Nanjing Social Security Medical Insurance Reimbursement Scope

(1) The medical expenses for outpatient chronic diseases (1) and three kinds of chronic diseases (see table 1 for details) incurred by the insured with a prescription for external use to the selected designated hospital for outpatient chronic diseases or the selected designated pharmacy shall be paid by the insured personally within the Qifubiaozhun, and the part exceeding the Qifubiaozhun shall be subsidized according to a certain proportion and limit. The part paid directly by the patient and the front desk of the hospital or pharmacy, and the part paid by the overall fund is settled by the medical insurance agency with the designated hospital or pharmacy every month. 2, chronic hepatitis C patients in the outpatient use of interferon alpha for antiviral treatment (including ordinary and long-term) the cost of a fixed subsidy. There is no qifubiaozhun for subsidies, and the basic medical insurance fund is paid at the rate of 70%. The maximum monthly payment limit is 3,200 yuan, and the excess expenses are paid by the patients themselves. The monthly limit fee is valid in the current month, and it is neither cumulative nor cumulative. Patients can also enjoy the treatment of chronic hepatitis C during interferon α treatment, and the expenses of auxiliary examination, treatment and medication can be included in the scope of chronic hepatitis C subsidy, and patients can enjoy this outpatient quota subsidy at different times during hospitalization. The designated medical institutions for interferon α treatment in hepatitis C outpatient department are: Nanjing Second Hospital and China No.81 People's Liberation Army Hospital. 3. Hemophilia is divided into mild, moderate and severe. The proportion of fund payment is 85% for working and 90% for retiring, and the payment limits are 6,543.8+0,000,50,000 and 6,543.8+0,000 respectively. (two) outpatient specific projects; When special personnel go to the designated hospital of their choice for medical treatment due to special diseases or purchase medicines from the designated pharmacy of their choice with an external prescription, the medical expenses for special items that meet the requirements of basic medical insurance will be settled directly with the front desk of the designated hospital or the designated pharmacy; Class B drugs and class B treatment items shall be paid by the insured respectively according to the prescribed proportion, and the rest shall be paid according to the provisions of basic medical insurance. (3) outpatient co-ordination 1. In a natural year, the medical expenses incurred by the insured in the outpatient service that meets the requirements (except the outpatient expenses that have been included in the "slow door" and "special" settlement), the expenses below the minimum deductible line shall be paid by the insured individual; The expenses above Qifubiaozhun and below the maximum payment limit shall be shared by the overall fund and individual. 2, outpatient co-ordinate the implementation of the first diagnosis and referral system based on community health service institutions. Insured persons can be first diagnosed or referred to community-managed medical institutions in designated community health service institutions for urban workers' basic medical insurance; Specialized hospitals can be used as the first medical institutions for all insured persons. If the insured person needs a referral, the first-visit medical institution shall be responsible for the referral, and emergency rescue is not subject to this restriction. 3. After the outpatient chronic disease subsidy limit is used up, it will be settled directly according to the outpatient overall treatment standard from the next cost, and the original chronic disease in the door does not need to be referred. After the subsidy limit for specific outpatient projects is used up, referral procedures must be handled according to the provisions of outpatient co-ordination, and ordinary medical records can be used to enjoy outpatient co-ordination treatment. Buying medicine in a pharmacy does not enjoy the overall treatment of outpatient service. (4) Mental illness 1, mental patients (suffering from schizophrenia, moderate and severe depression, mania, obsessive-compulsive disorder, mental retardation with psychosis, epilepsy with psychosis, paranoid psychosis, the same below), who suffer from mental illness, must issue a social security card and hang the number of "Medical Insurance Psychiatry Specialist". Within the scope of basic medical insurance payment, the expenses of psychiatric specialist diagnosis and treatment (including examination and medication expenses) do not need to be paid by individuals, and the municipal social security center will settle with the hospital according to the prescribed standards. 2, mental patients, mental illness requiring hospitalization, exempt from hospitalization Qifubiaozhun, the basic medical insurance coverage in line with the provisions of the individual pays part of the medical expenses, by the serious illness medical assistance fund, employers and individuals each pay one third. The medical expenses of mental patients with physical diseases shall be implemented according to the provisions of the basic medical insurance. For those who go abroad for a long time, the quota standard for outpatient mental illness is issued to individuals through the unit every year according to the monthly rate of 160 yuan. (5) Insured persons who have been bedridden in family beds for a long time and meet one of the following conditions: If the elderly over 70 years old need bedridden treatment due to stroke paralysis, advanced malignant tumor and fracture traction and meet the hospitalization conditions, they or their families shall apply to the designated medical institution with the qualification of family bed service nearby, and they can set up family beds after examination and diagnosis by doctors. There is no Qifubiaozhun for family sickbeds; The proportion of individual pays for family sickbeds is implemented with reference to the hospitalization policy of medical institutions at the same level; The medical insurance fund shall be settled with the designated medical institutions on a monthly basis, and the monthly payment limit shall be 1.350 yuan (the family sickbed inspection fee paid according to the medical insurance regulations shall not exceed 2 times per week); If the bed is booked for less than one month, it will be settled according to the daily limit of 45 yuan/bed. (6) Hospitalization 1, the hospitalization expenses incurred by the insured, the maximum payment limit of the basic medical insurance pooling fund is 1.8 million yuan in a natural year. Qifubiaozhun and class B drugs, diagnosis and treatment projects, service facilities, individuals bear part of the expenses and basic expenses outside the scope of medical insurance in proportion, individuals pay first, and the rest of the expenses are shared by the overall fund and individuals. 2. If the medical expenses within the scope of medical insurance payment incurred by employees' medical insurance insured in hospitalization in different places are above Qifubiaozhun, the proportion of on-the-job employees' overall fund payment in tertiary, secondary, primary and below medical institutions is 82%, 88% and 93% respectively; Retired (retired) personnel are 85%, 92% and 96% respectively; Before the founding of the People's Republic of China, the proportion of retired old workers participating in revolutionary work was 98.2%, 98.8% and 99.3% respectively. Expenses exceeding the maximum payment limit of the overall fund shall still be reimbursed according to the proportion paid by the serious illness medical assistance fund. After the rescue, the outpatient rescue expenses incurred by the insured who was transferred to hospital for treatment or died after the rescue were invalid shall be reimbursed according to hospitalization, and the Qifubiaozhun shall be exempted. (VII) Medical Assistance for Serious Illness The Medical Assistance Fund for Serious Illness mainly solves the medical expenses incurred by the insured in a natural year that exceed the maximum payment limit of the basic medical insurance pooling fund due to serious illness or disease. The payment scope and standard of medical assistance fund for serious illness shall be implemented according to the provisions of basic medical insurance. The maximum payment limit of the basic medical insurance co-ordination fund is above the medical expenses in medical insurance coverage, and the payment ratio of the serious illness medical assistance fund is 95%. (8) The medical expenses for specific items of hospitalization and outpatient service within the scope of basic medical insurance payment incurred by the insured for serious illness insurance in a natural year shall be paid by the serious illness insurance in accordance with the regulations on the basis of enjoying the basic medical insurance benefits, and the personal out-of-pocket expenses exceed the Qifubiaozhun for serious illness insurance. Qifubiaozhun for serious illness insurance is set at about 50% of the annual per capita disposable income of urban residents in the previous year (currently tentatively set at 20,000 yuan). For the expenses above Qifubiaozhun, "subsection calculation and cumulative payment" shall be implemented, and there is no maximum payment limit. The specific measures are as follows: 60% of the portion from 20,000 yuan (excluding 20,000 yuan, the same below) to 40,000 yuan (including 40,000 yuan, the same below); 40,000 yuan to 60,000 yuan, paying 65%; 70% of the 60,000 yuan to 80,000 yuan; 75% will be paid from 80,000 yuan to 654.38+10,000 yuan; 65,438+80% for the part above 10,000 yuan. The serious illness insurance system has been implemented since 20 15 1. After the implementation of the serious illness insurance system, the original secondary subsidy policy for employee medical insurance hospitalization expenses was cancelled. Insured persons who meet the conditions of medical assistance shall enjoy the treatment of civil medical assistance after enjoying the treatment of serious illness insurance. (9) Special gynecological examination items for female employees include: gynecological double-river examination, routine examination of vaginal secretions, pap cytology examination of cervical cancer, pelvic B-ultrasound (including uterus and its accessories) and hand examination of breast. Special gynecological examination is conducted every two years, from June, 1965 to May, 2020. Note: The expenses for special gynecological examination of female employees shall be paid by the basic medical insurance fund at 20 14 10 1.

Legal basis:

The reimbursement scope of Nanjing medical insurance (1) refers to the medical expenses for chronic diseases (1) and three kinds of chronic diseases (4 1) (see table 1 for details), which are incurred when the insured takes an external prescription to see a doctor in a designated outpatient hospital or buys medicines from a designated pharmacy. The medical expenses for chronic indications in outpatient clinics are paid by the insured. The part paid directly by the patient and the front desk of the hospital or pharmacy, and the part paid by the overall fund is settled by the medical insurance agency with the designated hospital or pharmacy every month. 2, chronic hepatitis C patients in the outpatient use of interferon alpha for antiviral treatment (including ordinary and long-term) the cost of a fixed subsidy. There is no qifubiaozhun for subsidies, and the basic medical insurance fund is paid at the rate of 70%. The maximum monthly payment limit is 3,200 yuan, and the excess expenses are paid by the patients themselves. The monthly limit fee is valid in the current month, and it is neither cumulative nor cumulative. Patients can also enjoy the treatment of chronic hepatitis C during interferon α treatment, and the expenses of auxiliary examination, treatment and medication can be included in the scope of chronic hepatitis C subsidy, and patients can enjoy this outpatient quota subsidy at different times during hospitalization. The designated medical institutions for the treatment of interferon α in hepatitis C outpatient department are: Nanjing Second Hospital and China People's Liberation Army No.81 Hospital. 3. Hemophilia is divided into mild, moderate and severe. The proportion of fund payment is 85% for working and 90% for retiring, and the payment limits are 6,543.8+0,000,50,000 and 6,543.8+0,000 respectively. (two) outpatient specific projects; When special personnel go to the designated hospital of their choice for medical treatment due to special diseases or purchase medicines from the designated pharmacy of their choice with an external prescription, the medical expenses for special items that meet the requirements of basic medical insurance shall be directly settled with the front desk of the designated hospital or the designated pharmacy; Class B drugs and class B treatment items shall be paid by the insured respectively according to the prescribed proportion, and the rest shall be paid according to the provisions of basic medical insurance. (3) outpatient co-ordination 1. In a natural year, the medical expenses incurred by the insured in the outpatient service that meets the requirements (except the outpatient expenses that have been included in the "slow door" and "special" settlement), the expenses below the minimum deductible line shall be paid by the insured individual; The expenses above Qifubiaozhun and below the maximum payment limit shall be shared by the overall fund and individual. 2, outpatient co-ordinate the implementation of the first diagnosis and referral system based on community health service institutions. Insured persons can be first diagnosed or referred to community-managed medical institutions in designated community health service institutions for urban workers' basic medical insurance; Specialized hospitals can be used as the first medical institutions for all insured persons. If the insured person needs a referral, the first-visit medical institution shall be responsible for the referral, and emergency rescue is not subject to this restriction. 3. After the outpatient chronic disease subsidy limit is used up, it will be settled directly according to the outpatient overall treatment standard from the next cost, and the original chronic disease in the door does not need to be referred. After the subsidy limit for specific outpatient projects is used up, referral procedures must be handled according to the provisions of outpatient co-ordination, and ordinary medical records can be used to enjoy outpatient co-ordination treatment. Buying medicine in a pharmacy does not enjoy the overall treatment of outpatient service. (4) Mental illness 1, mental patients (suffering from schizophrenia, moderate and severe depression, mania, obsessive-compulsive disorder, mental retardation with psychosis, epilepsy with psychosis, paranoid psychosis, the same below), who suffer from mental illness, must issue a social security card and hang the number of "Medical Insurance Psychiatry Specialist". Within the scope of basic medical insurance payment, the expenses of psychiatric specialist diagnosis and treatment (including examination and medication expenses) do not need to be paid by individuals, and the municipal social security center will settle with the hospital according to the prescribed standards. 2, mental patients, mental illness requiring hospitalization, exempt from hospitalization Qifubiaozhun, the basic medical insurance coverage in line with the provisions of the individual pays part of the medical expenses, by the serious illness medical assistance fund, employers and individuals each pay one third. The medical expenses of mental patients with physical diseases shall be implemented according to the provisions of the basic medical insurance. For those who go abroad for a long time, the quota standard for outpatient mental illness is issued to individuals through the unit every year according to the monthly rate of 160 yuan. (5) Insured persons who have been bedridden in family beds for a long time and meet one of the following conditions: If the elderly over 70 years old need bedridden treatment due to stroke paralysis, advanced malignant tumor and fracture traction and meet the hospitalization conditions, they or their families shall apply to the designated medical institution with the qualification of family bed service nearby, and they can set up family beds after examination and diagnosis by doctors. There is no Qifubiaozhun for family sickbeds; The proportion of individual pays for family sickbeds is implemented with reference to the hospitalization policy of medical institutions at the same level; The medical insurance fund shall be settled with the designated medical institutions on a monthly basis, and the monthly payment limit shall be 1.350 yuan (the family sickbed inspection fee paid according to the medical insurance regulations shall not exceed 2 times per week); If the bed is booked for less than one month, it will be settled according to the daily limit of 45 yuan/bed. (6) Hospitalization 1, the hospitalization expenses incurred by the insured, the maximum payment limit of the basic medical insurance pooling fund is 1.8 million yuan in a natural year. Qifubiaozhun and class B drugs, diagnosis and treatment projects, service facilities, individuals bear part of the expenses and basic expenses outside the scope of medical insurance in proportion, individuals pay first, and the rest of the expenses are shared by the overall fund and individuals. 2. The medical expenses within the scope of medical insurance payment incurred by employees' medical insurance insured in hospitalization in different places are above Qifubiaozhun, and the proportion of employees in tertiary, secondary, primary and below medical institutions is 82%, 88% and 93% respectively. Retired (retired) personnel are 85%, 92% and 96% respectively; Before the founding of the People's Republic of China, the proportion of retired old workers participating in revolutionary work was 98.2%, 98.8% and 99.3% respectively. Expenses exceeding the maximum payment limit of the overall fund shall still be reimbursed according to the proportion paid by the serious illness medical assistance fund. After the rescue, the outpatient rescue expenses incurred by the insured who was transferred to hospital for treatment or died after the rescue were invalid shall be reimbursed according to hospitalization, and the Qifubiaozhun shall be exempted. (VII) Medical Assistance for Serious Illness The Medical Assistance Fund for Serious Illness mainly solves the medical expenses incurred by the insured in a natural year that exceed the maximum payment limit of the basic medical insurance pooling fund due to serious illness or disease. The payment scope and standard of medical assistance fund for serious illness shall be implemented according to the provisions of basic medical insurance. The maximum payment limit of the basic medical insurance co-ordination fund is above the medical expenses in medical insurance coverage, and the payment ratio of the serious illness medical assistance fund is 95%. (8) The medical expenses for specific items of hospitalization and outpatient service within the scope of basic medical insurance payment incurred by the insured for serious illness insurance in a natural year shall be paid by the serious illness insurance in accordance with the regulations on the basis of enjoying the basic medical insurance benefits, and the personal out-of-pocket expenses exceed the Qifubiaozhun for serious illness insurance. Qifubiaozhun for serious illness insurance is set at about 50% of the annual per capita disposable income of urban residents in the previous year (currently tentatively set at 20,000 yuan). For the expenses above Qifubiaozhun, "subsection calculation and cumulative payment" shall be implemented, and there is no maximum payment limit. The specific measures are as follows: 60% of the portion from 20,000 yuan (excluding 20,000 yuan, the same below) to 40,000 yuan (including 40,000 yuan, the same below); 40,000 yuan to 60,000 yuan, paying 65%; 70% of the 60,000 yuan to 80,000 yuan; 75% will be paid from 80,000 yuan to 654.38+10,000 yuan; 65,438+80% for the part above 10,000 yuan. The serious illness insurance system has been implemented since 20 15 1. After the implementation of the serious illness insurance system, the original secondary subsidy policy for employee medical insurance hospitalization expenses was cancelled. Insured persons who meet the conditions of medical assistance shall enjoy the treatment of civil medical assistance after enjoying the treatment of serious illness insurance. (9) Special gynecological examination items for female employees include: gynecological double-river examination, routine examination of vaginal secretions, pap cytology examination of cervical cancer, pelvic B-ultrasound (including uterus and its accessories) and hand examination of breast. Special gynecological examination is conducted every two years, from June, 1965 to May, 2020. Note: The expenses for special gynecological examination of female employees shall be paid by the basic medical insurance fund of 20 14 10 1.