How to reimburse outpatient expenses for special diseases?

The threshold fee for medical insurance for urban and rural residents is also 500 yuan. Hospitalization and treatment of portal vein diseases within one year, or two or more portal vein diseases, are combined into a one-time minimum payment, and the maximum payment limit is 6.5438+0.8 million yuan. The reimbursement rate of students and children is different from that of adult residents. Students and children are reimbursed according to the proportion of 65% in first-class hospitals, 60% in second-class hospitals and 55% in third-class hospitals. Adult residents also pay according to different levels and hospital levels, with 65%, 60% and 55% for first-class hospitals, 60%, 55% and 50% for second-class hospitals and 55%, 50% and 45% for third-class hospitals.

Directly settled by designated medical institutions. The insured shall directly settle the outpatient medical expenses related to the applied diseases when handling the filing procedures for medical treatment in different places in the designated medical institutions and "dual-channel" pilot medical institutions in the city, and when choosing medical treatment in different places. When the insured handles the settlement, he should provide the original social security card (ID card) to the outpatient charge office for medical insurance bookkeeping.

Manual reimbursement. When the insured person falls ill and goes to a designated medical institution without online settlement for medical treatment, the medical expenses shall be paid in advance by the individual, and the medical insurance agency in the insured place shall apply for reimbursement. Step 1: Apply for reimbursement. The insured shall apply to the medical insurance agency of the insured place for reimbursement of outpatient medical expenses for specific diseases. The following original materials shall be provided: social security card (original ID card and personal bank account information for those who have not received social security card), original invoice for outpatient medical expenses, and detailed list of expenses (stamped with special seal of medical institution). Step 2: Review the payment. The medical insurance agency shall review the accepted materials and pay the reimbursement amount to the financial account or bank account of the social security card of the insured within 20 working days. Note: When handling the manual reimbursement of medical expenses, except for special circumstances such as force majeure or legal disputes, the insured shall go through the manual reimbursement procedures at the medical security agency in the insured place within 1 year from the deadline of diagnosis and treatment shown on the medical expenses document.

Reimbursement ratio of medical insurance for special diseases

1。 Payment line: 500 yuan;

2。 Reimbursement ratio: 85% of the outpatient medical expenses of Class A diseases exceed the deductible line; 75% of outpatient medical expenses for Class B diseases will be reimbursed.

3。 Maximum compensation limit: 50,000 yuan.

4。 Reimbursement of excess: the excess of 50,000 yuan shall be reimbursed by the large medical assistance fund according to regulations.

Procedures for reimbursement of medical insurance for special diseases

Applicants can enjoy the above reimbursement ratio as long as they apply for a special disease certificate. Reimbursement of medical insurance for special diseases can be carried out according to the following procedures.

1。 Required materials: application form for municipal co-ordination of basic medical care for special diseases, two recent 1 inch photos (one posted on the application form and the other used to prove special diseases in the sub-center), and the application form, copy of ID card and photos shall be signed and sealed by the unit or person.

2。 Reimbursement processing flow:

1) Submit the above materials to the medical insurance center in the area where the insured unit is located, and the flexible employees directly submit the above materials to the medical insurance center in the insured area. The monthly report time of special diseases is 1-20.

2) Applicants should call the medical insurance center of the insured place or directly go to the unit or medical insurance center to check the hospital address and inspection date from 23rd to 24th of each month (holidays are postponed), and arrive at the designated hospital on time at 8:30 on the inspection day.

3) On the day of examination, the applicant should bring the original outpatient medical records (including medical records within 2 years from the date of onset), the copy of inpatient medical records (stamped with the official seal of the hospital), the original examination materials (such as CT, MRI, coronary angiography, etc.) and the original films, the original ID card and the medical guarantee.

4) Insured persons who declare diabetes and liver cirrhosis (decompensation) need to go to the hospital for examination on an empty stomach (bring their own breakfast).

I hope the above content can help you. If in doubt, please consult a professional lawyer.

Legal basis:

Article 62 of People's Republic of China (PRC) Social Insurance Law

If the employer fails to declare the amount of social insurance premiums that should be paid according to the regulations, the amount that should be paid shall be determined according to 1 10% of the amount paid by the unit last month; After the payment unit completes the declaration procedures, the social insurance fee collection agency shall make settlement in accordance with the provisions.

Article 63

If the employer fails to pay social insurance premiums in full and on time, the social insurance premium collection agency shall order it to pay or make up within a time limit.

If the employer fails to pay or repay the social insurance premium within the time limit, the social insurance premium collection agency may inquire about its deposit account in banks and other financial institutions; And can apply to the relevant administrative departments at or above the county level to make a decision on the allocation of social insurance premiums, and notify their bank or other financial institutions in writing to allocate social insurance premiums. If the balance of the employer's account is less than the social insurance premium that should be paid, the social insurance premium collection agency may require the employer to provide guarantee and sign a deferred payment agreement.

If the employer fails to pay the social insurance premium in full and fails to provide guarantee, the social insurance premium collection agency may apply to the people's court for sealing up, distraining and auctioning the property whose value is equivalent to the social insurance premium that should be paid, so as to offset the social insurance premium with the proceeds from the auction.