What is the reimbursement ratio of Wuxi employees' medical insurance hospitalization?

Wuxi employee medical insurance hospitalization reimbursement ratio is divided into the following six categories:

(1) general outpatient service

Pay from personal account first, which can be used in designated medical institutions and retail pharmacies.

Outpatient co-ordination: patients can only see a doctor after signing a service agreement in their recognized community hospital, and can only use their personal accounts after they are exhausted. The actual maximum amount you can enjoy each year is: 5,000 yuan for employees and 6,000 yuan for retirees, and the personal burden ratio of medical expenses in the system is 30% and 15% respectively. Sign up for the first consultation at the community health service center; Need to be transferred to other medical institutions, according to the needs of the disease from the contracted community health service center, after the referral procedures, transferred to medical institutions for medical treatment.

Outpatient chronic diseases: 12 hypertension, coronary heart disease and other chronic diseases: first go to a municipal hospital for identification, and choose a medical institution that you think is convenient (not a community health service center) as your own outpatient medical institution. After registration and approval by the social security center offices in various districts, individuals under 70 years old will pay 800 yuan by themselves, and the medical insurance fund will pay 70%, with an annual maximum payment limit of 3,500 yuan; Retirees over 70 years of age, individuals pay 600 yuan, medical insurance fund pays 80%, and the annual maximum payment limit is 4,000 yuan.

(2) General hospitalization

1, hospitalization expenses according to regulations:

Tertiary hospitals: tertiary medical institutions are discharged, and the medical expenses are below 6,543.8+0,000 yuan (including 6,543.8+0,000 yuan), with 84% paid by the on-the-job staff's overall fund and 654.38+0.6% paid by individuals; Medical expenses 1 10,000 yuan to 40,000 yuan (including 40,000 yuan), 88% paid by the overall fund, and the individual pays 1.2% (the individual pays 50% of the above standard, the same below);

Hospitals below the second level: in the first and second level medical institutions, the medical expenses of employees are below 1 10,000 yuan (including 1 10,000 yuan), 88% is paid by the overall fund, and the proportion of individual self-payment is12%; Medical expenses 1 0,000 yuan to 40,000 yuan (including 40,000 yuan), 90% paid by the overall fund, and 0/0% paid by individuals (50% paid by retirement);

Community hospital: discharged from the community health service center, the medical expenses are below 40,000 yuan (including 40,000 yuan), 92% is paid by the overall fund, and 8% is paid by the individual (half is paid for retirement);

2. Large expenses: the proportion of medical expenses above 40,000 yuan paid by the fund and paid by individuals is 92% and 8% respectively.

3. initial hospitalization fee: the first hospitalization fee (threshold fee) is required. The tertiary hospital is working in 950 yuan and retiring in 750 yuan; The second-level hospital is working in 750 yuan, retiring 600, the first-level hospital is unified as 400 yuan, and the community health service center is unified as 300 yuan. During the year, the second hospitalization was 50% of the above standard, and the third and above hospitalization was 25% of the above standard.

(3) Outpatient special diseases

Medical expenses are exempt from the starting fee and enjoy the hospitalization reimbursement treatment of first-class medical institutions.

4. Office

Organized by Wuxi Social Insurance Fund Management Center, the service window is located in each district office.

(five) medical treatment in different places for the record.

If you have lived for a long time or have been stationed in a different place for more than half a year by the company and need medical treatment in a different place, you can fill in the Application Form for Medical Treatment in a Different Place (stamped with the seals of the company and the offices of the social security center), your ID card and social security card, go to the offices of the social security center for medical treatment in a different place for the record, and get the certificate of medical treatment in a different place. Three hospitals can be selected as designated hospitals in different places.

Information required for reimbursement of medical treatment in different places: If you have incurred hospitalization expenses in different places and have filed medical treatment in different places, please prepare the above information as soon as possible after discharge and submit it to the offices of the Social Security Center for reimbursement:

Personal second-generation ID card and social security card; Outpatient medical records, discharge summary, valid bills and expense details; Certificate of medical treatment in different places;

Personal bank card.

(6) One-card system in big cities

Insured employees in Wuxi (including Jiangyin and Yixing) who have received the "Jiangsu Social Security Card" can apply for the "one-card" registration in Wuxi social insurance agencies. The insured who has successfully registered can choose another place as the medical place on the basis of maintaining the medical treatment of the insured place. You can use the "Jiangsu Social Security Card" to swipe your card at designated medical institutions for medical treatment.

legal ground

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

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.