals are reimbursed 30%.

serious illness

All inpatients who participate in cooperative medical care, whose medical expenses exceed 5,000 yuan at one time or for the whole year, should be compensated by stages, that is, 500 1- 10000 yuan is 65%, and1-18000 yuan is 70%. The annual compensation limit of town-level cooperative medical system hospitalization, uremia outpatient hemodialysis and tumor outpatient radiotherapy and chemotherapy is 1. 1 ten thousand yuan.

exonerate

Medical treatment at one's own expense (no designated hospital or referral form), drugs purchased at one's own expense, drugs that cannot be reimbursed according to the provisions of public medical care, and medical expenses that do not conform to family planning; Outpatient treatment fee, visiting fee, hospitalization fee, meals fee, escort fee, nutrition fee, blood transfusion fee (except for family blood storage, which shall be reimbursed according to relevant regulations), cooling and heating fee, ambulance fee, special nursing fee, etc. Medical expenses for car accidents, fights, suicides, alcoholism, industrial accidents and medical accidents; Orthopedics, cosmetic surgery, dental implants, artificial limbs, organ transplantation, roll call surgery fees, consulting fees, etc. ; Within the scope of reimbursement, beyond the limit. [2]

cities and towns

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Urban residents hospitalized for more than two times in a settlement year, starting from the second hospitalization, no longer charge Qifubiaozhun fees. Transfer or hospitalization for more than two times, make up the difference of Qifubiaozhun in accordance with the provisions of transfer or hospitalization again.

Students, children

In a settlement year, medical expenses less than 6,543,800 yuan+0.8 million yuan that meet the scope of reimbursement occurred. The threshold of tertiary hospitals is 650 yuan, with a reimbursement rate of 50% and an upper limit of 2,000 yuan; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.

At least 70 years old and above.

In a settlement year, medical expenses below 654.38+10,000 yuan that meet the scope of reimbursement occur. The threshold of tertiary hospitals is 650 yuan, with a reimbursement rate of 50% and an upper limit of 2,000 yuan; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.

Other urban residents

In a settlement year, medical expenses below 654.38+10,000 yuan that meet the scope of reimbursement occur. The threshold for tertiary hospitals is 659 yuan, the reimbursement rate is 50%, and the upper limit is 2,000 yuan. The Qifubiaozhun for hospitalization in secondary hospitals is 300 yuan, and the reimbursement rate is 55%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 60%. [3]

Urban and rural residents

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20 16 65438+ 10/2 the State Council issued the Opinions on Integrating the Basic Medical Insurance System for Urban and Rural Residents, demanding that the basic medical insurance for urban residents (hereinafter referred to as urban residents' medical insurance) and the new rural cooperative medical system (hereinafter referred to as the new rural cooperative medical system) be integrated and a unified basic medical insurance system for urban and rural residents (hereinafter referred to as urban and rural residents' medical insurance) be established. [4] The following is the proportion of medical insurance reimbursement for urban and rural residents.

Hunan

Measures for the implementation of basic medical insurance for urban and rural residents in Hunan Province [5]

Twenty-seventh insured residents in the overall regional basic medical insurance designated medical institutions within the scope of the policy, by the urban and rural residents medical insurance fund to pay in proportion: township hospitals and community health service institutions not less than 80%; County-level medical institutions are not less than 70%; Municipal medical institutions are not less than 60%. Each overall planning area reasonably determines the specific payment ratio according to the income and expenditure of urban and rural residents' medical insurance fund.

Article 28 When insured residents are hospitalized in provincial-level designated medical institutions, the Qifubiaozhun shall be determined according to about 10% of the average hospitalization expenses of each provincial-level designated medical institution in the previous year, and not less than 1500 yuan. Within the scope of the policy, the proportion of hospitalization medical expenses paid shall not be less than 50%. The specific payment standard shall be reasonably determined by the Provincial Department of Human Resources and Social Security in conjunction with the Provincial Department of Finance according to the implementation of the medical insurance fund for urban and rural residents in the overall planning areas and the medical conditions of the insured residents.

Thirtieth medical insurance funds for urban and rural residents set the maximum payment limit for hospitalization. In a settlement year, the cumulative maximum payment limit of basic medical insurance for urban and rural residents (excluding serious illness insurance for urban and rural residents) is 6.5438+0.5 million yuan. [6]

Henan Province

Measures for the implementation of basic medical insurance for urban and rural residents in Henan Province (for Trial Implementation)

Thirteenth general outpatient medical treatment. Establish a perfect outpatient co-ordination system. All localities can set up an outpatient co-ordination fund according to about 50% of the local per capita payment, which is mainly used to pay the general outpatient medical expenses (including general medical expenses, the same below) incurred by insured residents in designated medical institutions at the grassroots level. There is no Qifubiaozhun for outpatient co-ordination, and the reimbursement rate is about 60%. The accumulated reimbursement amount during the year is controlled at about 2 times of the local per capita payment. At present, the conditions for establishing the outpatient co-ordination system are not available, but family account (personal account) is still adopted to pay the general outpatient medical expenses. Family account (individual account) included in the quota is determined according to the per capita standard of outpatient co-ordination. Family account (individual account) should gradually transition to outpatient co-ordination. The specific measures shall be formulated by the municipalities under the jurisdiction of each province.

Fourteenth outpatient chronic disease medical treatment. All localities should refer to the original basic medical insurance for urban residents and the relevant policies of the new rural cooperative medical system, and select some diseases (or treatment items) that need long-term or lifelong outpatient treatment and have high medical expenses to be included in the scope of outpatient chronic disease management. There is no Qifubiaozhun for outpatient chronic diseases, and the reimbursement rate is not less than 65%, and fixed-point treatment and quota management are implemented. The specific measures shall be formulated by the municipalities under the jurisdiction of each province.

Article 16 Hospitalization. The hospitalization expenses of insured residents within the policy scope of designated medical institutions shall be paid by individuals below the Qifubiaozhun; The above part of Qifubiaozhun shall be paid by the hospitalization pooling fund in proportion, and the amount shall not exceed the annual maximum payment limit of the hospitalization pooling fund.

Guiding opinions on Qifubiaozhun and reimbursement ratio of 20 17 insured residents are as follows:

kind

Hospital scope

Qifubiaozhun (yuan)

Reimbursement ratio

Town level

health clinics in towns and townships

(Community medical institutions)

200

200-70% within 800 yuan.

90% above 800 yuan

County level

Second-class or below a considerable scale

(including Grade II) Hospital

celebrity

400- 1500 yuan 63%

183% above 500 yuan

Municipal level

Second-class or below a considerable scale

(including Grade II) Hospital

500

500-3000 yuan 55%

More than 3000 yuan 75%

Tertiary hospital

900

900-4000 yuan 53%

More than 4000 yuan 72%

Provincial level

Second-class or below a considerable scale

(including Grade II) Hospital

600

600-4000 yuan 53%

More than 4000 yuan 72%

Tertiary hospital

1500

1500-7000 yuan 50%

More than 7000 yuan 68%

outside the province

1500

1500-7000 yuan 50%

More than 7000 yuan 68%

Insured residents 14 years old (including 14 years old) Qifubiaozhun will be halved. Other insured residents are hospitalized at or above the county level (including the county level) for the second time and later, and the Qifubiaozhun is halved.

Determine the annual maximum payment limit of hospitalization pooling fund. The maximum payment limit of 20 17 is150,000 yuan.

Municipalities under the jurisdiction of each province can appropriately adjust the Qifubiaozhun and reimbursement ratio of hospitals below the municipal level (including the municipal level) according to the fund income and expenditure and the level of medical consumption. [7]

Workers and staff

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Generally speaking, the economic development in different regions is different, so the reimbursement ratio is different. The following is an explanation of the proportion of employees' medical insurance in Beijing.

After receiving medical insurance, if they are on-the-job employees, the medical expenses above 1800 yuan can only be reimbursed, and the reimbursement rate 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. [8]

If it is hospitalization expenses, the minimum payment for employees and retirees is 1300 yuan when the basic medical insurance is used for the first time within one year in 2009. And the second and subsequent hospitalization medical expenses, Qifubiaozhun is determined by 50%, which is 650 yuan. 1 year The maximum payment limit of the basic medical insurance pooling fund (hospitalization expenses) is 70,000 yuan.

The reimbursement standard for hospitalization is related to the level of the hospital where the insured person is located. For example, in a tertiary hospital, employees have to pay 15%, that is, 85%, from the threshold to 30,000 yuan. The expenses of 30,000-40,000 yuan shall be paid by employees themselves 10%, and 90% shall be reimbursed; If the expenses exceed 40,000 yuan to the maximum payment limit, 95% can be reimbursed, and employees only need to pay 5%. Retirees pay 60% of the on-the-job employees, but all below the minimum threshold are paid by individuals.

The medical treatment items that employees' basic medical insurance does not pay are mainly those that are clinically unnecessary and have uncertain curative effects, and those that need special medical services, including registration fees and other services, non-disease treatment items such as beauty, treatment devices made of medical materials, hearing AIDS, magnetic therapy and other types of infertility treatment. According to the National Basic Medical Insurance Diagnosis and Treatment Project Scope, the details are as follows:

(1) service items. (1) Registration fee, out-of-hospital consultation fee, medical record fee, etc. (2) Special medical services, such as visiting fees, expedited fees for examination and treatment, additional fees for roll-call surgery, high-quality and low-price fees, and self-invited intensive care.

(2) Non-disease treatment projects. (1) all kinds of beauty and bodybuilding, as well as non-functional plastic surgery and orthopedic surgery; (2) various projects of losing weight, gaining weight and increasing height; (3) various health checks; (4) all kinds of preventive health care and diagnosis projects; (5) all kinds of medical consultation and medical appraisal.

(3) Diagnostic equipment and medical materials. (1) Examination and treatment items with large medical devices such as positron emission tomography (PET), electron beam cT and ophthalmic excimer laser therapeutic apparatus; (2) glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation devices; (3) all kinds of self-use health care, inspection and treatment equipment; (4) The provincial price department stipulates that one-time medical treatment cannot be charged separately.

(4) Treatment items. (1) The organ source or tissue source of various organ or tissue transplants; (2) Transplantation of organs or tissues other than kidneys, heart valves, corneal lamellae, blood vessels, bones and bone marrow; (3) Orthopedic surgery for myopia; (4) Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.

(5) others. (1) various infertility (pregnancy) and sexual dysfunction diagnosis and treatment projects; (2) All kinds of scientific and clinical diagnosis and treatment projects.