What is the reimbursement scope of Wuxi social security card and the proportion of medical reimbursement in 2023?

I compiled the reimbursement scope of Wuxi social security card and the reimbursement ratio of Wuxi hospital. This article is for reference only. If there is any change, please refer to the news released by official website. Social security cards have a wide range of functions. Cardholders can not only use the card for real-time settlement of medical insurance personal accounts, but also handle endowment insurance affairs; Apply for job registration and unemployment registration ... If you want to know more about the scope of reimbursement of Wuxi social security card and the proportion of reimbursement for medical treatment, let's take a look.

The scope of reimbursement for Wuxi social security card and the proportion of reimbursement for medical treatment in Wuxi hospitals are compiled through sorting. This article is for reference only. If there is any change, please refer to the news released by official website.

Social security cards have a wide range of functions. Cardholders can not only use the card for real-time settlement of medical insurance personal accounts, but also handle endowment insurance affairs; Go through the formalities of job registration and unemployment registration; Apply for unemployment insurance; Apply for employment training; Apply for labor ability appraisal and enjoy work-related injury insurance benefits; Handling labor and social security affairs online.

Wuxi social security card reimbursement scope

(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 see a doctor after signing a service agreement in their recognized community hospital, and their personal accounts can only be used after they are used up. 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.

◆ Chronic outpatient diseases: 12 hypertension, coronary heart disease and other chronic diseases: first go to the municipal hospital for identification, choose a medical institution that you think is convenient (not the community health service center) as your own appointment medical institution, and register and make an appointment at each district office of the social security center. After that, people and individuals under the age of 70 pay 800 yuan, and the medical insurance fund pays 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: The medical expenses of tertiary medical institutions are less than 1 10,000 yuan (including 1 10,000 yuan) when they leave the hospital, 84% of which are paid by the on-the-job employees' overall fund, and the individual pays16%; 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 Grade II: In Grade I and Grade II medical institutions, the medical expenses of on-the-job employees are below 6,543.8+0,000 yuan (including 6,543.8+0,000 yuan), 88% is paid by the overall fund, and the individual pays 654.38+0.2%; 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 for settlement, with medical expenses below 40,000 yuan (including 40,000 yuan), 92% paid by the overall fund and 8% paid by individuals (half 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;

◆ Proof 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.

Proportion of reimbursement of medical expenses in Wuxi hospitals

Two, Wuxi urban residents basic medical insurance benefits

(1) general outpatient service

◆ The medical treatment rate in the community health service center is 50%, and the limit is 800 yuan (including individual contributions within the scope of medical insurance);

◆ 45% of them went through referral procedures in hospitals inside and outside the city, and 50% of them didn't go through referral procedures;

(2) General hospitalization and special treatment

◆ The first visit should be in the community health service center. The qifubiaozhun for hospitalization medical expenses is 200 yuan, in which 90% of eligible medical expenses are paid by the fund and10% by individuals; Transferred to other medical institutions in the urban area, the initial hospitalization expenses for students and children are 300 yuan, and other residents are 600 yuan. If they are hospitalized in medical institutions below the second level, they will be paid according to 75% of the prescribed medical expenses, 25% for individuals, 65% for the funds of tertiary medical institutions, 35% for individuals, 55% for individuals transferred from the urban area, and 45% for individuals. If the transfer procedures are not handled according to the regulations, the fund will pay 50% of the above standards.

◆ Maximum limit: The maximum annual cumulative medical expenses of residents' basic medical insurance is 200,000 yuan. If the insured residents have paid for 5 years or more continuously, the maximum annual accumulated medical expenses will be increased by 50,000 yuan on this basis; The residents' medical insurance fund will no longer pay the part above the maximum annual accumulated medical expenses.

◆ The medical expenses for outpatient treatment of special diseases are 90%, and the annual maximum amount is combined with the general hospitalization medical expenses.

(three) Wuxi residents' basic medical insurance for medical treatment and reimbursement process:

1. First, the insured patients go to the personal appointment service center with their Medical Records of Residents and Social Security Card (children under 3 years old can go directly to the medical institutions designated by the personal appointment service center with pediatric diagnosis and treatment subjects);

2, the existing medical technology can not provide services, by himself or his family members with the above card to the individual agreed service center for referral procedures (valid for three days), transferred to the urban areas with the basic medical insurance for employees designated medical institutions for medical treatment;

3 insured residents in the city or other places (within the territory of China) in case of emergency, you can go to the nearest medical institution for medical treatment;

4, emergency (need to meet the "Jiangsu Province emergency diagnosis standard") and medical expenses without a card, with the consent of the community health service center to the insured.

Three, the content of medical insurance is not guaranteed:

The social medical insurance fund shall not pay the medical expenses incurred by the insured under the following circumstances:

(1) Except for emergency treatment, the expenses incurred by seeking medical treatment outside the designated service center agreed by the individual without approval and relevant procedures;

(two) the expenses incurred during the interruption of payment by the insured residents;

(three) beyond the medical insurance for urban residents drug list standards and medical service facilities;

(4) plastic surgery;

(5) Childbearing expenses;

(six) during the period of going abroad or leaving the country;

(seven) medical expenses due to crime, fighting, alcoholism, drug abuse, suicide, self injury, etc.;

(8) Intentional violation of regulations, traffic accidents and medical accidents;

(nine) medical expenses incurred in other cases in violation of laws and regulations;

(10) Other medical expenses that do not meet the payment scope stipulated by social medical insurance.

Fourth, seek medical treatment in different places.

(1) Settlement of medical treatment in different places in Jiangsu Province;

1, the insured person in different places first applies to the insured place, fills in the application form for medical treatment in different places, and the registration is successful;

2. With the stamped application form and ID card, you can apply for a local social security card in Wuxi, and then you can go to a designated hospital in Wuxi to settle the card.

(two) Wuxi insured to other parts of Jiangsu Province for medical treatment:

1, the insured can go through the formalities of medical treatment in another place if he lives in another place for a long time (more than 6 months);

2. Fill in the Application Form for Medical Treatment of Insured Persons in Different Places, and select three public medical institutions of different grades as designated medical institutions for medical treatment;

3, if you want to choose to enjoy the overall treatment of outpatient service, you should choose a community health service institution as the first designated medical institution under the same conditions;

4. Go through the registration formalities at the offices of Wuxi Social Security Center;

5. After successful registration, go through the transfer formalities at the medical insurance agency where the doctor is located;

6. The medical expenses incurred in that year will be settled at the end of June of the following year, and will not be reimbursed after the deadline.

Five, urban and rural residents serious illness insurance benefits

(a) enjoy the object:

Insured persons of basic medical insurance for urban residents and basic medical insurance for urban workers in our city.

(2) scope of protection:

The medical insurance for serious illness is not divided into diseases, and the compliant medical expenses for the treatment of special diseases in hospitalization and outpatient can be included in reimbursement.

(3) What are the situations in which medical insurance for critical illness cannot be reimbursed?

Not included in the city's social medical insurance settlement system, not included in the serious illness of medical insurance coverage, including work-related injury and maternity insurance medical expenses.

(four) reimbursement ratio and standard:

The actual payment ratio of serious illness insurance is not less than 50%, as follows:

◆ If the personal burden is 2 1 1,000-50,000 yuan (including 50,000 yuan), the subsidy will be 50%;

◆ If the personal burden is between 50,000 yuan and 654.38+10,000 yuan (including 654.38+10,000 yuan), the subsidy is 60%;

◆ If the personal burden is more than 654.38 million yuan, the subsidy will be 80%;

◆ The deductible line of medical insurance for serious illness is 2 1 1,000 yuan, and there is no ceiling line for the subsidy amount.

In addition, every two years, the human and social departments in Xicheng will adjust and introduce a new threshold according to the annual per capita disposable income of urban residents in the previous year.

I'm here to sort out the information about these problems, hoping to help you. The laws in China are gradually improving, and we look forward to helping more people.