Reimbursement scope of Shaanxi university student medical insurance

Taking Xi'an University of Architecture and Technology as an example, the reimbursement scope of Shaanxi university students' medical insurance is mainly divided into the following categories.

I. Daily Outpatient Clinic

With a social security card (or health insurance card), employees participating in the Shaanxi Provincial Health Insurance go to the provincial designated medical institutions announced by the Provincial Health Insurance Center every year (you can visit the website of the Shaanxi Provincial Department of Human Resources and Social Security), and register for medical treatment. Expenses incurred in general outpatient examination, treatment and purchase of medicines are paid with the fund of the individual account, and for the insufficiency of the fund of the individual account, the individual will pay for the expenses out of his/her own pocket. If the individual account fund is insufficient, the individual will pay out of his own pocket and will not be reimbursed.

Two, outpatient special chronic diseases

1, outpatient special chronic diseases: coronary atherosclerotic heart disease, essential hypertension, atherosclerotic cerebral infarction, cerebral embolism, cerebral hemorrhage, chronic aplastic anemia, rheumatic heart disease, cirrhosis of the liver (inoperative), diabetes mellitus, chronic obstructive pulmonary disease, malignant tumors, schizophrenia, Systemic lupus erythematosus, Parkinson's syndrome 14 diseases.

2, civil service outpatient special diseases: chronic glomerulonephritis, chronic hepatitis, mental illness (affective disorder, organic mental disorder), rheumatoid arthritis, primary cardiomyopathy, epilepsy, pulmonary heart disease, chronic bronchitis, gastroduodenal ulcers (with complications).

3, the declaration process: submit the declaration of disease-related materials, you can always go to the provincial health insurance management center commissioned by the identification of hospital health insurance office for the declaration procedures. For special reasons such as relocation can not declare, can be entrusted to friends and relatives to assist in the declaration. Specific matters can consult the medical insurance office.

4, cost reimbursement procedures: outpatient special chronic diseases and civil servants with outpatient special diseases of the insured with social security card, outpatient chronic disease special card to the provincial chronic disease designated medical institutions or designated pharmacies to enter the chronic disease system of medical treatment and purchase of medicines, outpatient special chronic disease 650 yuan per year to set up a minimum payment standard, all the medical costs in line with the provisions of the minimum payment standard, the provincial health insurance center network review and confirmation. The network audit of the provincial health insurance center will confirm this.

Calculating the annual limit of chronic diseases according to the month (including the current month) to which the confirmation belongs, within the annual limit, the individual pays 30%, and the fund pays 70%, and the person who still needs to take medication after the annual limit has been used up must enter the system of chronic diseases to purchase medication at full cost at the designated medical institutions or designated pharmacies. Each time the chronic disease purchases drugs individuals are required to retain invoices, settlement statements.

Individuals who pay more than 1,500 yuan out-of-pocket in a natural year can receive a second subsidy in the second year (see the specific subsidy notice for the program).

5, chronic disease purchase of drugs to implement cost limit management and purchase of drugs management: monthly fund to pay for the purchase of drugs does not exceed two times the monthly limit of its disease, each purchase of the same generic name of drugs does not exceed the amount of drugs for four weeks of its disease, no more than two times a month.

6, the annual limit is not used up next year can continue to use, use to pay again only 650 starting standard into the next year limit management.

Three, outpatient emergency rescue

1, the scope of the disease include: coma, severe shock, hemorrhage, poisoning, severe dehydration, febrile convulsions, severe trauma caused by severe respiratory distress, spontaneous or injury pneumothorax, hemopneumothorax, laryngeal infarction and tracheo-bronchial blockage, severe cardiac arrhythmia, internal and external bleeding of various causes of life-threatening, acute heart failure, respiratory failure, Renal failure and other vital signs have significant changes.

2. Payment standard: The medical expenses incurred in outpatient emergency rescue treatment shall be settled according to the cost of one hospitalization, and the starting standard can be exempted from deduction if there is first aid and then transferred to hospitalization.

3, the cost reimbursement procedures: by the insured person in the costs incurred within six months of the relevant information submitted to the University Health Insurance Office (Room 102, Apartment No. 6), the Office of Health Insurance reported to the Shaanxi Provincial Health Insurance Management Center for reimbursement. After the deadline, the provincial center will not be accepted.

Four, outpatient special examination and treatment:

1, outpatient special examination and treatment include: CT, nuclear magnetic **** vibration, cardiac ultrasound, cervical and cranial color Doppler angiography, gastric and duodenoscopy, colonoscopy, dynamic electrocardiography, hyperbaric oxygen chamber treatment, nuclear scanning. Bronchoscopy, extracorporeal shock wave lithotripsy for urinary system and biliary tract stones, extracorporeal radiofrequency for severe prostate hypertrophy, gynecological hysteroscopy, coronary angiography.

2, cost reimbursement procedures: insured workers with social security card and outpatient physician issued by the outpatient special examination and treatment application form to the hospital medical insurance office for review and confirmation, the reimbursement rate of 30% of the individual to pay for the fund to pay 70% of the direct reimbursement in the hospital. For personal reasons, the reimbursement will not be reimbursed if it is not settled in the hospital in accordance with the reimbursement rate.

V. Outpatient special treatment:

1. The scope of diseases includes: outpatient radiotherapy for malignant tumors, outpatient renal dialysis for chronic renal failure, and anti-rejection drugs after organ transplantation.

2, the cost of payment standards: chronic renal failure outpatient renal dialysis, organ transplantation after taking anti-rejection drugs in line with the cost of personal payment of 10%, the integrated fund to pay 90%, outpatient radiotherapy for malignant tumors in line with the cost of personal payment of 30%, the fund to pay 70%.

3, cost reimbursement procedures: insured workers in outpatient treatment of the above special diseases, first in the designated hospital to issue the "Shaanxi Province basic medical insurance outpatient special disease approval form" (issued by the specialist attending physician, signed by the director of the department, the designated medical institution medical insurance office seal), and then reported to the provincial medical insurance agencies for approval and filing.

After the approval of the provincial medical insurance agency, the individual part of the medical expenses shall be settled directly between the insured employee and the designated medical institution when the outpatient treatment of the above special diseases is carried out in accordance with the regulations. No reimbursement will be made if the expenses are not settled at the hospital in accordance with the reimbursement rate due to personal reasons. Individuals should keep the settlement form of special treatment expenses and related invoices for the second subsidy for civil servants at the end of the year.

Sixth, hospitalization:

1, medical procedures: insured workers need hospitalization due to illness, to Shaanxi Provincial Health Insurance designated hospitals with social security cards and outpatient physicians issued by the hospitalization certificate in the hospital health insurance office for examination and registration, for health insurance hospitalization procedures, to facilitate the management of hospitals according to the health insurance patients and reimbursement and settlement, when the hospital directly in the hospital health insurance office for settlement.

2, the principle of payment:

Basic medical care: the insured workers in the designated medical institutions in line with the policy of hospitalization costs, basic medical care in accordance with the prescribed ratio of reimbursement.

Seven, out-of-town medical treatment:

1. Scope: the insured person is hospitalized for sudden illness in a foreign place due to business trip, visiting relatives, studying, etc., or agreed to be referred to a foreign place for medical treatment by the six tertiary hospitals in the city.

2. Hospitals: local medical insurance designated medical institutions or public hospitals should be selected for treatment.

3, cost reimbursement procedures: the costs incurred by the individual first self-payment, the costs incurred within two months of the relevant information will be sent to the University Health Insurance Office, the Office of Health Insurance reported to the Shaanxi Provincial Health Insurance Management Center for reimbursement.

VIII. Management of medical treatment for people living abroad for a long time:

1. If the insured employees who live abroad for retirement or other reasons and work or study abroad for a long time, and if they are abroad for a continuous period of more than 6 months, they can fill in the "Registration Form of Medical Treatment for Provincial Insured Persons Living Abroad in Shaanxi Province", and then, after being confirmed by the Provincial Medical Insurance Center, they can choose three local designated hospitals for medical insurance and two designated pharmacies for medical insurance in their place of residence, and they can enjoy the benefits of the basic medical insurance in Shaanxi Province. You can enjoy the basic medical insurance treatment in Shaanxi Province.

2. Reimbursement of expenses: Individuals will pay for the expenses incurred, and then submit the relevant information to the University's Medical Insurance Office within six months, and the Medical Insurance Office will report to the Shaanxi Provincial Medical Insurance Management Center for reimbursement.

3. Those who apply for long-stay overseas medical treatment can get the "Explanation of Medical Insurance Matters Related to Long-Stay Overseas Medical Treatment for Provincial Health Insurance Employees" from the Medical Insurance Office.

Expanded information:

But the reimbursement of health insurance in Shaanxi Province will not be accepted in the following cases:

1, medical expenses incurred in non-scheduled medical institutions and non-scheduled pharmacies. Medical expenses;

2. Local expenses not settled in hospitals according to medical insurance procedures for personal reasons;

3. Local outpatient expenses incurred in non-emergency rescue;

4. Long-term residence in a different place (more than six consecutive months), please apply for the record of registration for medical treatment in a different place, and medical expenses before the confirmation of registration for the record of medical treatment in a different place are not admissible;

< p>5. Expenses incurred for medical treatment for non-sudden illnesses during the period of going out on official business, studying or visiting relatives in compliance with the basic medical insurance regulations;

6. Out-of-town referral expenses without going through the approval procedures according to the procedures;

7. Out-of-town referral expenses of local personnel for more than two months from the date of billing;

8. Overseas inpatient hospitalization, emergency rescue and special check-up of outpatient medical care for more than six months from the date of billing. Resuscitation, outpatient special examination, local emergency resuscitation expenses;

9. Medical expenses incurred during the period of going abroad or leaving the country.

Xi'an Architectural University of Science and Technology - Shaanxi Province medical insurance reimbursement? I. Daily Outpatient Clinic