Suzhou medical insurance hospitalization reimbursement ratio 2022

1, paid by the urban and rural residents' medical insurance fund in proportion: township hospitals and community health service institutions are not less than 80%; County-level medical institutions are not less than 70%; Municipal medical institutions are not less than 60%.

2. Insured residents are hospitalized in provincial-level designated medical institutions, and the Qifubiaozhun is determined according to 10% of the average hospitalization expenses of each provincial-level designated medical institution last year, and it is not less than 1500 yuan, and the proportion of hospitalization medical expenses paid within the policy scope is not less than 50%.

3. The medical insurance fund for urban and rural residents sets 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.

For the insured workers, the part within the policy scope of uremia dialysis, anti-rejection drug therapy after organ transplantation, radiotherapy and chemotherapy for malignant tumors and the treatment expenses accumulated within 40,000 yuan (including 40,000 yuan) shall be paid by the basic medical insurance pooling fund according to the proportion of 90%; 40,000 yuan to 654.38+10,000 yuan (including 654.38+10,000 yuan), and the basic medical insurance pooling fund pays 95%.

Insured workers in the settlement year in accordance with the provisions of the specific project of hospitalization and outpatient medical expenses, accumulated more than 6.5438+ten thousand yuan, by large medical expenses social * * * fund to pay 95%, individuals pay 5%. For urban and rural medical insurance participants, if the cost of uremia dialysis, radiotherapy and chemotherapy for malignant tumors and anti-rejection drugs after organ transplantation within the policy scope is less than 654.38+10,000 yuan, it will be paid by the residents' medical insurance fund according to the proportion of 90%.

General outpatient medical expenses (excluding specific outpatient medical expenses) that meet the requirements of Suzhou medical insurance settlement and payment shall be paid from personal account first. After the personal account is used up, in each settlement year (from April to March of the following year), the local supplementary medical insurance co-ordination fund will pay the employees (including flexible employment insured and "Xiebao" personnel) in proportion within the limit of 2,500 yuan (excluding the above-mentioned conceited amount). Among them, the outpatient expenses incurred by designated community health service stations (centers), outpatient departments (institutes), unit hospitals and township hospitals using social insurance cards are paid according to the standard of 70% of employees and 80% of retirees; Outpatient expenses incurred in other designated medical institutions and retail pharmacies in urban areas shall be settled according to the standard of 60% of employees and 70% of retirees.

2. Every time the insured person of Suzhou medical insurance is hospitalized, the medical expenses within the Qifubiaozhun shall be borne by the individual, and can also be offset by the balance of the personal account of the previous year.

(1) The Qifubiaozhun for the first hospitalization of Suzhou medical insurance participants in the settlement year (April of that year to March of the following year) is determined according to different levels of hospitals, namely hospitals above the municipal level: employees (including flexible employment participants and "cooperative participants", the same below) 800 yuan and retirees 700 yuan; District (county) level hospitals and specialized hospitals: 600 yuan, an on-the-job employee, and 500 yuan, a retiree; Grassroots hospitals such as villages and towns: workers and retirees are from 400 yuan.

(2) The Qifubiaozhun for the second hospitalization in that year is 50% of the Qifubiaozhun for the first time; Qifubiaozhun for the third and above hospitalization is unified as 200 yuan.

(3) If the patient has been hospitalized continuously for more than 180 days, the hospitalization settlement shall be made once every 180 days, and the part exceeding 180 days shall be treated as re-hospitalization.

(4) Where the insured persons with mental illness who are hospitalized in Guangji Hospital, Psychiatric Rehabilitation Hospital, Ankang Hospital in High-tech Zone and Taicang Ankang Hospital in this city meet the requirements of medical insurance settlement and payment, there is no minimum threshold for hospitalization expenses, and they will be settled directly by hospitalization settlement and installment payment.

5] If you need to be transferred to the city for continuous hospitalization due to illness, you can go to the municipal social security center with the settlement voucher and invoice after discharge according to the Qifubiaozhun of high-grade hospitals.

How to reimburse Suzhou medical insurance

1, on-site settlement

Material: ID card/social security card of the insured.

(1) Admission process: the insured person shall go through the social security registration formalities with his social security card or ID card (children can provide household registration book)-→ go to the ward for hospitalization.

(2) Discharge process: the doctor arranges discharge-→ go through the discharge settlement formalities at the inpatient charge office with my social security card or ID card (children can provide household registration book) and the information required by the hospital.

2. Sporadic reimbursement

Materials: the expenses shall be paid in advance by the individual, and relevant materials (original list of medical expenses, receipt or invoice, original diagnosis certificate, etc.). ) within three months after discharge, you must show the proof of reimbursement of hospitalization medical expenses to the social security institution where the insured person is located.

(1) Review the information submitted by the insured.

(2) After meeting the requirements, accounting shall be conducted according to the document requirements and the three catalog standards.

(3) Relevant information is entered into the medical insurance system, and the system will automatically settle accounts.

(4) Print the final list of basic medical insurance expenses.

(5) The agent confirms and signs for it.

Legal basis:

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

Article 7 The administrative department of social insurance in the State Council is responsible for the management of social insurance throughout the country, and other relevant departments in the State Council are responsible for the relevant social insurance work within their respective functions and duties.

The social insurance administrative department of the local people's government at or above the county level shall be responsible for the social insurance management within its administrative area, and other relevant departments of the local people's government at or above the county level shall be responsible for the relevant social insurance work within their respective functions and duties.

Eighth social insurance agencies to provide social insurance services, responsible for social insurance registration, personal rights and interests records, social insurance benefits payment and other work.